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Kieu V, Sumski C, Cohen S, Reinhardt E, Axelrod DM, Handler SS. The Use of Virtual Reality Learning on Transition Education in Adolescents with Congenital Heart Disease. Pediatr Cardiol 2023; 44:1856-1860. [PMID: 37676275 DOI: 10.1007/s00246-023-03292-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Abstract
Improvement in congenital heart disease (CHD) outcomes has created a growing population of adolescents and young adults with unique health needs that require thoughtful transition planning and eventual transfer of care to an adult provider. Often, poor health literacy and limited resources can lead to interrupted care, which places them at risk for adverse health-related consequences. In 2019, the Wisconsin Adult Congenital Heart Disease transition program partnered with Stanford Virtual Heart (SVH), a virtual reality (VR) platform, to allow young adult patients to learn about their CHD in a clinic-based setting. We completed a single-center pilot study to evaluate these patients' experience and perceptions to using VR during their transition education. At an initial transition visit, we used an immediate post-VR experience survey, scored using Likert scales of 1-5 (1 = strongly disagree, 5 = strongly agree). Twenty-two patients (13 males) between the ages of 16 and 19 participated. Lesions included pulmonary stenosis, Tetralogy of Fallot, atrial and ventricular septal defect, coarctation, aortic stenosis, hypoplastic left heart syndrome, and patent ductus arteriosus. Likert averages were 4.7 for finding VR helped with understanding their heart lesion, 4.6 for finding VR helped with understanding their heart surgery, 4.7 for enjoying the VR heart simulation, and 4.6 for finding that it was a good use of time. This study demonstrates that adolescents enjoyed using SVH and found it helpful. Clinical implementation shows promise as a plausible adjunct tool for transition education.
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Affiliation(s)
- Victor Kieu
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, 8915 W. Connell Ct, Milwaukee, WI, 53226, USA.
- Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA.
- Division of Pediatric Cardiology, Department of Pediatrics, Nemours Children's Health, Wilmington, Delaware, USA.
| | - Christopher Sumski
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, 8915 W. Connell Ct, Milwaukee, WI, 53226, USA
- Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
| | - Scott Cohen
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, 8915 W. Connell Ct, Milwaukee, WI, 53226, USA
- Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of Adult Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Emily Reinhardt
- Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Stephanie S Handler
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, 8915 W. Connell Ct, Milwaukee, WI, 53226, USA
- Herma Heart Institute at Children's Wisconsin, Milwaukee, WI, USA
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Motonaga KS, Sacks L, Olson I, Balasubramanian S, Chen S, Peng L, Feinstein JA, Silverman NH, Hanley FL, Axelrod DM, Krawczeski CD, Arunamata A, Kwiatkowski DM, Ceresnak SR. The development and efficacy of a paediatric cardiology fellowship online preparatory course. Cardiol Young 2023; 33:1975-1980. [PMID: 36440543 DOI: 10.1017/s1047951122003626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The transition from residency to paediatric cardiology fellowship is challenging due to the new knowledge and technical skills required. Online learning can be an effective didactic modality that can be widely accessed by trainees. We sought to evaluate the effectiveness of a paediatric cardiology Fellowship Online Preparatory Course prior to the start of fellowship. METHODS The Online Preparatory Course contained 18 online learning modules covering basic concepts in anatomy, auscultation, echocardiography, catheterisation, cardiovascular intensive care, electrophysiology, pulmonary hypertension, heart failure, and cardiac surgery. Each online learning module included an instructional video with pre-and post-video tests. Participants completed pre- and post-Online Preparatory Course knowledge-based exams and surveys. Pre- and post-Online Preparatory Course survey and knowledge-based examination results were compared via Wilcoxon sign and paired t-tests. RESULTS 151 incoming paediatric cardiology fellows from programmes across the USA participated in the 3 months prior to starting fellowship training between 2017 and 2019. There was significant improvement between pre- and post-video test scores for all 18 online learning modules. There was also significant improvement between pre- and post-Online Preparatory Course exam scores (PRE 43.6 ± 11% versus POST 60.3 ± 10%, p < 0.001). Comparing pre- and post-Online Preparatory Course surveys, there was a statistically significant improvement in the participants' comfort level in 35 of 36 (97%) assessment areas. Nearly all participants (98%) agreed or strongly agreed that the Online Preparatory Course was a valuable learning experience and helped alleviate some anxieties (77% agreed or strongly agreed) related to starting fellowship. CONCLUSION An Online Preparatory Course prior to starting fellowship can provide a foundation of knowledge, decrease anxiety, and serve as an effective educational springboard for paediatric cardiology fellows.
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Affiliation(s)
- Kara S Motonaga
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Loren Sacks
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Inger Olson
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Sowmya Balasubramanian
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Sharon Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Lynn Peng
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Norman H Silverman
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University, Palo Alto, CA, USA
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Scott R Ceresnak
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
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Abstract
This cross-sectional study assesses changes in views of medical scientific articles published in 3 leading medical journals since the start of the COVID-19 pandemic.
