The Baby Hearts Study - a case-control methodology with data linkage to evaluate risk and protective factors for congenital heart disease

Introduction

The Baby Hearts study aimed to investigate risk and protective factors for congenital heart disease (CHD), and to investigate the health behaviours of a representative sample of pregnant women in Northern Ireland.

Objectives

We describe and evaluate the population-based case-control design enhanced with data linkage to administrative health data.

Methods

Cases (mothers of babies with CHD, n=286) were recruited following diagnosis prenatally or postnatally. Controls (mothers of babies without CHD, n=966) were recruited at 18-22 weeks gestation, from all women attending each maternity unit during a designated month. Hybrid data collection methods were used, including a self-administered iPad/postal questionnaire, and linkage to maternity and prescription records.

Results

Refusal rates were low (8%). iPad questionnaire completion at clinic or home visit had high acceptability whereas postal questionnaires were poorly returned leading to a further 9-10% loss of eligible cases/controls. In total, 61% of eligible cases and 68% of eligible controls were recruited, closely representative of the Northern Ireland population, with no evidence of selection bias. Of those recruited, 97% gave consent for linkage to medical records. Thirty-three percent of women had an unplanned pregnancy and 76% suspected they were pregnant by 5 weeks gestation, with no significant differences between cases and controls. There was considerable discordance between self-report, maternity and prescription records regarding medications obtained/taken in the first trimester, but no evidence of differences between cases and controls that would indicate substantial recall bias. Although there was high concordance between self-report and maternity records regarding folic acid supplementation, cases had significantly lower concordance than controls.

Conclusions

Our results suggest hybrid data collection approaches are a useful way forward for aetiological studies to reduce responder burden and address and estimate recall bias, and that the Baby Hearts study protocol is suitable for replication in other populations, modified to the local context.

Supporting families of critically ill children at home using videoconferencing

Home videoconferencing links for families of children recently discharged with complex congenital heart disease may be useful in monitoring potentially unstable patients. A randomized controlled trial was carried out comparing home videoconferencing with telephone contact. Patients were randomized to an interventional videoconferencing group (n= 14), or to one of two control groups: the first (n = 9) received the same ad hoc telephone support that was available to all patients; the second group (n = 1 3) received regular telephone calls with the same protocol as those in the videoconferencing group. The results from the trial are still being analysed. Our experience with commercial cable modem transmission quickly showed that this is an unsuitable modality. Preliminary results with ISDN videoconferencing are encouraging. Initial results and feedback from families strongly suggest that videoconferencing provides significant benefits over telephone follow-up.

Prevalence factors associated with equine herpesvirus type 1 infection in equids with upper respiratory tract infection and/or acute onset of neurological signs from 2008 to 2014

The objective of the present case-control study was to determine prevalence factors associated with the detection of equine herpesvirus type 1 (EHV-1) by quantitative PCR (qPCR) in horses presented to veterinarians with clinical signs related to an upper respiratory tract infection and/or acute onset of neurological disease from March 2008 to December 2014. Nasal secretions and whole blood from 4228 equids with acute onset of fever, respiratory signs and/or neurological deficits were tested by qPCR for EHV-1. Categorical analyses were performed to determine the association between observations and EHV-1. A total of 117/4228 (2.7 per cent) equids tested qPCR-positive for EHV-1, with most of the isolates belonging to the non-neuropathogenic genotype (N752). EHV-1 PCR-positive equids were over-represented in racing horses. Depression, anorexia, nasal discharge and coughing were significantly less frequently reported in the EHV-1 qPCR-positive equids compared with the EHV-1 qPCR-negative cases. Neurological deficits were more frequently reported in the EHV-1 qPCR-positive cases. This study provides contemporary information on the frequency of EHV-1 detection by qPCR in blood and nasal secretions from horses with fever, respiratory signs and neurological deficits.

