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O'Connor AM, Cassedy A, Wray J, Brown KL, Cohen M, Franklin RCG, Gaynor JW, MacGloin H, Mahony L, Mussatto K, Newburger JW, Rosenthal DN, Teitel D, Ernst MM, Wernovsky G, Marino BS. Differences in Quality of Life in Children Across the Spectrum of Congenital Heart Disease. J Pediatr 2023; 263:113701. [PMID: 37640230 DOI: 10.1016/j.jpeds.2023.113701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To create complexity groups based upon a patient's cardiac medical history and to test for group differences in health-related quality of life (HRQOL). METHODS Patients 8-18 years with congenital heart disease (CHD) and parent-proxies from the Pediatric Cardiac Quality of Life Inventory (PCQLI) Testing Study were included. Outcome variables included PCQLI Total, Disease Impact, and Psychosocial Impact scores. Using a patient's medical history (cardiac, neurologic, psychological, and cognitive diagnosis), latent class analysis (LCA) was used to create CHD complexity groups. Covariates included demographics and burden of illness (number of: school weeks missed, physician visits in the past year, and daily medications). Generalized estimation equations tested for differences in burden of illness and patient and parent-proxy PCQLI scores. RESULTS Using 1482 CHD patients (60% male; 84% white; age 12.3 ± 3.0 years), latent class analysis (LCA) estimates showed 4 distinct CHD complexity groups (Mild, Moderate 1, Moderate 2, and Severe). Increasing CHD complexity was associated with increased risk of learning disorders, seizures, mental health problems, and history of stroke. Greater CHD complexity was associated with greater burden of illness (P < .01) and lower patient- and parent-reported PCQLI scores (P < .001). CONCLUSIONS LCA identified 4 congenital heart disease (CHD) complexity groupings. Increasing CHD complexity was associated with higher burden of illness and worse patient- and parent-reported HRQOL.
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Affiliation(s)
- Amy M O'Connor
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Jo Wray
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kate L Brown
- Department of Pediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mitchell Cohen
- Division of Cardiology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ; Division of Cardiology, Department of Pediatrics, Inova Children's Hospital, Falls Church, VA
| | - Rodney C G Franklin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Helen MacGloin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Jane W Newburger
- Division of Cardiology, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - David N Rosenthal
- Division of Cardiology, Department of Pediatrics, Lucille Packard Children's Hospital Stanford, Palo Alto, CA
| | - David Teitel
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Michelle M Ernst
- Division of Behavior Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gil Wernovsky
- Division of Cardiology, Departments of Pediatrics and Critical Care Medicine, Children's National Hospital, Washington, DC; Division of Cardiac Critical Care, Departments of Pediatrics and Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Bradley S Marino
- Divisions of Pediatric Cardiology and Critical Care Medicine, Department of Heart, Vascular & Thoracic, Children's Institute, Cleveland Clinic Children's, Cleveland, OH
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Truong DT, Trachtenberg FL, Pearson GD, Dionne A, Elias MD, Friedman K, Hayes KH, Mahony L, McCrindle BW, Oster ME, Pemberton V, Powell AJ, Russell MW, Shekerdemian LS, Son MB, Taylor M, Newburger JW. The NHLBI Study on Long-terM OUtcomes after the Multisystem Inflammatory Syndrome In Children (MUSIC): Design and Objectives. Am Heart J 2022; 243:43-53. [PMID: 34418362 PMCID: PMC8710361 DOI: 10.1016/j.ahj.2021.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/06/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Long-terM OUtcomes after the Multisystem Inflammatory Syndrome In Children (MUSIC) study aims to characterize the frequency and time course of acute and long-term cardiac and non-cardiac sequelae in multisystem inflammatory syndrome in children associated with COVID-19 (MIS-C), which are currently poorly understood. METHODS This multicenter observational cohort study will enroll at least 600 patients <21 years old who meet the Centers for Disease Control and Prevention case definition of MIS-C across multiple North American centers over 2 years. The study will collect detailed hospital and follow-up data for up to 5 years, and optional genetic testing. Cardiac imaging at specific time points includes standardized echocardiographic assessment (all participants) and cardiac magnetic resonance imaging (CMR) in those with left ventricular ejection fraction (LVEF) <45% during the acute illness. The primary outcomes are the worst LVEF and the highest coronary artery z-score of the left anterior descending or right coronary artery. Other outcomes include occurrence and course of non-cardiac organ dysfunction, inflammation, and major medical events. Independent adjudication of cases will classify participants as definite, possible, or not MIS-C. Analysis of the outcomes will include descriptive statistics and regression analysis with stratification by definite or possible MIS-C. The MUSIC study will provide phenotypic data to support basic and translational research studies. CONCLUSION The MUSIC study, with the largest cohort of MIS-C patients and the longest follow-up period to date, will make an important contribution to our understanding of the acute cardiac and non-cardiac manifestations of MIS-C and the long-term effects of this public health emergency.
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Affiliation(s)
- Dongngan T Truong
- Department of Pediatrics, Dvision of Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA.
| | | | - Gail D Pearson
- National Heart, Lung, and Blood Institute/NIH, Bethesda, MD, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Matthew D Elias
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Brian W McCrindle
- The Division of Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Matthew E Oster
- Children's Heart Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory Unviersity School of Medicine, Atlanta, GA, USA
| | | | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mark W Russell
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Lara S Shekerdemian
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Mary Beth Son
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Michael Taylor
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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3
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Goldberg DJ, Zak V, McCrindle BW, Ni H, Gongwer R, Rhodes J, Garofano RP, Kaltman JR, Lambert LM, Mahony L, Margossian R, Spector ZZ, Williams RV, Atz AM, Paridon SM. Exercise Capacity and Predictors of Performance After Fontan: Results from the Pediatric Heart Network Fontan 3 Study. Pediatr Cardiol 2021; 42:158-168. [PMID: 32975603 PMCID: PMC7867583 DOI: 10.1007/s00246-020-02465-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 06/23/2020] [Accepted: 09/16/2020] [Indexed: 12/22/2022]
Abstract
Impaired exercise following Fontan is a surrogate of morbidity. Single-center longitudinal data exist, but there is a lack of contemporary multi-center data. Ramp cycle ergometry was re-performed in consented participants who had originally participated in the Pediatric Heart Network's Fontan cross-sectional study. Annualized change was evaluated at maximal and submaximal exercise. Associations between these outcomes and patient characteristics were analyzed. There were 336 participants in Fontan 3, mean age 23.2 years. Paired measurements of peak oxygen consumption (peak VO2) were available for 95; peak exercise data at Fontan 3 were available for 275. Percent-predicted peak VO2 declined by 0.8 ± 1.7% per year (p < 0.001). At Fontan 3, the lowest performing peak VO2 tertile had the highest rate of overweight and obesity (p < 0.001). Female gender was more prevalent in the highest performing tertile (p = 0.004). Paired data at the ventilatory anaerobic threshold (VO2 at VAT) were available for 196; VAT data at Fontan 3 were available for 311. Percent-predicted VO2 at VAT decreased by 0.8 ± 2.6% per year (p < 0.001). At Fontan 3, VO2 at VAT was better preserved than peak VO2 across all tertiles, with higher rates of overweight and obesity in the lower performing group (p = 0.001). Female gender (p < 0.001) and left ventricular morphology (p = 0.03) were associated with better performance. Submaximal exercise is better preserved than maximal in the Fontan population, but declined at the same rate over the study period. The overall longitudinal rate of decline in exercise performance is slower than what has been described previously.
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Affiliation(s)
- David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | | | - Brian W. McCrindle
- The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Hua Ni
- Healthcore, Watertown, MA 02472, USA
| | | | - Jonathan Rhodes
- Children’s Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | - Robert P. Garofano
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Jonathan R. Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20892, USA
| | - Linda M. Lambert
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84132, USA
| | - Lynn Mahony
- Children’s Health Dallas, University of Texas Southwestern Medical School, Dallas, TX 75390, USA
| | - Renee Margossian
- Children’s Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | | | - Richard V. Williams
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84132, USA
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC 29425, USA
| | - Stephen M. Paridon
- Division of Cardiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
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Atz AM, Zak V, Mahony L, Uzark K, D'agincourt N, Goldberg DJ, Williams RV, Breitbart RE, Colan SD, Burns KM, Margossian R, Henderson HT, Korsin R, Marino BS, Daniels K, McCrindle BW. Longitudinal Outcomes of Patients With Single Ventricle After the Fontan Procedure. J Am Coll Cardiol 2017; 69:2735-2744. [PMID: 28571639 DOI: 10.1016/j.jacc.2017.03.582] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [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: 12/19/2016] [Revised: 03/19/2017] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multicenter longitudinal objective data for survival into adulthood of patients who have undergone Fontan procedures are lacking. OBJECTIVES This study sought to describe transplant-free survival and explore relationships between laboratory measures of ventricular performance and functional status over time. METHODS Exercise testing, echocardiography, B-type natriuretic peptide, functional health assessment, and medical history abstraction were repeated 9.4 ± 0.4 years after the Fontan Cross-Sectional Study (Fontan 1) and compared with previous values. Cox regression analysis explored risk factors for interim death or cardiac transplantation. RESULTS From the original cohort of 546 subjects, 466 were contacted again, and 373 (80%) were enrolled at 21.2 ± 3.5 years of age. Among subjects with paired testing, the percent predicted maximum oxygen uptake decreased (69 ± 14% vs. 61 ± 16%; p < 0.001; n = 95), ejection fraction decreased (58 ± 11% vs. 55 ± 10%; p < 0.001; n = 259), and B-type natriuretic peptide increased (median [interquartile range] 13 [7 to 25] pg/mol vs. 18 [9 to 36] pg/mol; p < 0.001; n = 340). At latest follow-up, a lower Pediatric Quality of Life Inventory physical summary score was associated with poorer exercise performance (R2 adjusted = 0.20; p < 0.001; n = 274). Cumulative complications since the Fontan procedure included additional cardiac surgery (32%), catheter intervention (62%), arrhythmia treatment (32%), thrombosis (12%), and protein-losing enteropathy (8%). Since Fontan 1, 54 subjects (10%) have received a heart transplant (n = 23) or died without transplantation (n = 31). The interval risk of death or/cardiac transplantation was associated with poorer ventricular performance and functional health status assessed at Fontan 1, but it was not associated with ventricular morphology, the subject's age, or the type of Fontan connection. CONCLUSIONS Interim transplant-free survival over 12 years in this Fontan cohort was 90% and was independent of ventricular morphology. Exercise performance decreased and was associated with worse functional health status. Future interventions might focus on preserving exercise capacity. (Relationship Between Functional Health Status and Ventricular Performance After Fontan-Pediatric Heart Network; NCT00132782).
