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Tran P, Lau C, Joshi M, Kuehl M, Maddock H, Banerjee P. Exploring Changes in Myocyte Structure, Contractility, and Energetics From Mechanical Unloading in Patients With Heart Failure Undergoing Ventricular Assist Device Implantation: A Systematic Review and Meta-Analysis. Heart Lung Circ 2024; 33:1097-1116. [PMID: 38704332 DOI: 10.1016/j.hlc.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 05/06/2024]
Abstract
AIMS Recent reports of myocardial recovery after mechanical unloading with left ventricular assist devices (LVADs) have challenged the prevailing notion that end-stage heart failure (HF) is irreversible. To improve our understanding of this phenomenon, we comprehensively analysed the structural, functional, and energetic changes in failing human cardiomyocytes after LVAD implantation. METHODS Based on a prospectively registered protocol (PROSPERO-CRD42022380214), 30 eligible studies were identified from 940 records with a pooled population of 648 patients predominantly with non-ischaemic cardiomyopathy. RESULTS LVAD led to a substantial regression in myocyte size similar to that of donor hearts (standardised mean difference, -1.29; p<0.001). The meta-regression analysis revealed that HF duration was a significant modifier on the changes in myocyte size. There were some suggestions of fibrosis reversal (-5.17%; p=0.009); however, this was insignificant after sensitivity analysis. Developed force did not improve in cardiac trabeculae (n=5 studies); however, non-physiological isometric contractions were tested. At the myocyte level (n=4 studies), contractile kinetics improved where the time-to-peak force reduced by 41.7%-50.7% and time to 50% relaxation fell by 47.4%-62.1% (p<0.05). Qualitatively, LVAD enhanced substrate utilisation and mitochondrial function (n=6 studies). Most studies were at a high risk of bias. CONCLUSION The regression of maladaptive hypertrophy, partial fibrosis reversal, and normalisation in metabolic pathways after LVAD may be a testament to the heart's remarkable plasticity, even in the advanced stages of HF. However, inconsistencies exist in force-generating capabilities. Using more physiological force-length work-loop assays, addressing the high risks of bias and clinical heterogeneity are crucial to better understand the phenomenon of reverse remodelling.
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Affiliation(s)
- Patrick Tran
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Clement Lau
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mithilesh Joshi
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Kuehl
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Maddock
- Centre for Health & Life Sciences, Coventry University, Coventry, UK
| | - Prithwish Banerjee
- Centre for Health & Life Sciences, Coventry University, Coventry, UK; Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
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Tran P, Linekar A, Dandekar U, Barker T, Balasubramanian S, Bhaskara-Pillai J, Shelley S, Maddock H, Banerjee P. Profiling the Biomechanical Responses to Workload on the Human Myocyte to Explore the Concept of Myocardial Fatigue and Reversibility: Rationale and Design of the POWER Heart Failure Study. J Cardiovasc Transl Res 2024; 17:275-286. [PMID: 37126208 PMCID: PMC10150683 DOI: 10.1007/s12265-023-10391-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
It remains unclear why some patients develop heart failure without evidence of structural damage. One theory relates to impaired myocardial energetics and ventricular-arterial decoupling as the heart works against adverse mechanical load. In this original study, we propose the novel concept of myocardial fatigue to capture this phenomenon and aim to investigate this using human cardiomyocytes subjected to a modern work-loop contractility model that closely mimics in vivo cardiac cycles. This proof-of-concept study (NCT04899635) will use human myocardial tissue samples from patients undergoing cardiac surgery to develop a reproducible protocol to isolate robust calcium-tolerant cardiomyocytes. Thereafter, work-loop contractility experiments will be performed over a range of preload, afterload and cycle frequency as a function of time to elicit any reversible reduction in contractile performance (i.e. fatigue). This will provide novel insight into mechanisms behind heart failure and myocardial recovery and serve as a valuable research platform in translational cardiovascular research.
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Affiliation(s)
- Patrick Tran
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK.