Posterior hip dislocation and ipsilateral isolated femoral neck fracture: A novel fixation method

It is accepted that a traumatic hip dislocation is a surgical emergency, this holds for the uncommon dislocation of the hip with femoral neck fracture however the surgical dilemma involves head salvage or replacement.

This case report describes the method and technique for stabilisation of the rare and challenging isolated posterior hip dislocation with an ipsilateral femoral neck fracture.

A 38-year-old gentleman was involved in a high-speed road traffic collision sustaining a posterior dislocation with ipsilateral femoral neck fracture. This was managed emergently with open reduction and osteosynthesis. The technique was by the modified placement of three cannulated screws through a posterior approach. The use of antegrade guide wires allowed accurate placement in a triangular configuration and temporary fixation to facilitate hip reduction prior to retrograde insertion of three 6.5mm cannulated screws.

The patient, although developing radiological avascular necrosis, continues to work and has returned to hobbies at 4.5 years.

Impact of a regional training program in fetal echocardiography for sonographers on the antenatal detection of major congenital heart disease

OBJECTIVES

The aims of this study were to ascertain the effect of a regional training program in fetal echocardiography for obstetric radiographers on the antenatal detection of major congenital heart disease (CHD) and to document short-term outcomes for major CHD.

METHODS

All 87 obstetric radiographers in Northern Ireland were invited to attend 2.5 days of training during a 1-year period. Data were collected before and after the training, over a 5-year study period, to assess the effect of training on the antenatal detection of CHD in the population.

RESULTS

The antenatal detection of major CHD rose significantly, from 28% (72/262) pretraining to 43% (36/84) in the year of training (P = 0.008). Antenatal diagnosis of four-chamber-view defects rose significantly (from 38% to 54%; P = 0.04), as did detection of outflow-tract-view defects (from 8% to 21%; P = 0.05). Twelve per cent (13/108) of cases died spontaneously in utero and 8% (9/108) were terminated. Only 78% (67/86) of live-born cases in which CHD had been diagnosed antenatally survived the neonatal period, compared to 93% (221/238) with a postnatal diagnosis of CHD (P < 0.001).

CONCLUSIONS

Even with a relatively simple training program, significant improvements can be made in the antenatal detection of CHD. With training, obstetric sonographers can successfully assess outflow tracts. Antenatally diagnosed cases have more complex CHD and this probably contributes to poor neonatal survival.

A controlled trial of early interventions to promote maternal adjustment and development in infants born with severe congenital heart disease

Abstract Background Congenital heart disease can have a negative impact on both infant development and maternal adjustment. This study considered the impact of a new programme of early psychosocial interventions on such outcomes, following the birth of a child with severe congenital heart disease. Methods Seventy infants and their mothers were assigned to an intervention or control group based on order of presentation to the unit. Interventions aimed at bolstering mother-infant transactions, through psychoeducation, parent skills training and narrative therapy techniques were implemented. Results Clinically and statistically significant gains were observed at 6-month follow-up on the mental (but not the psychomotor) scale of the Bayleys-II. Positive gains were also manifested on feeding practices, maternal anxiety, worry and appraisal of their situation. Conclusions A programme of generalizable psychosocial interventions is shown to have a positive impact on the infant with severe congenital heart disease and the mother.

Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

Assessing ASDs prior to device closure using 3D echocardiography. Just pretty pictures or a useful clinical tool?

AIMS

To determine the usefulness of three-dimensional transthoracic echocardiography (3D echo) in assessment of secundum atrial septal defects (ASDs) considered for device closure. To compare the findings from 3D echo with those from two-dimensional transoesophageal echocardiography (TOE) regarding dimensions, morphology and suitability for device closure.