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Affiliation(s)
- Andrew J. Giustini
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David M. Axelrod
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Salavitabar A, Figueroa CA, Lu JC, Owens ST, Axelrod DM, Zampi JD. Emerging 3D technologies and applications within congenital heart disease: teach, predict, plan and guide. Future Cardiol 2020; 16:695-709. [PMID: 32628520 DOI: 10.2217/fca-2020-0004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
3D visualization technologies have evolved to become a mainstay in the management of congenital heart disease (CHD) with a growing presence within multiple facets. Printed and virtual 3D models allow for a more comprehensive approach to educating trainees and care team members. Computational fluid dynamics can take 3D modeling to the next level, by predicting post-procedural outcomes and helping to determine surgical approach. 3D printing and extended reality are developing resources for pre-procedural planning and intra-procedural guidance with the potential to revolutionize decision-making and procedural success. Challenges still remain within existing technologies and their applications to the CHD field. Addressing these gaps, both by those within and outside of CHD, will transform education and patient care within our field.
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Affiliation(s)
- Arash Salavitabar
- C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI 48109, USA
| | - C Alberto Figueroa
- Departments of Biomedical Engineering & Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jimmy C Lu
- C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI 48109, USA
| | - Sonal T Owens
- C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI 48109, USA
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Jeffrey D Zampi
- C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI 48109, USA
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Abstract
This cross-sectional study examines the association between article citations, Altmetric attention scores, and cumulative page views of pediatric research articles from 4 high-impact medical journals.
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Affiliation(s)
- Andrew J. Giustini
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - David M. Axelrod
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Brian P. Lucas
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- White River Junction Veterans Affairs Hospital, White River Junction, Virginia
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Cox K, Arunamata A, Krawczeski CD, Reddy C, Kipps AK, Long J, Roth SJ, Axelrod DM, Hanley F, Shin A, Selamet Tierney ES. "Echo pause" for postoperative transthoracic echocardiographic surveillance. Echocardiography 2019; 36:2078-2085. [PMID: 31628768 DOI: 10.1111/echo.14505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/17/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND No guidelines exist for inpatient postoperative transthoracic echocardiographic (TTE) surveillance in congenital heart disease. We prospectively evaluated indications for postoperative TTEs in patients with congenital heart disease to identify areas to improve upon (Phase 1) and then assessed the impact of a simple pilot intervention (Phase 2). METHODS We included patients with RACHS-1 (Risk Adjustment for Congenital Heart Surgery) scores of 2 and 3 to keep the cohort homogenous. During Phase 1, we collected data prospectively to identify postoperative TTEs for which there were no new findings and no associated clinical management decisions ("potentially redundant" TTEs). During Phase 2, prior to placement of a TTE order, an "Echo Pause" was performed during rounds to prompt review of prior TTE results and indication for the current order. The number of "potentially redundant" TTEs during Phase 1 vs. Phase 2 was compared. RESULTS During Phase 1, 98 postoperative TTEs were performed on 51 patients. Potentially "redundant" TTEs were identified in two main areas: (a) TTEs ordered to evaluate pericardial effusion and (b) TTEs ordered with the indication of "postoperative," "follow-up," or "discharge" in the setting of a prior complete postoperative TTE and no apparent change in clinical status. During Phase 2, 101 TTEs were performed on 63 patients. The number of "potentially redundant" TTEs decreased from 14/98 (14%) to 5/101 (5%) (P = .026). CONCLUSION Our results suggest that the number of "potentially redundant" TTEs during inpatient postoperative surveillance of patients with congenital heart disease can be decreased by a simple intervention during rounds such as an "Echo Pause."
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Affiliation(s)
- Kelly Cox
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Charitha Reddy
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Alaina K Kipps
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Jin Long
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Stephen J Roth
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Frank Hanley
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Palo Alto, California
| | - Andrew Shin
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Elif Seda Selamet Tierney
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
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Ceresnak SR, Axelrod DM, Sacks LD, Motonaga KS, Johnson ER, Krawczeski CD. Advances in Pediatric Cardiology Boot Camp: Boot Camp Training Promotes Fellowship Readiness and Enables Retention of Knowledge. Pediatr Cardiol 2017; 38:631-640. [PMID: 28161811 DOI: 10.1007/s00246-016-1560-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/29/2016] [Indexed: 11/28/2022]
Abstract
We previously demonstrated that a pediatric cardiology boot camp can improve knowledge acquisition and decrease anxiety for trainees. We sought to determine if boot camp participants entered fellowship with a knowledge advantage over fellows who did not attend and if there was moderate-term retention of that knowledge. A 2-day training program was provided for incoming pediatric cardiology fellows from eight fellowship programs in April 2016. Hands-on, immersive experiences and simulations were provided in all major areas of pediatric cardiology. Knowledge-based examinations were completed by each participant prior to boot camp (PRE), immediately post-training (POST), and prior to the start of fellowship in June 2016 (F/U). A control group of fellows who did not attend boot camp also completed an examination prior to fellowship (CTRL). Comparisons of scores were made for individual participants and between participants and controls. A total of 16 participants and 16 control subjects were included. Baseline exam scores were similar between participants and controls (PRE 47 ± 11% vs. CTRL 52 ± 10%; p = 0.22). Participants' knowledge improved with boot camp training (PRE 47 ± 11% vs. POST 70 ± 8%; p < 0.001) and there was excellent moderate-term retention of the information taught at boot camp (PRE 47 ± 11% vs. F/U 71 ± 8%; p < 0.001). Testing done at the beginning of fellowship demonstrated significantly better scores in participants versus controls (F/U 71 ± 8% vs. CTRL 52 ± 10%; p < 0.001). Boot camp participants demonstrated a significant improvement in basic cardiology knowledge after the training program and had excellent moderate-term retention of that knowledge. Participants began fellowship with a larger fund of knowledge than those fellows who did not attend.