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Affiliation(s)
- Andrew M Atz
- Medical University of South Carolina, Charleston, South Carolina.
| | - Victor Zak
- New England Research Institutes, Watertown, Massachusetts
| | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | | | | | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | | | | | | | - Brian W McCrindle
- University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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O'Connor AM, Wray J, Tomlinson RS, Cassedy A, Jacobs JP, Jenkins KJ, Brown KL, Franklin RCG, Mahony L, Mussatto K, Newburger JW, Wernovsky G, Ittenbach RF, Drotar D, Marino BS. Impact of Surgical Complexity on Health-Related Quality of Life in Congenital Heart Disease Surgical Survivors. J Am Heart Assoc 2016; 5:e001234. [PMID: 27451455 PMCID: PMC5015349 DOI: 10.1161/jaha.114.001234] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 05/03/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical complexity and related morbidities may affect long-term patient quality of life (QOL). Aristotle Basic Complexity (ABC) score and Risk Adjustment in Congenital Heart Surgery (RACHS-1) category stratify the complexity of pediatric cardiac operations. The purpose of this study was to examine the relationship between surgical complexity and QOL and to investigate other demographic and clinical variables that might explain variation in QOL in pediatric cardiac surgical survivors. METHODS AND RESULTS Pediatric Cardiac Quality of Life (PCQLI) study participants who had undergone cardiac surgery were included. The PCQLI database provided sample characteristics and QOL scores. Surgical complexity was defined by the highest ABC raw score or RACHS-1 category. Relationships among surgical complexity and demographic, clinical, and QOL variables were assessed using ordinary least squares regression. A total of 1416 patient-parent pairs were included. Although higher ABC scores and RACHS-1 categories were associated with lower QOL scores (P<0.005), correlation with QOL scores was poor to fair (r=-0.10 to -0.29) for all groups. Ordinary least squares regression showed weak association with R(2)=0.06 to R(2)=0.28. After accounting for single-ventricle anatomy, number of doctor visits, and time since last hospitalization, surgical complexity scores added no additional explanation to the variance in QOL scores. CONCLUSIONS ABC scores and RACHS-1 categories are useful tools for morbidity and mortality predictions prior to cardiac surgery and quality of care initiatives but are minimally helpful in predicting a child's or adolescent's long-term QOL scores. Further studies are warranted to determine other predictors of QOL variation.
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Affiliation(s)
- Amy M O'Connor
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jo Wray
- Cardiorespiratory Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ryan S Tomlinson
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida, All Children's Hospital and Children's Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, St. Petersburg and Tampa, FL
| | - Kathy J Jenkins
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kate L Brown
- Cardiorespiratory Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rodney C G Franklin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kathleen Mussatto
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Wisconsin, Milwaukee, WI
| | - Jane W Newburger
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gil Wernovsky
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, PA Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, PA
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dennis Drotar
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Pitcher A, Emberson J, Lacro RV, Sleeper LA, Stylianou M, Mahony L, Pearson GD, Groenink M, Mulder BJ, Zwinderman AH, De Backer J, De Paepe AM, Arbustini E, Erdem G, Jin XY, Flather MD, Mullen MJ, Child AH, Forteza A, Evangelista A, Chiu HH, Wu MH, Sandor G, Bhatt AB, Creager MA, Devereux RB, Loeys B, Forfar JC, Neubauer S, Watkins H, Boileau C, Jondeau G, Dietz HC, Baigent C. Design and rationale of a prospective, collaborative meta-analysis of all randomized controlled trials of angiotensin receptor antagonists in Marfan syndrome, based on individual patient data: A report from the Marfan Treatment Trialists' Collaboration. Am Heart J 2015; 169:605-12. [PMID: 25965707 PMCID: PMC4441104 DOI: 10.1016/j.ahj.2015.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 01/17/2015] [Indexed: 12/01/2022]
Abstract
Rationale A number of randomized trials are underway, which will address the effects of angiotensin receptor blockers (ARBs) on aortic root enlargement and a range of other end points in patients with Marfan syndrome. If individual participant data from these trials were to be combined, a meta-analysis of the resulting data, totaling approximately 2,300 patients, would allow estimation across a number of trials of the treatment effects both of ARB therapy and of β-blockade. Such an analysis would also allow estimation of treatment effects in particular subgroups of patients on a range of end points of interest and would allow a more powerful estimate of the effects of these treatments on a composite end point of several clinical outcomes than would be available from any individual trial. Design A prospective, collaborative meta-analysis based on individual patient data from all randomized trials in Marfan syndrome of (i) ARBs versus placebo (or open-label control) and (ii) ARBs versus β-blockers will be performed. A prospective study design, in which the principal hypotheses, trial eligibility criteria, analyses, and methods are specified in advance of the unblinding of the component trials, will help to limit bias owing to data-dependent emphasis on the results of particular trials. The use of individual patient data will allow for analysis of the effects of ARBs in particular patient subgroups and for time-to-event analysis for clinical outcomes. The meta-analysis protocol summarized in this report was written on behalf of the Marfan Treatment Trialists' Collaboration and finalized in late 2012, without foreknowledge of the results of any component trial, and will be made available online (http://www.ctsu.ox.ac.uk/research/meta-trials).
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Marino B, Cassedy A, Brown K, Cvetkovic M, Costello J, Franklin R, Gaynor JW, Laker S, Levinson K, MacGloin H, Mahony L, McQuillan A, Mussatto K, O’Shea D, Newburger J, Sykes M, Teele S, Wernovsky G, Drotar D, Wray J. THE IMPACT OF DEMOGRAPHIC, SURGICAL AND INTENSIVE CARE UNIT FACTORS ON LONG-TERM QUALITY OF LIFE IN CONGENITAL HEART DISEASE SURGICAL SURVIVORS. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60544-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Atz AM, Zak V, Mahony L, Burns K, Goldberg D, Williams R, Breitbart R, Korsin R, Colan S, Marino BS, Margossian R, Daniels K, Uzark K, Henderson H, McCrindle B. LONGITUDINAL ASSESSMENT OF SINGLE VENTRICLE PATIENTS IN THE PEDIATRIC HEART NETWORK FONTAN COHORT. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Costello JM, Mussatto K, Cassedy A, Wray J, Mahony L, Teele SA, Brown KL, Franklin RC, Wernovsky G, Marino BS. Prediction by clinicians of quality of life for children and adolescents with cardiac disease. J Pediatr 2015; 166:679-83.e2. [PMID: 25722271 PMCID: PMC4347874 DOI: 10.1016/j.jpeds.2014.11.061] [Citation(s) in RCA: 22] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 10/16/2014] [Accepted: 11/26/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether clinicians could reliably predict health-related quality of life (HRQOL) for children with cardiac disease, the level of agreement in predicted HRQOL scores between clinician sub-types, and agreement between clinician-predicted HRQOL scores and patient and parent-proxy reported HRQOL scores. STUDY DESIGN In this multicenter, cross-sectional study, a random sample of clinical summaries of children with cardiac disease and related patient and parent-proxy reported HRQOL scores were extracted from the Pediatric Cardiac Quality of Life Inventory data registry. We asked clinicians to review each clinical summary and predict HRQOL. RESULTS Experienced pediatric cardiac clinicians (n = 140), including intensive care physicians, outpatient cardiologists, and intensive care, outpatient, and advanced practice nurses, each predicted HRQOL for the same 21 pediatric cardiac patients. Reliability within clinician subspecialty groups for predicting HRQOL was poor (intraclass correlation coefficients, 0.34-0.38). Agreement between clinician groups was low (Pearson correlation coefficients, 0.10-0.29). When comparing the average clinician predicted HRQOL scores to those reported by patients and parent-proxies by Bland Altman plots, little systematic bias was present, but substantial variability existed. Proportional bias was found, in that clinicians tended to overestimate HRQOL for those patients and parent-proxies who reported lower HRQOL, and underestimate HRQOL for those reporting higher HRQOL. CONCLUSIONS Clinicians perform poorly when asked to predict HRQOL for children with cardiac disease. Clinicians should be cognizant of these data when providing counseling. Incorporating reported HRQOL into clinical assessment may help guide individualized treatment decision-making.
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Affiliation(s)
- John M. Costello
- Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University Feinberg School of Medicine
| | | | - Amy Cassedy
- Cincinnati Children's Hospital Medical Center
| | - Jo Wray
- Great Ormond Street Hospital for Children NHS Trust
| | - Lynn Mahony
- University of Texas Southwestern Medical Center
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11
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Czosek RJ, Cassedy AE, Wray J, Wernovsky G, Newburger JW, Mussatto KA, Mahony L, Tanel RE, Cohen MI, Franklin RC, Brown KL, Rosenthal D, Drotar D, Marino BS. Quality of life in pediatric patients affected by electrophysiologic disease. Heart Rhythm 2015; 12:899-908. [PMID: 25602174 DOI: 10.1016/j.hrthm.2015.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 08/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Treatment of electrophysiologic (EP) disease in pediatric patients has improved; however, the effects on quality of life (QOL) are unknown. OBJECTIVE The purpose of this study was to compare QOL within EP disease groups and to other congenital heart diseases, to evaluate the effects of cardiac rhythm devices on QOL, and to identify drivers of QOL in EP disease. METHODS Cross-sectional study of patient/parent proxy-reported Pediatric Cardiac Quality of Life Inventory scores (Total, Disease Impact, Psychosocial Impact) in subjects aged 8 to 18 years from 11 centers with congenital complete heart block (CCHB), ventricular tachycardia (VT), supraventricular tachycardia (SVT), and long QT syndrome (LQTS). QOL was compared between EP disease groups and congenital heart disease groups [bicuspid aortic valve (BAV), tetralogy of Fallot (TOF), and Fontan]. General linear modeling was used to perform group comparisons and to identify predictors of QOL variation. RESULTS Among 288 patient-parent pairs, mean age was 12.8 ± 3.0 years. CCHB (μ = 83) showed higher patient Total QOL than other EP disease cohorts (P ≤ .02; LQTS μ = 73; SVT μ = 74). SVT (μ = 75) and LQTS (μ = 75) had lower patient Total scores than BAV (μ = 81; P ≤ .008). Patient/parent-proxy QOL scores for all EP disease groups were not different than TOF and higher than Fontan. The presence of a cardiac rhythm device was associated with lower QOL scores in LQTS (μ = 66 vs μ = 76; P < .01). Predictors of lower patient/parent-proxy QOL included EP disease type (P ≤ .03), increased medical care utilization (P ≤ .04), and no parental college degree (P ≤ .001). CONCLUSION Given the significant variation in QOL in EP disease type, stratification by EP disease type and increased medical care utilization may allow for targeted interventions to improve QOL.