METHODS AND RESULTS

Twenty-four patients were enrolled in this prospective, crossover study. Three-dimensional echo and TOE data were collected, analysed and compared, assessing quantitative data including maximum defect diameter, area and circumference. Qualitative morphology such as the presence of fenestrations and the defect margins were noted, and an assessment of the suitability for device closure was made using each modality. Eighteen (75%) of the 3D data sets produced usable data for analysis. In each case the maximum diameter of the defect was larger on 3D echo than on TOE (mean difference = 0.34 cm, P < 0.001). On three occasions suitability for device closure could not be determined using 3D echo. On the other 15 occasions there was agreement between the TOE and 3D echo data.

CONCLUSIONS

Three-dimensional echo provides comparable data with TOE when attempting to predict suitability for device closure without the need for general anaesthetic or sedation. It also provides useful additional dynamic and morphological information.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease

AIMS

To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD).

METHODS

90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning.

RESULTS

Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes.

CONCLUSIONS

The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Sonographic differences in venous return between piggyback versus caval interposition in adult liver transplantations

The piggyback technique (PT) is being used more frequently than caval interposition (CI) in adult orthotopic liver transplants (OLT). It is unclear whether PT alters venous return compared with CI, therefore leading to postoperative complications. The aim of our study was to analyze our experience with PT and CI by comparing ultrasound results of hepatic vein flow on the first postoperative day.

PATIENTS AND METHODS

This retrospective analysis of consecutive OLTs performed between 2002 and 2005 included data from a single blinded radiologist who reviewed all postoperative day 1 ultrasound examinations. The hepatic vein waveforms were scored as all phasic, all flat, or partially phasic/flat.

RESULTS

During the study period, we performed, 465 OLT among which 270 had available ultrasound examinations. The etiologies of liver disease were similar between the PT and CI cohorts, hepatitis C and alcoholic liver disease accounted for more than 60%. Two hundred eight (77%) had undergone PT and 62 (23%) CI. Among the PT, 60% were phasic, 31.1% were partially phasic/flat, and 8% were flat. When a CI was performed, 56.5% were phasic, 35.5% were partially phasic/flat, and 8% were flat.

CONCLUSIONS

There was no significant difference between PT and CI with regard to an effect on hepatic vein waveforms on the first operative day. Therefore, there do not appear to be early hemodynamic benefits of performing CI versus PT anastamoses of OLTs. Further studies may be needed to determine whether long-term sequelae follow the piggyback technique.

Petites bourgeoises and penny capitalists: women in retail in the Lille area during the nineteenth century

With few exceptions, historians have argued that in the nineteenth century women were excluded from most retail activities. In Europe women became increasingly concentrated in small-scale, undercapitalized, and short-lived stores. The “separate sphere” ideology in its different guises underlay this evolution. In North America, on the other hand, women capitalized on this ideology to carve a niche for themselves in trade and retailing. Women were not marginalized or segregated everywhere in Europe, however. In northern France the expansion of retail trade and overall improvements in standards of living provided women, especially married ones, with opportunities they were not reluctant to grasp. Though the activities of married women remained subordinated to the needs of their families, female retailers were neither particularly impoverished nor segregated in sectors deemed appropriate for persons of their sex.

Multiple intrapulmonary arteriovenous fistulas in childhood

Pulmonary arteriovenous fistulas (AVFs) are a rare but recognized cause of cyanosis in childhood. Lesions may be acquired as in hepatopulmonary syndrome or they may be congenital, particularly in association with certain multisystem disorders. Large fistulas are more common than multiple small connections. Two cases. both boys, presenting in the first decade of life are described. "Bubble" echocardiography was the most telling investigation and strongly suggested the presence of AVFs in both cases. Each patient then underwent cardiac catheterization, which demonstrated normal pulmonary artery pressure and diffuse pulmonary telangiectasis. Both patients were treated effectively with nifedipine and continue with this mode of therapy.