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
| | - Adam Linekar
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
- InoCardia Ltd, TechnoCentre, Puma Way, Coventry, UK
| | - Uday Dandekar
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Thomas Barker
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sendhil Balasubramanian
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jain Bhaskara-Pillai
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sharn Shelley
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
- InoCardia Ltd, TechnoCentre, Puma Way, Coventry, UK
| | - Helen Maddock
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
- InoCardia Ltd, TechnoCentre, Puma Way, Coventry, UK
| | - Prithwish Banerjee
- Centre for Sport, Exercise & Life Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
- Cardiology Department, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
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Khodaei S, Abdelkhalek M, Maftoon N, Emadi A, Keshavarz-Motamed Z. Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100180. [PMID: 37745677 PMCID: PMC10512011 DOI: 10.1016/j.shj.2023.100180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 09/26/2023]
Abstract
Background Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack. Methods We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries. Results Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]). Conclusions The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.
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Affiliation(s)
- Seyedvahid Khodaei
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Mohamed Abdelkhalek
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, Ontario, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Ontario, Canada
| | - Ali Emadi
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- Department of Electrical and Computer Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Zahra Keshavarz-Motamed
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Computational Science and Engineering, McMaster University, Hamilton, Ontario, Canada
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Sarıçam E, Dursun AD, Türkmen Sarıyıldız G, Can N, Bozkurt E, Gönüllü U, Basay N, Türkmen M, Denli A, Ünlü M. Laboratory and Imaging Evaluation of Cardiac Involvement in Patients with Post-Acute COVID-19. Int J Gen Med 2021; 14:4977-4985. [PMID: 34511982 PMCID: PMC8412825 DOI: 10.2147/ijgm.s321156] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background In the post-acute COVID-19 syndrome, many patients suffer from palpitations, effort-associated fatigue, and even sudden death. The mechanism of heart involvement in this syndrome is uncertain. The main purpose of the study was to identify possible cardiac involvement causes in patients with post-acute COVID-19 by using biomarkers such as NT-proBNP and nitric oxide (NO) and cardiac imaging modalities. Methods In this cross-sectional study, a total of 105 participants were included according to the existence of symptoms, and 40 of these participants were asymptomatic patients. The ages of the participants ranged from 20 to 50 years. All patients were healthy before COVID-19. The symptoms were defined as palpitations and/or fatigue association with exercise in post-acute COVID-19 term. The comparison of the two groups was made by using biochemical parameters (NT-proBNP, Troponin I, NO) and imaging techniques (echocardiography, cardiovascular magnetic resonance (CMR) and cardiac positron emission tomography (PET)). Results The symptomatic patients had higher NT-proBNP levels compared with asymptomatic patients (132.30±35.15; 76.86±16.79, respectively; p < 0.001). Interestingly, the symptomatic patients had lower NO levels than asymptomatic patients (9.20±3.08; 16.15±6.02, respectively; p < 0.001). Echocardiography and CMR were normal. However, we found regional increased 18F-FDG uptake on cardiac PET to be compatible with myocardial fatigue. Conclusion We found elevated NT-proNBP levels, low serum NO levels, and increased 18F-FDG uptake on cardiac PET in post-acute COVID syndrome. Cardiac PET could replace or be added to CMR for detecting subtle subacute/chronic myocarditis. The follow-up of patients with post-acute COVID-19 could target the possibility of risk of heart failure.