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Affiliation(s)
- Scott R Ceresnak
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA.
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Loren D Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Kara S Motonaga
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Emily R Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
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Koth AM, Axelrod DM, Reddy S, Roth SJ, Tacy TA, Punn R. Institution of Veno-arterial Extracorporeal Membrane Oxygenation Does Not Lead to Increased Wall Stress in Patients with Impaired Myocardial Function. Pediatr Cardiol 2017; 38:539-546. [PMID: 28005156 DOI: 10.1007/s00246-016-1546-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 12/01/2016] [Indexed: 11/24/2022]
Abstract
The effect of veno-arterial extracorporeal membrane oxygenation (VA ECMO) on wall stress in patients with cardiomyopathy, myocarditis, or other cardiac conditions is unknown. We set out to determine the circumferential and meridional wall stress (WS) in patients with systemic left ventricles before and during VA ECMO. We established a cohort of patients with impaired myocardial function who underwent VA ECMO therapy from January 2000 to November 2013. Demographic and clinical data were collected and inotropic score calculated. Measurements were taken on echocardiograms prior to the initiation of VA ECMO and while on full-flow VA ECMO, in order to derive wall stress (circumferential and meridional), VCFc, ejection fraction, and fractional shortening. A post hoc sub-analysis was conducted, separating those with pulmonary hypertension (PH) and those with impaired systemic output. Thirty-three patients met inclusion criteria. The patients' median age was 0.06 years (range 0-18.7). Eleven (33%) patients constituted the organ failure group (Gr2), while the remaining 22 (66%) patients survived to discharge (Gr1). WS and all other echocardiographic measures were not different when comparing patients before and during VA ECMO. Ejection and shortening fraction, WS, and VCFc were not statistically different comparing the survival and organ failure groups. The patients' position on the VCFc-WS curve did not change after the initiation of VA ECMO. Those with PH had decreased WS as well as increased EF after ECMO initiation, while those with impaired systemic output showed no difference in those parameters with initiation of ECMO. The external workload on the myocardium as indicated by WS is unchanged by the institution of VA ECMO support. Furthermore, echocardiographic measures of cardiac function do not reflect the changes in ventricular performance inherent to VA ECMO support. These findings are informative for the interpretation of echocardiograms in the setting of VA ECMO. ECMO may improve ventricular mechanics in those with PH as the primary diagnosis.
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Affiliation(s)
- Andrew M Koth
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA.
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Sushma Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Stephen J Roth
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Theresa A Tacy
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
| | - Rajesh Punn
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, 750 Welch Road, Suite # 325, Palo Alto, CA, 94304, USA
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Arunamata A, Axelrod DM, Kipps AK, McElhinney DB, Shin AY, Hanley FL, Olson IL, Roth SJ, Selamet Tierney ES. Practice Patterns in Postoperative Echocardiographic Surveillance after Congenital Heart Surgery in Children: A Single Center Experience. J Pediatr 2017; 180:87-91.e1. [PMID: 28029346 DOI: 10.1016/j.jpeds.2016.09.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/18/2016] [Accepted: 09/28/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To review current institutional practice and describe factors contributing to variation in inpatient postoperative imaging surveillance after congenital heart surgery. STUDY DESIGN We reviewed records of all children who underwent congenital heart surgery from June to December 2014. Number and primary indications for postoperative transthoracic echocardiograms (TTEs), providers involved, cardiovascular intensive care unit (CVICU) and total hospital length of stay, and Risk-Adjustment for Congenital Heart Surgery-1 scores were recorded. RESULTS A total of 253 children (age at surgery: 8 months [2 days-19 years]) received 556 postoperative TTEs (median 1 TTE/patient [1-14]), and 23% had ≥3 TTEs. Fifteen of 556 TTEs (2.7%) revealed a new abnormal finding. The majority of TTEs (59%) were performed in the CVICU (1.5 ± 1.1 TTEs/week/patient), with evaluation of function as the most common indication (44%). Attending physician practice >10 years was not associated with fewer TTEs (P = .12). Patients with ≥3 TTEs had higher Risk-Adjustment for Congenital Heart Surgery-1 scores (P = .001), longer CVICU lengths of stay (22 vs 3 days; P < .0001), longer overall hospitalizations (28 vs 7 days; P < .0001), and a higher incidence of mechanical circulatory support (10% vs 0%; P < .0001) than those with <3 TTEs. Eight patients with ≥3 TTEs did not survive, compared with 3 with <3 TTEs (P = .0004). CONCLUSIONS There was wide intra-institutional variation in echocardiographic use among similar complexity surgeries. Frequency of postoperative echocardiographic surveillance was associated with degree of surgical complexity and severity of postoperative clinical condition. Few studies revealed new abnormal findings. These results may help establish evidence-based guidelines for inpatient echocardiographic surveillance after congenital heart surgery.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA.