Social constructs of curricular change

The adoption of problem-based approaches to teaching and learning in dental and medical education requires educators to consider a significantly different role and responsibilities as teacher from what they have experienced previously. This qualitative study explored how some educators experienced and interpreted changes in the newly merged dental and medical curriculum at the University of British Columbia. Our findings present how educators explained and dealt with change. In-depth interviews provided considerable insight into factors influencing the resistance or acceptance to change. The educators' beliefs about teaching and learning and their understanding of the development and implementation process of change mediated these factors. Findings from this study should help administrators, faculty developers, and educators themselves to understand better how curricular change is experienced and to plan effective and appropriate faculty development.

Gastro-intestinal complications following neonatal cardiac catheterisation

BACKGROUND

Infants with congenital cyanotic heart disease are at increased risk of developing necrotising enterocolitis (NEC). We examined a cohort of infants with congenital cyanotic heart disease in order to assess the role of cardiac catheterisation in the pathogenesis of NEC.

METHODS

Sixty-five infants with congenital cyanotic heart disease were assessed in a retrospective study. The incidence of gastrointestinal complications was compared between infants who required cardiac catheterisation and those who did not.

RESULTS

There were 38 infants who required cardiac catheterisation and 27 who did not. Both groups were similar for known risk factors for NEC. Eleven of the catheterised infants developed bloody stools versus 4 of the non-catheterised infants (OR 2.34; 95% CI 0.65-8.36). Five of the catheterised infants developed classical NEC versus none of the non-catheterised infants (OR 4.24; 95% CI 0.47-38.5). Four of the five infants who developed NEC did so during re-introduction of feeds following cardiac catheterisation.

CONCLUSION

Infants with congenital cyanotic heart disease appear to be at a greater risk of gastrointestinal complications including necrotising enterocolitis in the days following cardiac catheterisation. We suggest a more cautious approach to feeding is required during this period.

A cost-effectiveness and cost-utility analysis of radiosurgery vs. resection for single-brain metastases

PURPOSE

The median survival of well-selected patients with single-brain metastases treated with whole-brain irradiation and resection or radiosurgery is comparable, although a randomized trial of these two modalities has not been performed. In this era of cost containment, it is imperative that health-care professionals make fiscally prudent decisions. The present environment necessitates a critical appraisal of apparently equi-efficacious therapeutic modalities, and it is within this context that we present a comparison of the actual costs of resection and radiosurgery for brain metastases.

METHODS AND MATERIALS

Survival and quality of life outcome data for radiation alone or with surgery were obtained from two randomized trials, and radiosurgical results were obtained from a multiinstitutional analysis that specifically evaluated patients meeting surgical criteria. Only linear accelerator radiosurgery data were considered. Cost analysis was performed from a societal view point, and the following parameters were evaluated: actual cost, cost ratios, cost effectiveness, incremental cost effectiveness, cost utility, incremental cost utility, and national cost burden. The computerized billing records for all patients undergoing resection or radiosurgery for single-brain metastases from January 1989 to July 1994 were reviewed. A total of 46 resections and 135 radiosurgery procedures were performed. During the same time period, 454 patients underwent whole-brain radiation alone. An analysis of the entire bill was performed for each procedure, and each itemized cost was assigned a proportionate figure. The relative cost ratios of resection and radiosurgery were compared using the Wilcoxon rank sum test. Cost effectiveness of each modality, defined as the cost per year of median survival, was evaluated. Incremental cost effectiveness, defined as the additional cost per year of incremental gain in median survival, compared to the next least expensive modality, was also determined. To calculate the societal or national impact of these practices, the proportion of patients potentially eligible for aggressive management was estimated and the financial impact was determined using various utilization ratios for radiosurgery and surgery.

RESULTS

Both resection and radiosurgery yielded superior survival and functional independence, compared to whole brain radiotherapy alone, with minor differences in outcome between the two modalities; resection resulted in a 1.8-fold increase in cost, compared to radiosurgery. The latter modality yielded superior cost outcomes on all measures, even when a sensitivity analysis of up to 50% was performed. A reversal estimate indicated that in order for surgery to yield equal cost effectiveness, its cost would have to decrease by 48% or median survival would have to improve by 108%. The average cost per week of survival was $310 for radiotherapy, $524 for resection plus radiation, and $270 for radiosurgery plus radiation.