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Affiliation(s)
- Richard J Czosek
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Amy E Cassedy
- Department of Biostatistics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jo Wray
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | | | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Lynn Mahony
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas
| | - Ronn E Tanel
- Division of Pediatric Cardiology, UCSF Benioff Children's Hospital, and Department of Pediatrics, UCSF School of Medicine, San Francisco, California
| | - Mitchell I Cohen
- Phoenix Children's Hospital and Arizona Pediatric Cardiology Consultants/Pediatrix, University of Arizona School of Medicine-Phoenix, Phoenix, Arizona
| | - Rodney C Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Kate L Brown
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - David Rosenthal
- Department of Pediatrics, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Dennis Drotar
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bradley S Marino
- The Heart Institute, Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Lacro RV, Dietz HC, Sleeper LA, Yetman AT, Bradley TJ, Colan SD, Pearson GD, Selamet Tierney ES, Levine JC, Atz AM, Benson DW, Braverman AC, Chen S, De Backer J, Gelb BD, Grossfeld PD, Klein GL, Lai WW, Liou A, Loeys BL, Markham LW, Olson AK, Paridon SM, Pemberton VL, Pierpont ME, Pyeritz RE, Radojewski E, Roman MJ, Sharkey AM, Stylianou MP, Wechsler SB, Young LT, Mahony L. Atenolol versus losartan in children and young adults with Marfan's syndrome. N Engl J Med 2014; 371:2061-71. [PMID: 25405392 PMCID: PMC4386623 DOI: 10.1056/nejmoa1404731] [Citation(s) in RCA: 335] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Aortic-root dissection is the leading cause of death in Marfan's syndrome. Studies suggest that with regard to slowing aortic-root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. METHODS We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan's syndrome. The primary outcome was the rate of aortic-root enlargement, expressed as the change in the maximum aortic-root-diameter z score indexed to body-surface area (hereafter, aortic-root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. RESULTS From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an aortic-root z score greater than 3.0. The baseline-adjusted rate of change in the mean (±SE) aortic-root z score did not differ significantly between the atenolol group and the losartan group (-0.139±0.013 and -0.107±0.013 standard-deviation units per year, respectively; P=0.08). Both slopes were significantly less than zero, indicating a decrease in the aortic-root diameter relative to body-surface area with either treatment. The 3-year rates of aortic-root surgery, aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. CONCLUSIONS Among children and young adults with Marfan's syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364.).
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Affiliation(s)
- Ronald V Lacro
- From Boston Children's Hospital, Boston (R.V.L., S.D.C., E.S.S.T., J.C.L.); Johns Hopkins University School of Medicine, Baltimore (H.C.D.); New England Research Institutes, Watertown, MA (L.A.S., S.D.C., S.C., G.L.K.); Primary Children's Hospital and the University of Utah, Salt Lake City (A.T.Y.); Hospital for Sick Children, Toronto (T.J.B., E.R.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.D.P., V.L.P., M.P.S.); Medical University of South Carolina, Charleston (A.M.A.); Cincinnati Children's Medical Center, Cincinnati (D.W.B.); Washington University School of Medicine, St. Louis (A.C.B., A.M.S.); Ghent University Hospital, Ghent, Belgium (J.D.B., B.L.L.); Icahn School of Medicine at Mount Sinai (B.D.G.), Children's Hospital of New York (W.W.L.), and Weill Medical College of Cornell University (M.J.R.) - all in New York; Rady Children's Hospital, University of California, San Diego (P.D.G.); Texas Children's Hospital, Houston (A.L.); Vanderbilt University School of Medicine, Nashville (L.W.M.); Seattle Children's Hospital, Seattle (A.K.O.); Children's Hospital of Philadelphia (S.M.P.) and the University of Pennsylvania (R.E.P.), Philadelphia; Children's Hospital and Clinics of Minnesota, Minneapolis (M.E.P.); Duke University Medical Center, Durham, NC (S.B.W.); Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (L.T.Y.); and the University of Texas Southwestern Medical Center, Dallas (L.M.)
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13
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Atz AM, Zak V, Mahony L, Uzark K, Shrader P, Gallagher D, Paridon SM, Williams RV, Breitbart RE, Colan SD, Kaltman JR, Margossian R, Pasquali SK, Allen K, Lai WW, Korsin R, Marino BS, Mirarchi N, McCrindle BW. Survival data and predictors of functional outcome an average of 15 years after the Fontan procedure: the pediatric heart network Fontan cohort. CONGENIT HEART DIS 2014; 10:E30-42. [PMID: 24934522 DOI: 10.1111/chd.12193] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [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] [Accepted: 05/04/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Multicenter longitudinal outcome data for Fontan patients surviving into adulthood are lacking. The aim of this study was to better understand contemporary outcomes in Fontan survivors by collecting follow-up data in a previously well-characterized cohort. DESIGN Baseline data from the Fontan Cross-Sectional Study (Fontan 1) were previously obtained in 546 Fontan survivors aged 11.9 ± 3.4 years. We assessed current transplant-free survival status in all subjects 6.8 ± 0.4 years after the Fontan 1 study. Anatomic, clinical, and surgical data were collected along with socioeconomic status and access to health care. RESULTS Thirty subjects (5%) died or underwent transplantation since Fontan 1. Subjects with both an elevated (>21 pg/mL) brain natriuretic peptide and a low Child Health Questionnaire physical summary score (<44) measured at Fontan 1 were significantly more likely to die or undergo transplant than the remainder, with a hazard ratio of 6.2 (2.9-13.5). Among 516 Fontan survivors, 427 (83%) enrolled in this follow-up study (Fontan 2) at 18.4 ± 3.4 years of age. Although mean scores on functional health status questionnaires were lower than the general population, individual scores were within the normal range in 78% and 88% of subjects for the Child Health Questionnaire physical and psychosocial summary score, and 97% and 91% for the SF-36 physical and mental aggregate score, respectively. Since Fontan surgery, 119 (28%) had additional cardiac surgery; 55% of these (n = 66) in the interim between Fontan 1 and Fontan 2. A catheter intervention occurred in 242 (57%); 32% of these (n = 78) after Fontan 1. Arrhythmia requiring treatment developed in 118 (28%) after Fontan surgery; 58% of these (n = 68) since Fontan 1. CONCLUSIONS We found 95% interim transplant-free survival for Fontan survivors over an average of 7 years of follow-up. Continued longitudinal investigation into adulthood is necessary to better understand the determinants of long-term outcomes and to improve functional health status.
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Affiliation(s)
- Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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14
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Atz AM, Zak V, Mahony L, Uzark K, Shrader P, Gallagher D, Paridon S, Williams R, Breitbart R, Colan S, Kaltman J, Margossian R, Pasquali S, Allen K, Lai W, Korsin R, Marino B, Mirarchi N, McCrindle B. THE PEDIATRIC HEART NETWORK FONTAN FOLLOW-UP STUDY: SURVIVAL DATA AND PREDICTORS OF FUNCTIONAL OUTCOME 7 YEARS LATER. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60496-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McCrindle BW, Zak V, Breitbart RE, Mahony L, Shrader P, Lai WW, Burns KM, Colan SD, Williams RV, Goldberg D, Hill KD, Khaikin S, Atz AM. The relationship of patient medical and laboratory characteristics to changes in functional health status in children and adolescents after the Fontan procedure. Pediatr Cardiol 2014; 35:632-40. [PMID: 24264999 PMCID: PMC3959245 DOI: 10.1007/s00246-013-0831-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 06/16/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
Abstract
Despite hypothesized concerns about deterioration beginning in adolescence, longitudinal data and associated factors regarding standardized assessment of physical functioning are not available for Fontan patients. Parents who participated in the Fontan Cross-Sectional Study completed the Child Health Questionnaire at 2 time points for 245 subjects ages 6-18 years. Associations between change in Physical Functioning Summary Score and baseline patient, medical, and laboratory characteristics (mean age 9.5 ± 1.7 years) and follow-up patient and medical characteristics (mean age 16.2 ± 1.6 years) were determined by regression analyses. During a mean of 6.7 ± 0.4 years, a small (not clinically important) but statistically significant decrease in score from 46.2 ± 11.7 to 44.5 ± 12.1 (p < 0.03) was noted. Subjects with higher baseline scores had a greater decrease in score (r = -0.48; p < 0.001). A multivariable model of patient and medical characteristics (R(2) = 0.11) showed that a greater decrease in score was significantly associated with interim development of asthma (n = 13; parameter estimate [PE] -6.6; p < 0.05) or other chronic respiratory, lung, or breathing problems (n = 13; PE -12.5; p < 0.001) and the presence of protein-losing enteropathy at any time (n = 12; PE -9.4; p = 0.006). Change in score was not significantly associated with baseline laboratory measures of exercise capacity and ventricular characteristics and function. Therefore, although physical functioning may be stable during adolescence for many Fontan patients, deterioration occurs in some in association with respiratory conditions and protein-losing enteropathy. Further longitudinal study is necessary to better understand the relationship between clinical morbidities and functional health status as these patients transition into adulthood.