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Alaina K Kipps
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Andrew Y Shin
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Inger L Olson
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Stephen J Roth
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
| | - Elif Seda Selamet Tierney
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA
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Arunamata A, Axelrod DM, Bianco K, Balasubramanian S, Quirin A, Tacy TA. Chronic antepartum maternal hyperoxygenation in a case of severe fetal Ebstein's anomaly with circular shunt physiology. Ann Pediatr Cardiol 2017; 10:284-287. [PMID: 28928616 PMCID: PMC5594941 DOI: 10.4103/apc.apc_20_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Perinatal mortality remains high among fetuses diagnosed with Ebstein's anomaly of the tricuspid valve. The subgroup of patients with pulmonary valve regurgitation is at particularly high risk. In the setting of pulmonary valve regurgitation, early constriction of the ductus arteriosus may be a novel perinatal management strategy to reduce systemic steal resulting from circular shunt physiology. We report the use of chronic antepartum maternal oxygen therapy for constriction of the fetal ductus arteriosus and modulation of fetal pulmonary vascular resistance in a late presentation of Ebstein's anomaly with severe tricuspid valve regurgitation, reversal of flow in the ductus arteriosus, and continuous pulmonary valve regurgitation.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Katherine Bianco
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Sowmya Balasubramanian
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Amy Quirin
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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12
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Anand V, Kwiatkowski DM, Ghanayem NS, Axelrod DM, DiNardo J, Klugman D, Krishnamurthy G, Siehr S, Stromberg D, Yates AR, Roth SJ, Cooper DS. Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World J Pediatr Congenit Heart Surg 2016; 7:81-8. [PMID: 26714998 DOI: 10.1177/2150135115614576] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.
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Affiliation(s)
- Vijay Anand
- Department of Critical Care, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - David M Kwiatkowski
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - David M Axelrod
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - James DiNardo
- Department of Anesthesia, Boston Children's Hospital, Boston, MA, USA
| | - Darren Klugman
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Stephanie Siehr
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Daniel Stromberg
- Department of Pediatrics and Critical Care Medicine, Medical City Children's Hospital, Dallas, TX, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Stephen J Roth
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Hollander SA, Montez-Rath ME, Axelrod DM, Krawczeski CD, May LJ, Maeda K, Rosenthal DN, Sutherland SM. Recovery From Acute Kidney Injury and CKD Following Heart Transplantation in Children, Adolescents, and Young Adults: A Retrospective Cohort Study. Am J Kidney Dis 2016; 68:212-218. [DOI: 10.1053/j.ajkd.2016.01.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/25/2016] [Indexed: 01/11/2023]
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14
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Axelrod DM, Alten JA, Berger JT, Hall MW, Thiagarajan R, Bronicki RA. Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference. World J Pediatr Congenit Heart Surg 2016; 6:575-87. [PMID: 26467872 DOI: 10.1177/2150135115598211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.
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Affiliation(s)
- David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey A Alten
- Section of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - John T Berger
- Division of Critical Care Medicine, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA Division of Cardiology, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA
| | - Mark W Hall
- The Ohio State University College of Medicine, Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi Thiagarajan
- Intensive Care Unit, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Ronald A Bronicki
- Section of Critical Care Medicine and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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15
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Hollander SA, Axelrod DM, Bernstein D, Cohen HJ, Sourkes B, Reddy S, Magnus D, Rosenthal DN, Kaufman BD. Compassionate deactivation of ventricular assist devices in pediatric patients. J Heart Lung Transplant 2016; 35:564-7. [PMID: 27197773 DOI: 10.1016/j.healun.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/14/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022] Open
Abstract
Despite greatly improved survival in pediatric patients with end-stage heart failure through the use of ventricular assist devices (VADs), heart failure ultimately remains a life-threatening disease with a significant symptom burden. With increased demand for donor organs, liberalizing the boundaries of case complexity, and the introduction of destination therapy in children, more children can be expected to die while on mechanical support. Despite this trend, guidelines on the ethical and pragmatic issues of compassionate deactivation of VAD support in children are strikingly absent. As VAD support for pediatric patients increases in frequency, the pediatric heart failure and palliative care communities must work toward establishing guidelines to clarify the complex issues surrounding compassionate deactivation. Patient, family and clinician attitudes must be ascertained and education regarding the psychological, legal and ethical issues should be provided. Furthermore, pediatric-specific planning documents for use before VAD implantation as well as deactivation checklists should be developed to assist with decision-making at critical points during the illness trajectory. Herein we review the relevant literature regarding compassionate deactivation with a specific focus on issues related to children.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA.