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Affiliation(s)
- Ersin Sarıçam
- Department of Cardiology, Medicana International Ankara Hospital, Ankara, Turkey.,Department of Cardiology, Atılım University Medical School, Ankara, Turkey
| | - Ali Doğan Dursun
- Department of Physiology, Atılım University Medical School, Ankara, Turkey.,Check-up Center, Home Care Services, Medicana International Ankara Hospital, Ankara, Turkey
| | - Gülçin Türkmen Sarıyıldız
- Department of General Surgery, Medicana International Ankara Hospital, Ankara, Turkey.,Operating Room Services, Vocational School of Health Services, Atılım University, Ankara, Turkey
| | - Nalan Can
- Department of Nuclear Medicine, Medicana International Ankara Hospital, Ankara, Turkey
| | - Engin Bozkurt
- Department of Cardiology, Medicana International Ankara Hospital, Ankara, Turkey
| | - Uğur Gönüllü
- Department of Pulmonary Medicine, Atılım University Medical School, Ankara, Turkey
| | - Nihal Basay
- Department of Pulmonary Medicine, Medicana International Ankara Hospital, Ankara, Turkey
| | - Meral Türkmen
- Department of Internal Medicine, Medicana International Ankara Hospital, Ankara, Turkey
| | - Abdülaziz Denli
- Department of Physical Medicine and Rehabilitation, Medicana International Ankara Hospital, Ankara, Turkey
| | - Mustafa Ünlü
- Department of Nuclear Medicine, Gazi University Medical School, Ankara, Turkey
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Tran P, Joshi M, Banerjee P. Concept of myocardial fatigue in reversible severe left ventricular systolic dysfunction from afterload mismatch: a case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab089. [PMID: 34113768 PMCID: PMC8186914 DOI: 10.1093/ehjcr/ytab089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/17/2021] [Accepted: 02/19/2021] [Indexed: 11/14/2022]
Abstract
Background There is already extensive literature on the natural history of hypertensive heart disease (HHD) and aortic stenosis (AS). Once these patients develop severe left ventricular systolic dysfunction (LVSD) despite guideline-directed therapy for heart failure (HF), it is often thought to be end-stage from irreversible adverse remodelling. Our case series challenges this traditional paradigm. A more holistic model that factors in the interactions between the ventricle and vasculature is required. Based on a novel hypothetical concept of myocardial fatigue, we propose that occasionally LVSD is not an inherent myocardial or valvular disease but a consequence of an arterial afterload mismatch. By addressing this, the ventricle may recover and contract efficiently in unison with the arterial system. Case summary We present two cases of severe LVSD in a young lady with long-standing essential hypertension and a gentleman with stable severe AS. Both patients were already established on HF medications. After optimizing their blood pressure control, repeat echocardiography revealed normalization of left ventricular ejection fraction within 3 months, along with a demonstrable improvement in ventricular-arterial coupling and for AS, a reduction in valvular-arterial impedance. Discussion Just as Frank-Starling's law was discovered by initially drawing analogies to skeletal muscle behaviour, it is biologically plausible that cardiac fatigue can occur in the setting of afterload mismatch. The chance of recovery rests upon early recognition before it transitions to irreversible myocardial damage. Only by testing new emerging theories of HF can we galvanize original research and find new avenues to understanding this complex syndrome.
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Affiliation(s)
- Patrick Tran
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, CV2 2DX, UK
| | - Mithilesh Joshi
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, CV2 2DX, UK
| | - Prithwish Banerjee
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, CV2 2DX, UK.,University of Warwick Medical School, UK.,Coventry University, UK
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Abstract
Purpose of Review Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. Recent Findings The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research. Summary Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.
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Ali D, Callan N, Ennis S, Powell R, McGuire S, McGregor G, Weickert MO, Miller MA, Cappuccio FP, Banerjee P. Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): does increased arterial stiffness associate with HFpEF, in addition to ageing and vascular effects of comorbidities? Rationale and design. BMJ Open 2019; 9:e027984. [PMID: 31748285 PMCID: PMC6886989 DOI: 10.1136/bmjopen-2018-027984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS There has been a paradigm shift proposing that comorbidities are a major contributor towards the heart failure with preserved ejection fraction (HFpEF) syndrome. Furthermore, HFpEF patients have abnormal macrovascular and microvascular function, which may significantly contribute towards altered ventricular-vascular coupling in these patients. The IDENTIFY-HF study will investigate whether gradually increased arterial stiffness (in addition to ageing) as a result of increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF. METHODS AND ANALYSIS In our observational study, arterial compliance and microvascular function will be assessed in five groups (Groups A to E) of age, sex and body mass index matched subjects (age ≥70 years in all groups):Group A; normal healthy volunteers without major comorbidities such as hypertension and diabetes mellitus (control). Group B; patients with hypertension without diabetes mellitus or heart failure (HF). Group C; patients with hypertension and diabetes mellitus without HF. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (parallel group). Vascular function and arterial compliance will be assessed using pulse wave velocity, as the primary outcome measure. Further outcome measures include cutaneous laser Doppler flowmetry as a measure of endothelial function, transthoracic echocardiography and exercise tolerance measures. Biomarkers include NT-proBNP, high-sensitivity troponin T, as well as serum galectin-3 as a marker of fibrosis. ETHICS AND DISSEMINATION The study was approved by the regional research ethics committee (REC), West Midland and Black Country 17/WM/0039, UK, and permission to conduct the study in the hospital was also obtained from the RDI, UHCW NHS Trust. The results will be published in peer-reviewed journals and presented in local, national and international medical society meetings. TRIAL REGISTRATION NUMBER NCT03186833.