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Affiliation(s)
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Wyman W. Lai
- Columbia University Medical Center, New York, NY
| | | | | | | | | | | | - Svetlana Khaikin
- University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC
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Mellion K, Uzark K, Cassedy A, Drotar D, Wernovsky G, Newburger JW, Mahony L, Mussatto K, Cohen M, Limbers C, Marino BS. Health-related quality of life outcomes in children and adolescents with congenital heart disease. J Pediatr 2014; 164:781-788.e1. [PMID: 24412135 DOI: 10.1016/j.jpeds.2013.11.066] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 10/18/2013] [Accepted: 11/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare health-related quality of life (HRQOL) in a group of pediatric patients with congenital heart disease (CHD) and healthy controls and patients with other chronic diseases, and to compare HRQOL among patients with CHD of various severity categories with one another, with controls, and with patients with other chronic diseases. STUDY DESIGN In this cross-sectional survey, t tests were used to compare patient and proxy-reported Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) scores (including total, physical health, and psychosocial health summary scores) in children (aged 8-12 years) and adolescents (aged 13-18 years) between controls and (1) a composite CHD population; and (2) patients in each of 3 CHD severity categories: mild (no intervention), biventricle (BV; postintervention), and single ventricle (SV; postpalliation). PedsQL scores among CHD severity categories were compared by ANOVA. PedsQL scores were also compared in the CHD population and children with other chronic diseases without age stratification using t tests. RESULTS There were 1138 (children, n = 625; adolescents, n = 513) and 771 (children, n = 528; adolescents, n = 243) patient and/or proxy reporters in the CHD and healthy control groups, respectively. Total, physical health, and psychosocial health summary scores were lower in the composite CHD, BV, and SV groups compared with controls (P < .0001). There were significant differences among disease severity categories for all scores (P < .01). The composite CHD, BV, and SV groups had similar PedsQL scores as end-stage renal disease, asthma, and obesity populations. CONCLUSION Children and adolescents with BV and SV CHD have significantly lower HRQOL than healthy controls and similar HRQOL as patients with other chronic pediatric diseases. Interventions targeting both physical and psychosocial domains are needed to improve HRQOL in this high-risk population.
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Affiliation(s)
- Katelyn Mellion
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Karen Uzark
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Amy Cassedy
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dennis Drotar
- Division of Behavioral and Clinical Psychology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gil Wernovsky
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jane W Newburger
- Division of Cardiology, Department of Pediatrics, Children's Hospital Boston, Boston, MA
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, TX
| | - Kathy Mussatto
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Mitchell Cohen
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ
| | - Christine Limbers
- Department of Psychology and Neuroscience, Baylor University, Waco, TX
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Cassedy A, Drotar D, Ittenbach R, Hottinger S, Wray J, Wernovsky G, Newburger JW, Mahony L, Mussatto K, Cohen MI, Marino BS. The impact of socio-economic status on health related quality of life for children and adolescents with heart disease. Health Qual Life Outcomes 2013; 11:99. [PMID: 23777248 PMCID: PMC3691729 DOI: 10.1186/1477-7525-11-99] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 06/12/2013] [Indexed: 01/11/2023] Open
Abstract
Background Socioeconomic status (SES) is known to influence children’s health-related quality of life. Many SES indicators assess distinct dimensions of a family’s position rather than measuring the same underlying construct. Many researchers, however, see SES indicators as interchangeable. The primary aim of this study was to determine which measure of SES had the strongest impact on health-related quality of life. Methods This is a secondary analysis of the Pediatric Cardiac Quality of Life Inventory Validation Study. The SES variables were family income, Hollingshead Index (occupational prestige), and highest parent educational attainment level. Health-related quality of life was measured using the Pediatric Cardiac Quality of Life Inventory. Correlations tested the relationship among the three SES indicators. Regression-based modeling was used to calculate the strength of the association between SES measures and the Pediatric Cardiac Quality of Life Inventory. Results The correlations among the SES measures were moderately high, with the correlation between the Hollingshead Index and parental education being r = 0.62 (95% CI = 0.56-0.65). There were equally high correlations between family income and the Hollingshead (r = 0.61, 95% CI = 0.57-0.65) and a slightly lower correlation between family income and parental education (r = 0.55, 95% CI = 0.52-0.59). Family income had the highest explanatory value compared to the Hollingshead Index or parental educational attainment, while controlling for sex, race, current cardiac status, and original diagnosis, accounting for 4-5% of the variation in patient and parent Pediatric Cardiac Quality of Life Inventory Total score, respectively, compared to the other SES measures. Conclusion Family income as an SES measure demonstrated the greatest fidelity with respect to health-related quality of life as measured by the Pediatric Cardiac Quality of Life Inventory across respondent groups and explained more of the variation compared to the Hollingshead Index or highest parental educational attainment.
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Affiliation(s)
- Amy Cassedy
- Department of Pediatrics, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Atz AM, Travison TG, McCrindle BW, Mahony L, Glatz AC, Kaza AK, Breitbart RE, Colan SD, Kaltman JR, Margossian R, Pasquali SK, Wang Y, Gersony WM. Cardiac performance and quality of life in patients who have undergone the Fontan procedure with and without prior superior cavopulmonary connection. Cardiol Young 2013; 23:335-43. [PMID: 22824161 PMCID: PMC3578173 DOI: 10.1017/s1047951112001175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A superior cavopulmonary connection is commonly performed before the Fontan procedure in patients with a functionally univentricular heart. Data are limited regarding associations between a prior superior cavopulmonary connection and functional and ventricular performance late after the Fontan procedure. METHODS We compared characteristics of those with and without prior superior cavopulmonary connection among 546 subjects enrolled in the Pediatric Heart Network Fontan Cross-Sectional Study. We further compared different superior cavopulmonary connection techniques: bidirectional cavopulmonary anastomosis (n equals 229), bilateral bidirectional cavopulmonary anastomosis (n equals 39), and hemi-Fontan (n equals 114). RESULTS A prior superior cavopulmonary connection was performed in 408 subjects (75%); the proportion differed by year of Fontan surgery and centre (p-value less than 0.0001 for each). The average age at Fontan was similar, 3.5 years in those with superior cavopulmonary connection versus 3.2 years in those without (p-value equals 0.4). The type of superior cavopulmonary connection varied by site (p-value less than 0.001) and was related to the type of Fontan procedure. Exercise performance, echocardiographic variables, and predominant rhythm did not differ by superior cavopulmonary connection status or among superior cavopulmonary connection types. Using a test of interaction, findings did not vary according to an underlying diagnosis of hypoplastic left heart syndrome. CONCLUSIONS After controlling for subject and era factors, most long-term outcomes in subjects with a prior superior cavopulmonary connection did not differ substantially from those without this procedure. The type of superior cavopulmonary connection varied significantly by centre, but late outcomes were similar.
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Affiliation(s)
- Andrew M Atz
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Lacro RV, Guey LT, Dietz HC, Pearson GD, Yetman AT, Gelb BD, Loeys BL, Benson DW, Bradley TJ, De Backer J, Forbus GA, Klein GL, Lai WW, Levine JC, Lewin MB, Markham LW, Paridon SM, Pierpont ME, Radojewski E, Selamet Tierney ES, Sharkey AM, Wechsler SB, Mahony L. Characteristics of children and young adults with Marfan syndrome and aortic root dilation in a randomized trial comparing atenolol and losartan therapy. Am Heart J 2013; 165:828-835.e3. [PMID: 23622922 DOI: 10.1016/j.ahj.2013.02.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Pediatric Heart Network designed a clinical trial to compare aortic root growth and other short-term cardiovascular outcomes in children and young adults with Marfan syndrome randomized to receive atenolol or losartan. We report here the characteristics of the screened population and enrolled subjects. METHODS AND RESULTS Between 2007 and 2011, 21 clinical sites randomized 608 subjects, aged 6 months to 25 years who met the original Ghent criteria and had a body surface area-adjusted aortic root diameter z-score >3.0. The mean age at study entry was 11.2 years, 60% were male, and 25% were older teenagers and young adults. The median aortic root diameter z-score was 4.0. Aortic root diameter z-score did not vary with age. Mitral valve prolapse and mitral regurgitation were more common in females. Among those with a positive family history, 56% had a family member with aortic surgery, and 32% had a family member with a history of aortic dissection. CONCLUSIONS Baseline demographic, clinical, and anthropometric characteristics of the randomized cohort are representative of patients in this population with moderate to severe aortic root dilation. The high percentage of young subjects with relatives who have had aortic dissection or surgery illustrates the need for more definitive therapy; we expect that the results of the study and the wealth of systematic data collected will make an important contribution to the management of individuals with Marfan syndrome.
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Tabbutt S, Ghanayem N, Ravishankar C, Sleeper LA, Cooper DS, Frank DU, Lu M, Pizarro C, Frommelt P, Goldberg CS, Graham EM, Krawczeski CD, Lai WW, Lewis A, Kirsh JA, Mahony L, Ohye RG, Simsic J, Lodge AJ, Spurrier E, Stylianou M, Laussen P. Risk factors for hospital morbidity and mortality after the Norwood procedure: A report from the Pediatric Heart Network Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144:882-95. [PMID: 22704284 DOI: 10.1016/j.jtcvs.2012.05.019] [Citation(s) in RCA: 240] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 03/21/2012] [Accepted: 05/09/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to identify risk factors for mortality and morbidity during the Norwood hospitalization in newborn infants with hypoplastic left heart syndrome and other single right ventricle anomalies enrolled in the Single Ventricle Reconstruction trial. METHODS Potential predictors for outcome included patient- and procedure-related variables and center volume and surgeon volume. Outcome variables occurring during the Norwood procedure and before hospital discharge or stage II procedure included mortality, end-organ complications, length of ventilation, and hospital length of stay. Univariate and multivariable Cox regression analyses were performed with bootstrapping to estimate reliability for mortality. RESULTS Analysis included 549 subjects prospectively enrolled from 15 centers; 30-day and hospital mortality were 11.5% (63/549) and 16.0% (88/549), respectively. Independent risk factors for both 30-day and hospital mortality included lower birth weight, genetic abnormality, extracorporeal membrane oxygenation (ECMO) and open sternum on the day of the Norwood procedure. In addition, longer duration of deep hypothermic circulatory arrest was a risk factor for 30-day mortality. Shunt type at the end of the Norwood procedure was not a significant risk factor for 30-day or hospital mortality. Independent risk factors for postoperative renal failure (n = 46), sepsis (n = 93), increased length of ventilation, and hospital length of stay among survivors included genetic abnormality, lower center/surgeon volume, open sternum, and post-Norwood operations. CONCLUSIONS Innate patient factors, ECMO, open sternum, and lower center/surgeon volume are important risk factors for postoperative mortality and/or morbidity during the Norwood hospitalization.