| | - David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Harvey J Cohen
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Barbara Sourkes
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
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Abstract
The premature neonate with congenital heart disease (CHD) represents a challenging population for clinicians and researchers. The interaction between prematurity and CHD is poorly understood; epidemiologic study suggests that premature newborns are more likely to have CHD and that fetuses with CHD are more likely to be born premature. Understanding the key physiologic features of this special patient population is paramount. Clinicians have debated optimal timing for referral for cardiac surgery, and management in the postoperative period has rapidly advanced. This article summarizes the key concepts and literature in the care of the premature neonate with CHD.
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Affiliation(s)
- David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, 750 Welch Road, Suite 321, Palo Alto, CA 94304, USA.
| | - Valerie Y Chock
- Division of Neonatology, Department of Pediatrics, Stanford University Medical Center, 750 Welch Road, Suite 315, MC 5731, Palo Alto, CA 94304, USA
| | - V Mohan Reddy
- Pediatric Cardiothoracic Surgery, University of California San Francisco Medical Center, 550 16th Street, Floor 5, MH5-745, San Francisco, CA 94143-0117, USA
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17
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Frymoyer A, Su F, Grimm PC, Sutherland SM, Axelrod DM. Theophylline Population Pharmacokinetics and Dosing in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass. J Clin Pharmacol 2016; 56:1084-93. [PMID: 26712558 DOI: 10.1002/jcph.697] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/17/2015] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) frequently develop acute kidney injury due to renal ischemia. Theophylline, which improves renal perfusion via adenosine receptor inhibition, is a potential targeted therapy. However, children undergoing cardiac surgery and CPB commonly have alterations in drug pharmacokinetics. To help understand optimal aminophylline (salt formulation of theophylline) dosing strategies in this population, a population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM) from 71 children (median age 5 months; 90% range 1 week to 10 years) who underwent cardiac surgery requiring CPB and received aminophylline as part of a previous randomized controlled trial. A 1-compartment model with linear elimination adequately described the pharmacokinetics of theophylline. Weight scaled via allometry was a significant predictor of clearance and volume. In addition, allometric scaled clearance increased with age implemented as a power maturation function. Compared to prior reports in noncardiac children, theophylline clearance was markedly reduced across age. In the final population pharmacokinetic model, optimized empiric dosing regimens were developed via Monte Carlo simulations. Doses 50% to 75% lower than those recommended in noncardiac children were needed to achieve target serum concentrations of 5 to 10 mg/L.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Felice Su
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Paul C Grimm
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - David M Axelrod
- Department of Pediatrics, Stanford University, Stanford, CA, USA
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18
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Guth AA, Frey JD, Alperovich M, Kim JC, Axelrod DM, Shapiro RL, Choi M, Karp NS, Schnabel FR. Abstract P2-12-08: Oncologic outcomes after nipple-sparing mastectomy: A single-institution experience. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-12-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Nipple-sparing mastectomy (NSM) is the latest advancement in the treatment of breast cancer. Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0 to 14.3%. We investigated the outcomes of NSM at our institution.
Methods: Patients undergoing NSM at our institution from 2006 to 2014 were identified. Patient demographics, tumor characteristics, and outcomes were collected. Locoregional recurrence was compared to previously published NSM and SSM results compiled from 14 and 11 studies in the literature. Institutional review board approval was obtained prior to the initiation of this study.
Results: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. 149 patients (248 breasts) had long-term follow-up available. Average patient age and BMI were 47.4 and 24.28. Eighty-five percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.41 centimeters with the most common histologic type being invasive ductal carcinoma (66.7%) followed by DCIS (23.8%). Nodal disease was present in 14.8% of patients. Average patient follow-up was 30.72 months. There was one (0.7%) incidence of ipsilateral chest-wall recurrence in a 44 year-old (p<0.0001, compared to aggregate NSM and SSM data). There were 0.36 complications per patient. There were 3 incidences of nipple-areola complex (NAC) necrosis: 2 partial thickness necrosis and 1 full thickness necrosis.