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Affiliation(s)
- Danish Ali
- Department of Academic Cardiology, University Hospitals Coventry & Warwickshire NHS trust, Coventry, UK
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Nualla Callan
- Department of Academic Cardiology, University Hospitals Coventry & Warwickshire NHS trust, Coventry, UK
| | - Stuart Ennis
- Department of Cardiac Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Cardiff Centre for Exercise & Health, Cardiff Metropolitan University, Cardiff, UK
| | - Richard Powell
- Department of Cardiac Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Scott McGuire
- Department of Cardiac Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Gordon McGregor
- Department of Cardiac Rehabilitation, Centre for Exercise & Health, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Martin O Weickert
- University of Warwick, Warwick Medical School, Coventry, UK
- Department of Endocrinology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
- Dept of Health & Life Sciences, Coventry University, Coventry, UK
| | - Michelle A Miller
- Division of Translational and Systems Medicine, University of Warwick, Warwick Medical School, Coventry, UK
| | - Francesco P Cappuccio
- Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, UK
| | - Prithwish Banerjee
- University of Warwick, Warwick Medical School, Coventry, UK
- Dept of Health & Life Sciences, Coventry University, Coventry, UK
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Pierce J, Hiebert JB, Mahoney D, Shen Q, Peltzer J, Rahman F, Johnson S, Pierce JT. Development of a point-of-contact technique to measure adenosine triphosphate: A quality improvement study. Ann Med Surg (Lond) 2019; 41:29-32. [PMID: 31011421 PMCID: PMC6462498 DOI: 10.1016/j.amsu.2019.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/31/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose Patients with heart failure with preserved ejection fraction (HFpEF) experience fatigue due to impaired myocardial bioenergetics. Cardiomyocyte function depends on the delivery of adenosine triphosphate (ATP), yet there is no convenient bedside method to measure ATP. The purpose of this study was to develop a point-of-contact measurement of ATP that can be used in a clinical setting. Methods In a laboratory setting, digital finger punctures were conducted using 5 μl and 10 μl of capillary blood placed into various amounts of water (H2O). After mixing the solution for 10 s, a Hygiena AquaSnapTM Free ATP probe was placed into the solution for 10 s for the detection of ATP. The probe was then placed into the Hygiena luminometer for 15 s, and a value in relative light units (RLU) was obtained. Results Test samples using 10 μl of blood diluted from 50 to 500 mls of H2O produced ATP readings of 10,000-7569 RLUs. Using 5 μl of blood in 375–900 ml of H2O decreased the ATP values to 6459-4189 RLUs. Dilutional volume sparing experiments were conducted with ATP standards to determine the concentration of ATP per RLUs. Conclusion Patients with HFpEF have increased metabolic demand and impaired myocardial bioenergetics. Thus, identifying a method to measure ATP that is quick and accurate is imperative to accurately assess cellular energy production in this population. Point-of-contact measures, such as ATP, are needed for precision-guided treatment. Data from this study provides the first step toward developing evidence for health policies related to managing fatigue. Adenosine triphosphate (ATP) is required for almost all cells to produce energy. A point-of-contact instrument is needed in the clinical setting to measure ATP. To assess the symptom of fatigue, a measure of ATP is preferred. Using blood from a finger stick, an ATP measurement can be obtained in 2 min.
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Affiliation(s)
- Janet Pierce
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - John B Hiebert
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Diane Mahoney
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Qiuhua Shen
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Jill Peltzer
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Faith Rahman
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Samantha Johnson
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - John T Pierce
- University of Kansas Medical Center, School of Nursing, Mail Stop 4043, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
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