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Affiliation(s)
- Sarah Tabbutt
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Tweddell JS, Sleeper LA, Ohye RG, Williams IA, Mahony L, Pizarro C, Pemberton VL, Frommelt PC, Bradley SM, Cnota JF, Hirsch J, Kirshbom PM, Li JS, Pike N, Puchalski M, Ravishankar C, Jacobs JP, Laussen PC, McCrindle BW. Intermediate-term mortality and cardiac transplantation in infants with single-ventricle lesions: risk factors and their interaction with shunt type. J Thorac Cardiovasc Surg 2012; 144:152-9. [PMID: 22341427 DOI: 10.1016/j.jtcvs.2012.01.016] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 01/04/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The study objective was to identify factors associated with death and cardiac transplantation in infants undergoing the Norwood procedure and to determine differences in associations that might favor the modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt. METHODS We used competing risks methodology to analyze death without transplantation, cardiac transplantation, and survival without transplantation. Parametric time-to-event modeling and bootstrapping were used to identify independent predictors. RESULTS Data from 549 subjects (follow-up, 2.7 ± 0.9 years) were analyzed. Mortality risk was characterized by early and constant phases; transplant was characterized by only a constant phase. Early phase factors associated with death included lower socioeconomic status (P = .01), obstructed pulmonary venous return (P < .001), smaller ascending aorta (P = .02), and anatomic subtype. Constant phase factors associated with death included genetic syndrome (P < .001) and lower gestational age (P < .001). The right ventricle-to-pulmonary artery shunt demonstrated better survival in the 51% of subjects who were full term with aortic atresia (P < .001). The modified Blalock-Taussig shunt was better among the 4% of subjects who were preterm with a patent aortic valve (P = .003). Lower pre-Norwood right ventricular fractional area change, pre-Norwood surgery, and anatomy other than hypoplastic left heart syndrome were independently associated with transplantation (all P < .03), but shunt type was not (P = .43). CONCLUSIONS Independent risk factors for intermediate-term mortality include lower socioeconomic status, anatomy, genetic syndrome, and lower gestational age. Term infants with aortic atresia benefited from a right ventricle-to-pulmonary artery shunt, and preterm infants with a patent aortic valve benefited from a modified Blalock-Taussig shunt. Right ventricular function and anatomy, but not shunt type, were associated with transplantation.
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Ravishankar C, Zak V, Bellinger D, Cook A, Gaynor JW, Ghanayem N, Krawczeski C, Licht DJ, Mahony L, Newburger J, Pemberton V, Atz T, Khaikin S, Sananes R, Williams IA, Williams RV, Hsu D. LINEAR GROWTH FAILURE IS ASSOCIATED WITH WORSE NEURODEVELOPMENTAL OUTCOME IN INFANTS WITH SINGLE VENTRICLE PHYSIOLOGY. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60420-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Atz AM, Zak V, Breitbart RE, Colan SD, Pasquali SK, Hsu DT, Lu M, Mahony L, Paridon SM, Puchalski MD, Geva T, McCrindle BW. Factors associated with serum brain natriuretic peptide levels after the Fontan procedure. CONGENIT HEART DIS 2011; 6:313-21. [PMID: 21435188 DOI: 10.1111/j.1747-0803.2011.00496.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although a useful marker of heart failure in adults, the utility of brain natriuretic peptide concentration (BNP) for children after the Fontan procedure is not well studied. DESIGN BNP was measured in 510 patients who were 6-18 years old in the Pediatric Heart Network Fontan cross-sectional study at a median of 8.2 years after Fontan. Patients underwent echocardiography, exercise testing, magnetic resonance imaging (MRI) and functional health status questionnaires. Associations of BNP with baseline patient characteristics, medical history and cross-sectional assessment were examined with multivariable linear regression analyses. RESULTS The distribution of BNP was highly skewed, median 13.0 pg/mL (interquartile range: 7.1, 25.9), and was normalized with logarithmic transformation (logBNP). Among medical history variables, logBNP was greater in females (P= .02) and older patients (P < .001). Presence of pre-Fontan systolic ventricular dysfunction, greater number of post-Fontan complications, and thrombosis after Fontan were independently associated with higher logBNP (R(2) = 0.16). Age-adjusted logBNP was significantly related to Fontan connection type (lower with extracardiac conduits, higher with atriopulmonary connection; P < .001). Lower physical functioning health status (R(2) = 0.05), lower chronotropic index during exercise (R(2) = 0.17), indices of diastolic dysfunction measured by echocardiography (R(2) = 0.15), and higher total ventricular mass on MRI (R(2) = 0.33) were related to higher logBNP. CONCLUSIONS Despite a markedly abnormal circulation, BNP was variable but within a normal range in the majority of Fontan patients in this large outpatient cohort. Higher BNP was associated with several markers of suboptimal outcome, although associations were weak. The routine use of BNP as an outpatient surveillance tool in asymptomatic Fontan patients is not warranted.
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Affiliation(s)
- Andrew M Atz
- Medical University of South Carolina, Charleston, SC 29425, USA.
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24
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Marino BS, Drotar D, Cassedy A, Davis R, Tomlinson RS, Mellion K, Mussatto K, Mahony L, Newburger JW, Tong E, Cohen MI, Helfaer MA, Kazak AE, Wray J, Wernovsky G, Shea JA, Ittenbach R. External validity of the pediatric cardiac quality of life inventory. Qual Life Res 2011; 20:205-14. [PMID: 21188538 PMCID: PMC3418540 DOI: 10.1007/s11136-010-9731-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE The Pediatric Cardiac Quality of Life Inventory (PCQLI) is a disease-specific, health-related quality of life (HRQOL) measure for pediatric heart disease (HD). The purpose of this study was to demonstrate the external validity of PCQLI scores. METHODS The PCQLI development site (Development sample) and six geographically diverse centers in the United States (Composite sample) recruited pediatric patients with acquired or congenital HD. Item response option variability, scores [Total (TS); Disease Impact (DI) and Psychosocial Impact (PI) subscales], patterns of correlation, and internal consistency were compared between samples. RESULTS A total of 3,128 patients and parent participants (1,113 Development; 2,015 Composite) were analyzed. Response option variability patterns of all items in both samples were acceptable. Inter-sample score comparisons revealed no differences. Median item-total (Development, 0.57; Composite, 0.59) and item-subscale (Development, DI 0.58, PI 0.59; Composite, DI 0.58, PI 0.56) correlations were moderate. Subscale-subscale (0.79 for both samples) and subscale-total (Development, DI 0.95, PI 0.95; Composite, DI 0.95, PI 0.94) correlations and internal consistency (Development, TS 0.93, DI 0.90, PI 0.84; Composite, TS 0.93, DI 0.89, PI 0.85) were high in both samples. CONCLUSION PCQLI scores are externally valid across the US pediatric HD population and may be used for multi-center HRQOL studies.
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Affiliation(s)
- Bradley S Marino
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA.
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25
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Auerbach SR, Richmond ME, Addonizio LJ, Lamour JM, Hsu DT, Blume ED, Shaddy RE, Mahony L, Pahl E. Response to Letter Regarding Article, “BNP Levels Predict Outcome in Pediatric Heart Failure Patients: Post Hoc Analysis of the Pediatric Carvedilol Trial”. Circ Heart Fail 2010. [DOI: 10.1161/circheartfailure.110.958629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Daphne T. Hsu
- Albert Einstein College of Medicine Bronx, NY (Lamour, Hsu)
| | | | | | - Lynn Mahony
- University of Texas Southwestern Medical Center Dallas, Tex (Mahony)
| | - Elfriede Pahl
- Northwestern University's Feinberg School of Medicine Chicago, Ill (Pahl)
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26
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Marino BS, Tomlinson RS, Wernovsky G, Drotar D, Newburger JW, Mahony L, Mussatto K, Tong E, Cohen M, Andersen C, Shera D, Khoury PR, Wray J, Gaynor JW, Helfaer MA, Kazak AE, Shea JA. Validation of the pediatric cardiac quality of life inventory. Pediatrics 2010; 126:498-508. [PMID: 20805147 PMCID: PMC3418527 DOI: 10.1542/peds.2009-2973] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [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] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The purpose of this multicenter study was to confirm the validity and reliability of the Pediatric Cardiac Quality of Life Inventory (PCQLI). METHODS Seven centers recruited pediatric patients (8-18 years of age) with heart disease (HD) and their parents to complete the PCQLI and generic health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]) and non-quality of life (Self-Perception Profile for Children [SPPC]/Self-Perception Profile for Adolescents [SPPA] and Youth Self-Report [YSR]/Child Behavior Checklist [CBCL]) tools. PCQLI construct validity was assessed through correlations of PCQLI scores between patients and parents and with severity of congenital HD, medical care utilization, and PedsQL, SPPC/SPPA, and YSR/CBCL scores. PCQLI test-retest reliability was evaluated. RESULTS The study enrolled 1605 patient-parent pairs. Construct validity was substantiated by the association of lower PCQLI scores with Fontan palliation and increased numbers of cardiac operations, hospital admissions, and physician visits (P<.001); moderate to good correlations between patient and parent PCQLI scores (r=0.41-0.61; P<.001); and fair to good correlations between PCQLI total scores and PedsQL total (r=0.70-0.76), SPPC/SPPA global self-worth (r=0.43-0.46), YSR/CBCL total competency (r=0.28-0.37), and syndrome and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-oriented scale (r=-0.58 to -0.30; P<.001) scores. Test-retest reliability correlations were excellent (r=0.78-0.90; P<.001). CONCLUSIONS PCQLI scores are valid and reliable for children and adolescents with congenital and acquired HD and may be useful for future research and clinical management.