Patient Demographics and Tumor CharacteristicsAge (years)47.7RaceCaucasian: 127 (85.2%) Non-Caucasian: 22 (14.8%)BMI24.28Tobacco History7 (4.7%)Radiation History8 (5.4%)BRCA 1/2 Status10 (6.7%)Family History38 (25.5%)Unilateral vs. Bilateral NSMUnilateral: 76 (51.0%) Bilateral: 73 (49.0%)Indication for MastectomyTherapeutic: 126 (84.6%) Prophylactic: 23 (15.4%)Neoadjuvant Therapy6 (4.0%)Follow-Up (months) (Range)30.72 (57.6-8.28)Tumor Size (cm)1.41Histologic Type (Percent of Therapeutic NSM)IDC: 82 (66.7%) DCIS: 30 (23.8%) ILC: 7 (5.6%) Invasive Other: 6 (4.8%) Mixed Type: 1 (0.8%)Pathologic StageStage 0: 52 (34.9%) Stage I: 54 (36.2%) Stage IIA: 14 (9.4%) Stage IIB: 8 (5.4%) Stage IIIA: 3 (2.0%) Stage IIIC: 1 (0.7%)Receptor StatusER (+): 90 (60.4%) PR (+): 79 (53.0%) Her 2/neu (+): 6 (4.0%) Ki-67 (High): 35 (23.5%)Positive Nodal Status22 (14.8%)
NSM Complications per Patient22 (14.8%)Frozen Section: 6 (7 breasts) (4.0%) Permanent Section: 2 (1.3%)Mastectomy Flap Necrosis12 (8.1%)Nipple-Areola Complex NecrosisPartial-Thickness: 2 (1.3%) Full-Thickness: 1 (0.67%)Nipple-Areola Complex Excision (Patient Preference)1 (0.67%)Implant Extrusion4 (2.7%)CellulitisOral Antibiotics: 12 (8.1%) Intravenous Antibiotics: 2 (1.3%)Hematoma4 (2.7%)Seroma3 (2.0%)Wound Dehiscence1 (0.67%)Capsular Contracture2 (1.3%)Thoracodorsal Nerve Spasm1 (0.67%)Microvascular Free Flap Failure1 (0.67%)
Conclusions: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.7% with no nipple-areolar complex recurrence. This rate is significantly lower than aggregate published rates for both NSM and SSM.
Citation Format: Guth AA, Frey JD, Alperovich M, Kim JC, Axelrod DM, Shapiro RL, Choi M, Karp NS, Schnabel FR. Oncologic outcomes after nipple-sparing mastectomy: A single-institution experience. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-08.
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Affiliation(s)
- AA Guth
- NYU Langone Medical Center, NY, NY
| | - JD Frey
- NYU Langone Medical Center, NY, NY
| | | | - JC Kim
- NYU Langone Medical Center, NY, NY
| | | | | | - M Choi
- NYU Langone Medical Center, NY, NY
| | - NS Karp
- NYU Langone Medical Center, NY, NY
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19
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May LJ, Montez-Rath ME, Yeh J, Axelrod DM, Chen S, Maeda K, Almond CSD, Rosenthal DN, Hollander SA, Sutherland SM. Impact of ventricular assist device placement on longitudinal renal function in children with end-stage heart failure. J Heart Lung Transplant 2015; 35:449-56. [PMID: 26653933 DOI: 10.1016/j.healun.2015.10.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/21/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although ventricular assist devices (VADs) restore hemodynamics in those with heart failure, reversibility of end-organ dysfunction with VAD support is not well characterized. Renal function often improves in adults after VAD placement, but this has not been comprehensively explored in children. METHODS Sixty-three children on VAD support were studied. Acute kidney injury (AKI) was defined by Kidney Disease: Improving Global Outcomes criteria. Estimated glomerular filtration rate (eGFR) was determined by the Schwartz method. Generalized linear mixed-effects models compared the pre-VAD and post-VAD eGFR for the cohort and sub-groups with and without pre-VAD renal dysfunction (pre-VAD eGFR < 90 ml/min/1.73 m(2)). RESULTS The pre-VAD eGFR across the cohort was 84.0 ml/min/1.73 m(2) (interquartile range [IQR] 62.3-122.7), and 55.6% (34 of 63) had pre-VAD renal dysfunction. AKI affected 60.3% (38 of 63), with similar rates in those with and without pre-existing renal dysfunction. Within the cohort, the nadir eGFR occurred 1 day post-operatively (62.9 ml/min/1.73 m(2); IQR, 51.2-88.9 ml/min/1.73 m(2); p < 0.001). By Day 5, however, the eGFR exceeded the baseline (99.0 ml/min/1.73 m(2); IQR, 59.3-146.7 ml/min/1.73 m(2); p = 0.03) and remained significantly higher through the first post-operative week. After adjusting for age, gender, and AKI, the eGFR continued to increase throughout the entire 180-day study period (β = 0.0025; 95% confidence interval, 0.0015-0.0036; p < 0.001). Patients with pre-VAD renal dysfunction experienced the greatest improvement in the eGFR (β = 0.0051 vs β = 0.0013, p < 0.001). CONCLUSIONS Renal dysfunction is prevalent in children with heart failure undergoing VAD placement. Although peri-operative AKI is common, renal function improves substantially in the first post-operative week and for months thereafter. This is particularly pronounced in those with pre-VAD renal impairment, suggesting that VADs may facilitate recovery and maintenance of kidney function in children with advanced heart failure.