CONCLUSIONS

For selected patients, aggressive strategies such as resection or radiosurgery are warranted, as they result in improved median survival and functional independence. Radiosurgery appears to be the more cost-effective procedure.

Evaluation of a national health promotion program in South Australia

This paper reports the findings of the evaluation of the South Australian component of the National Better Health Program. The evaluation used analysis of focus-group interviews and key documents to assess the value of the state program. The evaluation demonstrated that for a relatively small investment ($2.4 million was allocated to the project over four years, representing only 0.5 per cent of the annual budget for teaching hospitals in South Australia), much can be achieved by harnessing the energy of local communities. The evaluation concluded that more attention should be directed to structural change, with an emphasis on collaboration across sectors, and community participation. Some key issues for the planning and implementation of health promotion were highlighted: the challenge of marrying local initiatives based on community development with national health promotion objectives; the importance of dedicated and assured funding; the need for increased training and support for health promotion workers; and the importance of continuing a focus on equity in the implementation of health promotion. The paper concludes by questioning the value of the current Australian goals, targets and strategies for health, given the findings from this evaluation.

Understanding the determinants of preventive oral health behaviours

Achieving oral health for the client is the goal of dental hygiene practice. The two major threats to oral health, dental caries and periodontal disease, can almost always be controlled if clients adopt appropriate oral health behaviours. A review of the literature indicates that many factors determine whether or not a client will adopt appropriate oral health behaviours. These factors include demographics, socialization, emotional status, perceptions and dental beliefs. Determining a client's attitudes towards oral health requires the active participation of both the client and the dental hygienist. Interview techniques borrowed from participatory and ethnographic research can be used during the assessment phase of the dental hygiene process to allow the dental hygienist to systematically explore the factors that may affect the practice of preventive oral health behaviours. Data gathered during this phase can then be used in the planning phase of the dental hygiene process to develop a strategy which is specifically designed to meet the assessed needs of the individual client.

Acute dissection of the right ventricular outflow tract after balloon dilatation in a patient with previously corrected tetralogy of Fallot

Percutaneous balloon dilatation has been used successfully to dilate various stenoses occurring after repair of congenital heart disease. Acute dissection of a stenotic right ventricular outflow tract occurred after attempted balloon dilatation in a patient with previously corrected tetralogy of Fallot.

St. Jude Medical prosthesis in children

From December 1980 through April 1992, 20 children 2 to 18 years of age underwent valve replacement with the St. Jude Medical prosthesis. Nine children underwent aortic valve replacement, eight underwent mitral valve replacement, and the three children with corrected transposition underwent left-sided tricuspid valve replacement. Of the 20 patients, 17 underwent 23 previous procedures. All but five patients received adequate adult-sized prostheses. There was one hospital death (5%). All hospital survivors received maintenance doses of sodium warfarin. Follow-up was 100% complete with a total of 106 patient-years. There were no late deaths and no thromboembolic or anticoagulant-related bleeding. None of the patients had prosthetic valve endocarditis or a periprosthetic leak. Reoperation was not required in any patient. The great majority of the children (16 of 19) were in New York Heart Association functional class I, two were in class II, and one with complex congenital heart disease was in class III at the time this article was written. This study illustrates the excellent results of cardiac valve replacement with the St. Jude Medical prosthesis in children and confirms the safety of sodium warfarin in this age group.