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Affiliation(s)
- Bradley S. Marino
- Division of Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Ryan S. Tomlinson
- Division of Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Gil Wernovsky
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dennis Drotar
- Division of Behavioral and Clinical Psychology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jane W. Newburger
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts,Department of Pediatrics, School of Medicine, Harvard University, Boston, Massachusetts
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Kathleen Mussatto
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth Tong
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco, Children’s Hospital, San Francisco, California
| | - Mitchell Cohen
- Division of Cardiology, Department of Pediatrics, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Charlotte Andersen
- Division of Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - David Shera
- Division of Epidemiology and Biostatistics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Philip R. Khoury
- Division of Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jo Wray
- Department of Paediatric Cardiology, Royal Brompton and Harefield National Health Service Trust, London, United Kingdom
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark A. Helfaer
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne E. Kazak
- Division of Psychology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Judy A. Shea
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Williams RV, Ravishankar C, Zak V, Evans F, Atz AM, Border WL, Levine J, Li JS, Mahony L, Mital S, Pearson GD, Prakash A, Hsu DT. Birth weight and prematurity in infants with single ventricle physiology: pediatric heart network infant single ventricle trial screened population. CONGENIT HEART DIS 2010; 5:96-103. [PMID: 20412481 DOI: 10.1111/j.1747-0803.2009.00369.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Although congenital heart disease is associated with low birth weight and prematurity, there is little information about these birth outcomes in infants with single ventricle physiology. We describe the birth outcomes (i.e., gestational age and birth weight) in neonates with single ventricle physiology screened for enrollment in the Pediatric Heart Network's Infant Single Ventricle Trial, compare these outcomes with US norms, and examine the association of birth outcomes with anatomic diagnosis and race. PATIENTS AND METHODS All neonates with single ventricle physiology presenting to Infant Single Ventricle Trial centers were screened for enrollment. Demographic data and anatomic diagnoses were obtained from medical records. RESULTS A total of 1245 neonates with single ventricle physiology were screened at 10 centers (63 to 266 per center). Diagnoses included hypoplastic left heart syndrome in 49%, unbalanced atrioventricular septal defect in 12%, and tricuspid atresia in 9%. Preterm birth occurred in 16% of neonates with single ventricle physiology vs. 12% in normal neonates (P < .001), low birth weight (<2.5 kg) in 18% vs. 8% in normals (P < .001), and small for gestational age (<10th percentile by definition) in 22% vs. 10% in normals (P < .001). A genetic syndrome was reported in 8%. The percentage of preterm birth, low birth weight, and small for gestational age was similar between screened neonates with and without hypoplastic left heart syndrome. CONCLUSIONS In this large, contemporary cohort of neonates with single ventricle physiology, rates of preterm birth, low birth weight, and small for gestational age were higher than in the general population, but similar between screened neonates with and without hypoplastic left heart syndrome.
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Affiliation(s)
- Richard V Williams
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
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28
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Hsu DT, Zak V, Mahony L, Sleeper LA, Atz AM, Levine JC, Barker PC, Ravishankar C, McCrindle BW, Williams RV, Altmann K, Ghanayem NS, Margossian R, Chung WK, Border WL, Pearson GD, Stylianou MP, Mital S. Enalapril in infants with single ventricle: results of a multicenter randomized trial. Circulation 2010; 122:333-40. [PMID: 20625111 DOI: 10.1161/circulationaha.109.927988] [Citation(s) in RCA: 201] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitor therapy improves clinical outcome and ventricular function in adults with heart failure. Infants with single-ventricle physiology have poor growth and are at risk for abnormalities in ventricular systolic and diastolic function. The ability of angiotensin-converting enzyme inhibitor therapy to preserve ventricular function and improve somatic growth and outcomes in these infants is unknown. METHODS AND RESULTS The Pediatric Heart Network conducted a double-blind trial involving 230 infants with single-ventricle physiology randomized to receive enalapril (target dose 0.4 mg . kg(-1) . d(-1)) or placebo who were followed up until 14 months of age. The primary end point was weight-for-age z score at 14 months. The primary analysis was intention to treat. A total of 185 infants completed the study. There were 24 and 21 withdrawals or deaths in the enalapril and placebo groups, respectively (P=0.74). Weight-for-age z score was not different between the enalapril and placebo groups (mean+/-SE -0.62+/-0.13 versus -0.42+/-0.13, P=0.28). There were no significant group differences in height-for-age z score, Ross heart failure class, brain natriuretic peptide concentration, Bayley scores of infant development, or ventricular ejection fraction. The incidence of death or transplantation was 13% and did not differ between groups. Serious adverse events occurred in 88 patients in the enalapril group and 87 in the placebo group. CONCLUSIONS Administration of enalapril to infants with single-ventricle physiology in the first year of life did not improve somatic growth, ventricular function, or heart failure severity. The results of this randomized trial do not support the routine use of enalapril in this population.
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Affiliation(s)
- Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, 3415 Bainbridge Ave., Bronx, NY 10457, USA.
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29
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Ohye RG, Sleeper LA, Mahony L, Newburger JW, Pearson GD, Lu M, Goldberg CS, Tabbutt S, Frommelt PC, Ghanayem NS, Laussen PC, Rhodes JF, Lewis AB, Mital S, Ravishankar C, Williams IA, Dunbar-Masterson C, Atz AM, Colan S, Minich LL, Pizarro C, Kanter KR, Jaggers J, Jacobs JP, Krawczeski CD, Pike N, McCrindle BW, Virzi L, Gaynor JW. Comparison of shunt types in the Norwood procedure for single-ventricle lesions. N Engl J Med 2010; 362:1980-92. [PMID: 20505177 PMCID: PMC2891109 DOI: 10.1056/nejmoa0912461] [Citation(s) in RCA: 664] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood procedure with a modified Blalock-Taussig (MBT) shunt, the first palliative stage for single-ventricle lesions with systemic outflow obstruction, is associated with high mortality. The right ventricle-pulmonary artery (RVPA) shunt may improve coronary flow but requires a ventriculotomy. We compared the two shunts in infants with hypoplastic heart syndrome or related anomalies. METHODS Infants undergoing the Norwood procedure were randomly assigned to the MBT shunt (275 infants) or the RVPA shunt (274 infants) at 15 North American centers. The primary outcome was death or cardiac transplantation 12 months after randomization. Secondary outcomes included unintended cardiovascular interventions and right ventricular size and function at 14 months and transplantation-free survival until the last subject reached 14 months of age. RESULTS Transplantation-free survival 12 months after randomization was higher with the RVPA shunt than with the MBT shunt (74% vs. 64%, P=0.01). However, the RVPA shunt group had more unintended interventions (P=0.003) and complications (P=0.002). Right ventricular size and function at the age of 14 months and the rate of nonfatal serious adverse events at the age of 12 months were similar in the two groups. Data collected over a mean (+/-SD) follow-up period of 32+/-11 months showed a nonsignificant difference in transplantation-free survival between the two groups (P=0.06). On nonproportional-hazards analysis, the size of the treatment effect differed before and after 12 months (P=0.02). CONCLUSIONS In children undergoing the Norwood procedure, transplantation-free survival at 12 months was better with the RVPA shunt than with the MBT shunt. After 12 months, available data showed no significant difference in transplantation-free survival between the two groups. (ClinicalTrials.gov number, NCT00115934.)
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Affiliation(s)
- Richard G Ohye
- University of Michigan Medical School, Ann Arbor, MI, USA.
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30
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McCrindle BW, Zak V, Sleeper LA, Paridon SM, Colan SD, Geva T, Mahony L, Li JS, Breitbart RE, Margossian R, Williams RV, Gersony WM, Atz AM. Laboratory measures of exercise capacity and ventricular characteristics and function are weakly associated with functional health status after Fontan procedure. Circulation 2009; 121:34-42. [PMID: 20026781 DOI: 10.1161/circulationaha.109.869396] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients after the Fontan procedure are at risk for suboptimal functional health status, and associations with laboratory measures are important for planning interventions and outcome measures for clinical trials. METHODS AND RESULTS Parents completed the generic Child Health Questionnaire for 511 Fontan Cross-Sectional Study patients 6 to 18 years of age (61% male). Associations of Child Health Questionnaire Physical and Psychosocial Functioning Summary Scores (FSS) with standardized measurements from prospective exercise testing, echocardiography, magnetic resonance imaging, and measurement of brain natriuretic peptide were determined by regression analyses. For exercise variables for maximal effort patients only, the final model showed that higher Physical FSS was associated only with higher maximum work rate, accounting for 9% of variation in Physical FSS. For echocardiography, lower Tei index (particularly for patients with extracardiac lateral tunnel connections), lower indexed end-systolic volume, and the absence of atrioventricular valve regurgitation for patients having Fontan procedure at age <2 years were associated with higher Physical FSS, accounting for 14% of variation in Physical FSS. For magnetic resonance imaging, ratio of lower mass to end-diastolic volume and midquartiles of indexed end-systolic volume (nonlinear) were associated with higher Physical FSS, accounting for 11% of variation. Lower brain natriuretic peptide was significantly but weakly associated with higher Physical FSS (1% of variation). Significant associations for Psychosocial FSS with laboratory measures were fewer and weaker than for Physical FSS. CONCLUSIONS In relatively healthy Fontan patients, laboratory measures account for a small proportion of the variation in functional health status and therefore may not be optimal surrogate end points for trials of therapeutic interventions.
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Affiliation(s)
- Brian W McCrindle
- Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.