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Affiliation(s)
- Lindsay J May
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Justin Yeh
- Division of Pediatric Cardiology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - David M Axelrod
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Christopher S D Almond
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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20
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Abstract
Isolation of the right subclavian artery (RSCA) is rare, and this finding in association with d-transposition of the great arteries (d-TGA) is extremely unusual. We present a case of an isolated RSCA in a newborn with d-TGA in whom the clinical presentation was diagnostic. We discuss the imaging modalities used to confirm the diagnosis, the embryological basis of the finding, and the surgical repair.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics (Cardiology), Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Stanton B Perry
- Department of Pediatrics (Cardiology), Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Alaina K Kipps
- Department of Pediatrics (Cardiology), Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Shreyas S Vasanawala
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - David M Axelrod
- Department of Pediatrics (Cardiology), Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
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21
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Motonaga KS, Punn R, Axelrod DM, Ceresnak SR, Hanisch D, Kazmucha JA, Dubin AM. Diminished exercise capacity and chronotropic incompetence in pediatric patients with congenital complete heart block and chronic right ventricular pacing. Heart Rhythm 2015; 12:560-565. [DOI: 10.1016/j.hrthm.2014.11.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Indexed: 12/29/2022]
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22
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Abstract
In summary, AKI after pediatric congenital cardiac surgery represents an important diagnostic and therapeutic challenge in the modern day intensive care unit. AKI in the immediate postoperative period not only portends a poor short-term outcome, but also may relate to chronic kidney disease and mortality in the long term. Its association with increased morbidity, cost, and mortality demands the attention of clinicians and researchers. Future studies should employ a standard AKI definition and should focus on both the mitigation and prevention of AKI events.
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Affiliation(s)
- David M Axelrod
- Division of Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, CA, USA.
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Marti JL, Ayo D, Levine P, Hernandez O, Rescigno J, Axelrod DM. Non-image guided fine needle aspiration of palpable axillary lymph nodes in breast cancer patients. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #1013
Introduction
 While the utility of ultrasound-guided axillary lymph node FNA is well established, there is a paucity of data on non-image guided office-based FNA of palpable axillary lymphadenopathy. We investigate the sensitivity and specificity of non-image guided FNA of axillary lymphadenopathy in patients presenting with breast cancer, and report factors correlating with a positive FNA result.
 Methods
 Retrospective review of 80 consecutive patients who underwent office-based FNA of palpable axillary lymph nodes between 2004-2008, with cytology results compared with histology during axillary sentinel node or lymph node dissection. Pearson correlation, chi-square and Fisher exact tests were used to determine correlation with other clinical and pathologic data.
 Results
 Mean age was 56 with a median tumor size of 2.2 cm and 39% have pNO disease. Non-image guided axillary FNA was 82% sensitive, 100% specific, and 89% accurate. Positive predictive value was 100% and negative predictive value was 76%. Therefore only 24% of patients who had a negative FNA had axillary involvement compared to 61% for the entire group.
 A significant correlation or association was identified between positive FNA cytology and breast tumor size (p=0.02), number of pathologic positive lymph nodes (p<0.0001), presentation with a palpable breast mass (p=0.003), radiographic lymphadenopathy (p=0.0005), lymphovascular invasion (p=0.003), stage of disease (P<0.0001), and N stage (p<0.0001). There was a borderline significant association with her2neu receptor status (p=0.08).
 Age, lymph node size, ER/PR status, Ki-67 index, tumor histology, multicentric disease, degree of differentiation and nuclear grade were all not significantly correlated or associated with positive FNA.
 Conclusions
 Non-image guided FNA of palpable axillary lymphadenopathy in breast cancer patients is a very sensitive and specific test. Prompt determination of lymph node positivity benefits select patients, permitting avoidance of ultrasound, sentinel lymph node biopsy, or delay in receiving neoadjuvant therapy. This results in time and cost savings for the patient and the health care system, and expedites definitive management of the patient.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1013.
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Affiliation(s)
- JL Marti
- 1 Surgery, New York University School of Medicine, New York, NY
| | - D Ayo
- 1 Surgery, New York University School of Medicine, New York, NY
| | - P Levine
- 2 Pathology, New York University School of Medicine, New York, NY
| | - O Hernandez
- 2 Pathology, New York University School of Medicine, New York, NY
| | - J Rescigno
- 3 Radiation Oncology, St. Vincent's Comprehensive Cancer Center, New York, NY
| | - DM Axelrod
- 1 Surgery, New York University School of Medicine, New York, NY
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24
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Abstract
In vivo experiments on strains of mice that differ in the risk of developing mammary cancer have demonstrated a correlation between the extent of 16 alpha-hydroxylation of estradiol and incidence of mammary cancer. The ability of human mammary terminal duct lobular unit (TDLU), the site of neoplastic transformation, to metabolize estradiol or to accumulate estradiol metabolites has not been unequivocally established. Using a newly developed human mammary TDLU explant culture system and a radiometric assay for estradiol metabolism, we compared the site-specific metabolism of estradiol by the 17-oxidation, 2-hydroxylation, and 16 alpha-hydroxylation pathways in noninvolved human mammary tissue. The relative extent of estradiol 16 alpha-hydroxylation was found to be increased in TDLU from patients in the luteal phase of the menstrual cycle in relation to either those from patients in the follicular phase or from postmenopausal subjects. This study demonstrates that TDLU can metabolize estradiol extrahepatically and that 16 alpha-hydroxylation in the target tissue is dependent on the phase of the menstrual cycle. Furthermore, the specific, risk-related increase in 16 alpha-hydroxylation suggests that intrinsic metabolic ability of the target tissue leading to the formation of 16 alpha-hydroxyestrone from estradiol may be a determinant in, or a marker for, the relative risk of developing mammary cancer.