A SNOMED analysis of three years' accessioned cases (40,124) of a surgical pathology department: implications for pathology-based demographic studies

Pathology departments devote considerable energy toward indexing diagnoses. To date, there have been no detailed tabulations of the results of these efforts. We have thoroughly analyzed three years' surgical pathology reports (40,124) generated for 29,127 different patients from the University of Florida at Gainesville between Jan 1, 1990, and December 31, 1992. 64,921 SNOMED code entries (averaging 1.6 codes per specimen and 1.4 specimens per patient) were accounted for by 1,998 distinct SNOMED morphologies. A mere 21 entities accounted for 50% of the morphology code occurrences. 265 entities accounted for 90% of the morphology code occurrences, indicating that the diagnostic efforts of pathology departments are contained within a small fraction of the many thousands of morphologic entities available in the SNOMED nomenclature. One of the key problems in using SNOMED data collected from surgical pathology reports is the redundancy of lesions reported for single patients (i.e., a patient's disease may be coded on more than one specimen from the patient, leading to false conclusions regarding the incidence of disease in the population). In this study, redundant SNOMED data was removed by eliminating repeat morphology/topography pairs whenever they occur for a single patient. SNOMED data can be stratified on the basis of age and sex (data fields included on every surgical pathology report). This analysis represents the first published analysis of SNOMED data from a large pathology service, and demonstrates how SNOMED data can be compiled in a form that preserves patient privacy.

Kawasaki disease--the Northern Ireland experience

In the period 1985-1991 inclusive, forty five cases of Kawasaki Disease were identified in Northern Ireland. The number of cases increased each year until 1988 when the incidence was 19 per million population under 16 years, the highest reported for any region in the United Kingdom (data from British Paediatric Surveillance Unit). A high incidence of cardiac involvement was found, with 18(40%) having proximal coronary artery dilatation or aneurysm. and 8(17.7%) with pericardial effusion detected by 2D Echocardiography during or shortly after the acute illness. One year after disease onset, persistent coronary artery changes were detectable by 2D Echocardiography in 53% of those initially affected. There have been no deaths and no patient has so far developed myocardial infarction. One patient has required coronary artery bypass grafting. A protocol for the acute management and long term follow-up of Kawasaki Disease is suggested.

Irresectable hepatoma treated by intrahepatic iodized oil doxorubicin hydrochloride: initial results

In this study we describe the investigation and treatment of 14 patients with primary hepatocellular carcinoma. Patients were treated with intra-arterial infusion of iodized oil and doxorubicin hydrochloride. Five of these patients were alive after 1 year. Twelve patients showed a fall in alpha-fetoprotein, and in seven of these patients, the fall in alpha-fetoprotein was greater than 50%.

Traumatic mitral valve rupture in a child

The case of a 6-year-old boy who ruptured his mitral valve after blunt chest trauma and who subsequently had successful mitral valve replacement with a size 25 St. Judge Medical prosthesis is reported. The diagnosis, investigation, and treatment of traumatic valvar rupture are discussed.

Ventricular tachycardia associated with Coxsackie B4 virus infection

We describe a case of ventricular tachycardia in association with acute Coxsackie B4 virus infection occurring in an otherwise normal infant. The dysrhythmia responded to flecainide acetate.

Comparison of steady-state blood levels of two carbamazepine formulations

The steady-state plasma level produced by brand-name carbamazepine (CBZ) (Tegretol, Ciba-Geigy) was compared with a generic formulation (Parke-Davis) in 10 subjects with partial epilepsy in a randomized, double-blind, cross-over clinical trial. In addition, seizure frequency and clinical and laboratory signs of toxicity were evaluated. Our results failed to show any difference in CBZ blood levels, seizure frequency, or clinical or laboratory signs of toxicity in patients receiving either the brand-name or generic formulation.

Adrenocorticotropic hormone, glucose and displacement activities in pigeons

The possibility that displacement activities might be consequences of stress-induced humoral responses was investigated. Adrenocorticotropic hormone and glucose were injected into the brain ventricles of unrestrained domestic pigeons. ACTH leads to an increased frequency of yawning and headshaking and glucose to a decrease in arousal. It is concluded that these behavioural responses correspond partly with the displacement activities shown by birds. The role of the cerebrospinal fluid as a mediator of behaviourally active substances is discussed.