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31
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Auerbach S, Richmond M, Lamour J, Blume E, Addonizio L, Shaddy R, Mahony L, Pahl E, Hsu D. 21: BNP Levels Predict Outcome in Pediatric Heart Failure Patients: Post-Hoc Analysis of the Pediatric Carvedilol Trial. J Heart Lung Transplant 2009. [DOI: 10.1016/j.healun.2008.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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32
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Hsu DT, Mital S, Ravishankar C, Margossian R, Li JS, Sleeper LA, Williams RV, Levine JC, McCrindle BW, Atz AM, Servedio D, Mahony L. Rationale and design of a trial of angiotensin-converting enzyme inhibition in infants with single ventricle. Am Heart J 2009; 157:37-45. [PMID: 19081394 DOI: 10.1016/j.ahj.2008.08.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 08/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Angiotensin converting enzyme (ACE) inhibitors are known to improve clinical outcome and ventricular function in adults with heart failure. Infants with single-ventricle physiology show abnormalities in ventricular function as well as poor growth. The ability of an ACE inhibitor to preserve ventricular function and improve growth in these infants is unknown. METHODS The Pediatric Heart Network designed a randomized, double-blind trial to compare outcomes in infants with single-ventricle physiology receiving enalapril or placebo. Neonates < or =45 days old were eligible. The primary outcome is weight-for-age Z-score at 14 months of age. Secondary outcomes include other measures of somatic growth, laboratory and functional measures of heart failure, developmental indices, measures of ventricular size and function, and the relationship of the renin-angiotensin-aldosterone system genotype to the response to enalapril. The incidence and spectrum of adverse events will also be compared between treatment groups. RESULTS A total of 1,245 neonates were screened and 533 (43%) were eligible. The consent rate was 43%; 230 subjects were enrolled. Parental reluctance to participate was the primary reason for non-consent in 79% of the eligible nonconsenting patients. Randomized patients were older, more likely to be male, and more likely to have hypoplastic left heart syndrome than the eligible patients who did not enroll. CONCLUSIONS The results of this randomized trial will make an important contribution to the management of infants with single-ventricle physiology by determining whether initiation of ACE inhibition therapy in the neonatal period improves growth, clinical outcome, and ventricular function.
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Burns JC, Best BM, Mejias A, Mahony L, Fixler DE, Jafri HS, Melish ME, Jackson MA, Asmar BI, Lang DJ, Connor JD, Capparelli EV, Keen ML, Mamun K, Keenan GF, Ramilo O. Infliximab treatment of intravenous immunoglobulin-resistant Kawasaki disease. J Pediatr 2008; 153:833-8. [PMID: 18672254 PMCID: PMC2856847 DOI: 10.1016/j.jpeds.2008.06.011] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.1] [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: 12/04/2007] [Revised: 04/28/2008] [Accepted: 06/12/2008] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate the safety, tolerability, and pharmacokinetics of the anti-tumor necrosis factor-alpha monoclonal antibody infliximab in subjects with intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD). STUDY DESIGN We conducted a multicenter, randomized, prospective trial of second IVIG infusion (2 g/kg) versus infliximab (5 mg/kg) in 24 children with acute KD and fever after initial treatment with IVIG. Primary outcome measures were the safety, tolerability, and pharmacokinetics of infliximab. Secondary outcome measures were duration of fever and changes in markers of inflammation. RESULTS Study drug infusions were associated with cessation of fever within 24 hours in 11 of 12 subjects treated with infliximab and in 8 of 12 subjects retreated with IVIG. No infusion reactions or serious adverse events were attributed to either study drug. No significant differences were observed between treatment groups in the change from baseline for laboratory variables, fever, or echocardiographic assessment of coronary arteries. CONCLUSIONS Both infliximab and a second IVIG infusion were safe and well tolerated in the subjects with KD who were resistant to standard IVIG treatment. The optimal management of patients resistant to IVIG remains to be determined.
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Affiliation(s)
- Jane C. Burns
- Dept. of Pediatrics, Univ of California San Diego (UCSD) School of Medicine and Rady Children's Hospital San Diego, La Jolla, CA 92093
| | - Brookie M. Best
- Dept. of Pediatrics, Univ of California San Diego (UCSD) School of Medicine and Rady Children's Hospital San Diego, La Jolla, CA 92093,Skaggs School of Pharmacy and Pharmaceutical Sciences, UCSD, La Jolla, CA 92093
| | - Asuncion Mejias
- Dept. of Pediatrics, Univ. of Texas Southwestern Medical Center at Dallas and Children's Medical Center, Dallas, TX
| | - Lynn Mahony
- Dept. of Pediatrics, Univ. of Texas Southwestern Medical Center at Dallas and Children's Medical Center, Dallas, TX
| | - David E. Fixler
- Dept. of Pediatrics, Univ. of Texas Southwestern Medical Center at Dallas and Children's Medical Center, Dallas, TX
| | - Hasan S. Jafri
- Dept. of Pediatrics, Univ. of Texas Southwestern Medical Center at Dallas and Children's Medical Center, Dallas, TX
| | - Marian E. Melish
- Dept. of Pediatrics, John A. Burns School of Medicine, Univ. of Hawaii, Kapiolani Medical Center, Honolulu, HI
| | - Mary Anne Jackson
- Dept. of Pediatrics, Children's Mercy Hospital & Clinics, Kansas City, MO
| | - Basim I. Asmar
- Dept of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - David J. Lang
- Dept of Pediatrics, Children's Hospital of Orange County, Orange, CA
| | - James D. Connor
- Dept. of Pediatrics, Univ of California San Diego (UCSD) School of Medicine and Rady Children's Hospital San Diego, La Jolla, CA 92093
| | - Edmund V. Capparelli
- Dept. of Pediatrics, Univ of California San Diego (UCSD) School of Medicine and Rady Children's Hospital San Diego, La Jolla, CA 92093
| | | | | | | | - Octavio Ramilo
- Dept. of Pediatrics, Univ. of Texas Southwestern Medical Center at Dallas and Children's Medical Center, Dallas, TX
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34
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Anderson PAW, Sleeper LA, Mahony L, Colan SD, Atz AM, Breitbart RE, Gersony WM, Gallagher D, Geva T, Margossian R, McCrindle BW, Paridon S, Schwartz M, Stylianou M, Williams RV, Clark BJ. Contemporary outcomes after the Fontan procedure: a Pediatric Heart Network multicenter study. J Am Coll Cardiol 2008; 52:85-98. [PMID: 18598886 PMCID: PMC4385517 DOI: 10.1016/j.jacc.2008.01.074] [Citation(s) in RCA: 286] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 01/17/2008] [Accepted: 01/26/2008] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We characterized a large cohort of children who had a Fontan procedure, with measures of functional health status, ventricular size and function, exercise capacity, heart rhythm, and brain natriuretic peptide (BNP). BACKGROUND The characteristics of contemporary Fontan survivors are not well described. METHODS We enrolled 546 children (age 6 to 18 years, mean 11.9 years) and compared them within pre-specified anatomic and procedure subgroups. History and outcome measures were obtained within a 3-month period. RESULTS Predominant ventricular morphology was 49% left ventricular (LV), 34% right ventricular (RV), and 19% mixed. Ejection fraction (EF) was normal for 73% of subjects; diastolic function grade was normal for 28%. Child Health Questionnaire mean summary scores were lower than for control subjects; however, over 80% of subjects were in the normal range. Brain natriuretic peptide concentration ranged from <4 to 652 pg/ml (median 13 pg/ml). Mean percent predicted peak O2 consumption was 65% and decreased with age. Ejection fraction and EF Z score were lowest, and semilunar and atrioventricular (AV) valve regurgitation were more prevalent in the RV subgroup. Older age at Fontan was associated with more severe AV valve regurgitation. Most outcomes were not associated with a superior cavopulmonary connection before Fontan. CONCLUSIONS Measures of ventricular systolic function and functional health status, although lower on average in the cohort compared with control subjects, were in the majority of subjects within 2 standard deviations of the mean for control subjects. Right ventricular morphology was associated with poorer ventricular and valvular function. Effective strategies to preserve ventricular and valvular function, particularly for patients with RV morphology, are needed.
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Lacro RV, Dietz HC, Wruck LM, Bradley TJ, Colan SD, Devereux RB, Klein GL, Li JS, Minich LL, Paridon SM, Pearson GD, Printz BF, Pyeritz RE, Radojewski E, Roman MJ, Saul JP, Stylianou MP, Mahony L. Rationale and design of a randomized clinical trial of beta-blocker therapy (atenolol) versus angiotensin II receptor blocker therapy (losartan) in individuals with Marfan syndrome. Am Heart J 2007; 154:624-31. [PMID: 17892982 PMCID: PMC3042860 DOI: 10.1016/j.ahj.2007.06.024] [Citation(s) in RCA: 178] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 06/20/2007] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cardiovascular disease, including aortic root dilation, dissection, and rupture, is the leading cause of mortality in patients with Marfan syndrome (MFS). The maximal aortic root diameter at the sinuses of Valsalva is considered the best predictor of adverse cardiovascular outcome. Although advances in therapy have improved life expectancy, affected individuals continue to suffer cardiovascular morbidity and mortality. Recent studies in an FBN1-targeted mouse model of MFS with aortic disease similar to that seen in humans showed that treatment with losartan normalized aortic root growth and aortic wall architecture. METHODS The Pediatric Heart Network designed a randomized clinical trial to compare aortic root growth and other short-term cardiovascular outcomes in subjects with MFS receiving atenolol or losartan. Individuals 6 months to 25 years of age with a body surface area-adjusted aortic root z score >3.0 will be eligible for inclusion. The primary aim is to compare the effect of atenolol therapy with that of losartan therapy on the rate of aortic root growth over 3 years. Secondary end points include progression of aortic regurgitation; incidence of aortic dissection, aortic root surgery, and death; progression of mitral regurgitation; left ventricular size and function; echocardiographically derived measures of central aortic stiffness; skeletal and somatic growth; and incidence of adverse drug reactions. CONCLUSION This randomized trial should make a substantial contribution to the management of individuals with MFS and expand our understanding of the mechanisms responsible for the aortic manifestations of this disorder.