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Affiliation(s)
- N T Telang
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York New York 10021
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25
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Abstract
The metabolism of E2 via the 16 alpha-hydroxylation pathway is reported to be elevated in breast cancer patients as well as in subjects at high risk for developing breast cancer. The biological relevance of the metabolic pathway during the initiational events that lead to the tumorigenic transformation of mammary epithelium is not fully understood. The results obtained from the in vitro experiments discussed in this report permit the following conclusions: 1. Human mammary TDLU, the presumptive target site for breast cancer, possesses metabolic competence to biotransform E2. 2. The biotransformation of E2 in TDLU via the 16 alpha-hydroxylation pathway is responsive to endogenous hormonal changes and to the presence of cancer, and is susceptible to carcinogenic insult. 3. The relative extent of E2 16 alpha-hydroxylation may constitute a sensitive metabolic marker for evaluating the susceptibility of noninvolved mammary epithelium to carcinogen-induced transformation.
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Affiliation(s)
- N T Telang
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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26
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Abstract
A case of sigmoid carcinoma in a 16-year-old boy is presented and the topic of colonic carcinoma in the young is reviewed. Although colon carcinoma in the younger patient is uncommon, its prognosis is distinctly worse than in the adult population, because the preponderance of mucinous adenocarcinoma in children and young adults represents a more virulent type of colonic malignancy and because the delay in diagnosis contributes to a more advanced stage of the disease at the time of presentation. When dealing with symptoms potentially referrable to this disease, a thorough diagnostic work-up should ensue.
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Affiliation(s)
- R H Rose
- Department of Surgery, Beth Israel Medical Center, New York, NY 10003
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27
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Axelrod DM, Menendez-Botet CJ, Kinne DW, Osborne MP. Levels of estrogen and progesterone receptor proteins in patients with breast cancer during various phases of the menses. Cancer Invest 1988; 6:7-14. [PMID: 3365573 DOI: 10.3109/07357908809077024] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Analysis of estrogen and progesterone receptor proteins was carried out in 75 premenopausal and 79 postmenopausal patients with primary operable breast carcinoma who were treated from January 1983 to December 1984. The frequency of estrogen receptor protein positive/progesterone receptor protein positive (+/+); estrogen receptor protein negative/progesterone receptor protein negative (-/-); estrogen receptor protein negative/progesterone receptor protein positive (-/+); and estrogen receptor protein positive/progesterone receptor protein negative (+/-) was 40.5%, 30.5%, 23%, and 6% in premenopausal patients, respectively, and 52%, 24%, 2.5%, and 21.5% in postmenopausal patients, respectively (p less than 0.001). The mean positive estrogen receptor protein concentration (expressed as femtomoles per milligram of protein +/- SEM) was significantly higher in postmenopausal patients (54 +/- 6) than in premenopausal patients (19 +/- 2) (p less than 0.005). The progesterone receptor protein values did not differ significantly between these two groups. The phase of the menstrual cycle was recorded at the time of surgery in the 75 premenopausal women. Maximum receptor positivity occurred in the secretory phase, however, this difference is not statistically significant, and our data suggest that there are no distributional differences between the phase of menses and positivity of estrogen and progesterone receptor proteins. Future studies which included analyses of circulating sex steroid levels and receptor proteins will provide a better understanding of complex hormonal regulatory mechanisms which exist in patients with breast cancer.
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Affiliation(s)
- D M Axelrod
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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28
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Abstract
Thirty-five women with breast cancer and primary hyperparathyroidism (1 degree HPT) were admitted to Memorial Hospital during a 25-year period. The incidence of primary hyperparathyroidism in the breast cancer patients was similar to the incidence in the total patient population at Memorial Sloan-Kettering Cancer Center (0.15% and 0.14%, respectively). The patients with 1 degree HPT disease had clinical findings which distinguished them from those patients with cancer-related hypercalcemia. Eighty percent of the breast cancer patients with primary hyperparathyroidism had earlier stage disease (Stage 0, Stage 1, Stage 2); whereas 97% of the patients with breast cancer and hypercalcemia (not due to 1 degree HPT) had advanced disease. There appeared to be a trend towards improved survival in the breast cancer patients with primary hyperparathyroidism when compared to patients of similar stage of disease who did not have parathyroid disease.
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