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Affiliation(s)
- Ronald V Lacro
- Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
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Shaddy RE, Boucek MM, Hsu DT, Boucek RJ, Canter CE, Mahony L, Ross RD, Pahl E, Blume ED, Dodd DA, Rosenthal DN, Burr J, LaSalle B, Holubkov R, Lukas MA, Tani LY. Carvedilol for children and adolescents with heart failure: a randomized controlled trial. JAMA 2007; 298:1171-9. [PMID: 17848651 DOI: 10.1001/jama.298.10.1171] [Citation(s) in RCA: 349] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CONTEXT Although beta-blockers improve symptoms and survival in adults with heart failure, little is known about these medications in children and adolescents. OBJECTIVE To prospectively evaluate the effects of carvedilol in children and adolescents with symptomatic systemic ventricular systolic dysfunction. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized, double-blind, placebo-controlled study of 161 children and adolescents with symptomatic systolic heart failure from 26 US centers. In addition to treatment with conventional heart failure medications, patients were assigned to receive placebo or carvedilol. Enrollment began in June 2000 and the last dose was given in May 2005 (each patient received medication for 8 months). INTERVENTIONS Patients were randomized in a 1:1:1 ratio to twice-daily dosing with placebo, low-dose carvedilol (0.2 mg/kg per dose if weight <62.5 kg or 12.5 mg per dose if weight > or =62.5 kg), or high-dose carvedilol (0.4 mg/kg per dose if weight <62.5 kg or 25 mg per dose if weight > or =62.5 kg) and were stratified according to whether each patient's systemic ventricle was a left ventricle or not. MAIN OUTCOME MEASURES The primary outcome was a composite measure of heart failure outcomes in patients receiving carvedilol (low- and high-dose combined) vs placebo. Secondary efficacy variables included individual components of this composite, echocardiographic measures, and plasma b-type natriuretic peptide levels. RESULTS There was no statistically significant difference between groups for the composite end point based on the percentage of patients who improved, worsened, or were unchanged. Among 54 patients assigned to placebo, 30 improved (56%), 16 worsened (30%), and 8 were unchanged (15%); among 103 patients assigned to carvedilol, 58 improved (56%), 25 worsened (24%), and 20 were unchanged (19%). The rates of worsening were lower than expected. The odds ratio for worsened outcome for patients in the combined carvedilol group vs the placebo group was 0.79 (95% CI, 0.36-1.59; P = .47). A prespecified subgroup analysis noted significant interaction between treatment and ventricular morphology (P = .02), indicating a possible differential effect of treatment between patients with a systemic left ventricle (beneficial trend) and those whose systemic ventricle was not a left ventricle (nonbeneficial trend). CONCLUSIONS These preliminary results suggest that carvedilol does not significantly improve clinical heart failure outcomes in children and adolescents with symptomatic systolic heart failure. However, given the lower than expected event rates, the trial may have been underpowered. There may be a differential effect of carvedilol in children and adolescents based on ventricular morphology. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00052026.
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Affiliation(s)
- Robert E Shaddy
- Department of Pediatrics, University of Utah School of Medicine and Primary Children's Medical Center, Salt Lake City, USA.
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Li JS, Yow E, Berezny KY, Rhodes JF, Bokesch PM, Charpie JR, Forbus GA, Mahony L, Boshkov L, Lambert V, Bonnet D, Michel-Behnke I, Graham TP, Takahashi M, Jaggers J, Califf RM, Rakhit A, Fontecave S, Sanders SP. Clinical Outcomes of Palliative Surgery Including a Systemic-to-Pulmonary Artery Shunt in Infants With Cyanotic Congenital Heart Disease. Circulation 2007; 116:293-7. [PMID: 17592082 DOI: 10.1161/circulationaha.106.652172] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aspirin (ASA) often is used to prevent thrombosis in infants with congenital heart disease after placement of a systemic-to-pulmonary artery shunt, but its effect on outcomes is unknown. METHODS AND RESULTS The present multicenter study prospectively collected data on 1-year postoperative rates of death, shunt thrombosis, or hospitalization age <4 months for bidirectional Glenn/hemi-Fontan surgery in 1004 infants. The use and dose of ASA were recorded. Kaplan-Meier event rates were calculated for each event and the composite outcome, and a Cox regression model was constructed for time to event. Model terms were ASA use and type of surgery, with adjustment for age at surgery. Diagnoses were hypoplastic left heart syndrome (n=346), tricuspid atresia (n=103), tetralogy of Fallot (n=127), pulmonary atresia (n=177), heterotaxy syndrome (n=38), and other (n=213). There were 344 shunts placed without cardiopulmonary bypass (closed shunt), 287 shunts with bypass (open shunt), 323 Norwood procedures, and 50 Sano procedures. Overall, 80% of patients received ASA. One-year postoperative events rates were high: 38% for the composite end point, 26% for death, and 12% for shunt thrombosis. After the exclusion of patients with early mortality, patients receiving ASA had a lower risk of shunt thrombosis (hazard ratio, 0.13; P=0.008) and death (closed shunt: hazard ratio, 0.41, P=0.057; open shunt: hazard ratio, 0.10, P<0.001; Norwood: hazard ratio, 0.34, P<0.001; Sano: hazard ratio, 0.68, P=NS) compared with those not receiving ASA. CONCLUSIONS The morbidity and mortality for infants after surgical placement of a systemic-to-pulmonary artery shunt are high. ASA appears to lower the risk of death and shunt thrombosis in the present observational study.
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Affiliation(s)
- Jennifer S Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
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Sleeper LA, Anderson P, Hsu DT, Mahony L, McCrindle BW, Roth SJ, Saul JP, Williams RV, Geva T, Colan SD, Clark BJ. Design of a large cross-sectional study to facilitate future clinical trials in children with the Fontan palliation. Am Heart J 2006; 152:427-33. [PMID: 16923408 PMCID: PMC4266479 DOI: 10.1016/j.ahj.2006.02.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 02/07/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinical trials in children with congenital heart disease are often limited by the absence of the following: (1) a primary outcome that can be observed in a reasonable period; (2) information regarding health-related quality of life; (3) knowledge of the correlation between health status and ventricular function and exercise performance; (4) a sufficient number of children at a single institution to provide adequate statistical power; and (5) procedural and management differences between and within institutions. METHODS The NHLBI-funded Pediatric Heart Network designed a cross-sectional study of children aged 6 to 18 years, from 7 pediatric clinical centers, who had undergone a Fontan procedure as treatment for congenital heart disease. Health-related quality of life was measured by the Child Health Questionnaire and the Congenital Heart Adolescent and Teenager Questionnaire. Ventricular function was assessed by maximal exercise testing, echocardiography, cardiac magnetic resonance imaging, and B-type natriuretic peptide. The study was designed to detect a correlation of R > or = 0.30 between health status scores and measures of ventricular function and performance in a subcohort with all study measures completed. RESULTS A total of 1078 children were screened by chart review; 644 (60%) were eligible. The consent rate was 85% and 546 children were enrolled. Acquisition of echocardiograms, B-type natriuretic peptide, and health status was > or = 94%; completion rates were lower for maximal exercise testing (76%) and cardiac magnetic resonance imaging (41%). CONCLUSIONS This large study provides unique information regarding the relationship between health status and clinical measures in post-Fontan patients that will facilitate the design of future randomized trials.
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Affiliation(s)
- Lynn A Sleeper
- New England Research Institutes, Watertown, MA 02472, USA.
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Mahony L, Sleeper LA, Anderson PAW, Gersony WM, McCrindle BW, Minich LL, Newburger JW, Saul JP, Vetter VL, Pearson GD. The Pediatric Heart Network: a primer for the conduct of multicenter studies in children with congenital and acquired heart disease. Pediatr Cardiol 2006; 27:191-8. [PMID: 16261271 DOI: 10.1007/s00246-005-1151-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most contemporary diagnostic and treatment strategies for pediatric patients with cardiovascular disease are not supported by evidence from clinical trials but instead are based on expert opinion, single-institution observational studies, or extrapolated from adult cardiovascular medicine. In response to this concern, the National Heart, Lung, and Blood Institute established the Pediatric Heart Disease Clinical Research Network (PHN) in 2001. The purposes of this article are to describe the initiation, structure, and function of the PHN; to review the ongoing studies; and to address current and future challenges. To date, four randomized clinical trials and two observational studies have been launched. Design and conduct of complex, multicenter studies in children with congenital and acquired heart disease must address numerous challenges, including identification of an appropriate clinically relevant primary endpoint, lack of preliminary data on which to base sample size calculations, and recruitment of an adequate number of subjects. The infrastructure is now well developed and capable of implementing complex, multicenter protocols efficiently and recruiting subjects effectively. The PHN is uniquely positioned to contribute to providing evidence-based medicine for and improving the outcomes of pediatric patients with cardiovascular disease.
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Affiliation(s)
- L Mahony
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Rosenthal D, Chrisant MRK, Edens E, Mahony L, Canter C, Colan S, Dubin A, Lamour J, Ross R, Shaddy R, Addonizio L, Beerman L, Berger S, Bernstein D, Blume E, Boucek M, Checchia P, Dipchand A, Drummond-Webb J, Fricker J, Friedman R, Hallowell S, Jaquiss R, Mital S, Pahl E, Pearce FB, Pearce B, Rhodes L, Rotondo K, Rusconi P, Scheel J, Pal Singh T, Towbin J. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant 2005; 23:1313-33. [PMID: 15607659 DOI: 10.1016/j.healun.2004.03.018] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- David Rosenthal
- International Society for Heart and Lung Transplantation, Addison, Texas.
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Abstract
OBJECTIVE Children undergoing cardiac surgery often experience traumatic situations related to their care and may be at risk for developing posttraumatic stress disorder (PTSD). The purpose of this study was to examine children's responses to cardiac surgery and the factors that mediate responses. STUDY DESIGN Forty-three 5- to 12-year-old children undergoing cardiac surgery were evaluated pre- and postoperatively for PTSD. The effect of baseline cognitive level, temperament, family support, and length of intensive care unit (ICU) stay on PTSD symptomatology was examined. RESULTS No child had PTSD pre-operatively. For the entire group, the number of PTSD symptoms increased significantly from pre- to postoperatively (Wilcoxon signed rank test; Z=-2.62, P<.001). PTSD symptoms increased in 10 (23%) children, decreased in 1 child, and did not change in 32 (74%) children. Five of the 43 children (12%) met criteria for PTSD postoperatively. Length of ICU stay was the only predictor of PTSD, P<.001. The number of PTSD symptoms increased if ICU stay exceeded 48 hours. CONCLUSIONS Children undergoing cardiac surgery are at risk for developing PTSD, especially if the ICU stay is prolonged. These findings provide a basis to develop risk stratification methods and targeted interventions for this population.
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Affiliation(s)
- Dana Connolly
- Department of Pediatrics, New York University School of Medicine, 540 First Avenue, Suite 9U, New York, NY 10016, USA.
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Scheinkestel CD, Adams F, Mahony L, Bailey M, Davies AR, Nyulasi I, Tuxen DV. Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal replacement therapy. Nutrition 2003; 19:733-40. [PMID: 12921882 DOI: 10.1016/s0899-9007(03)00107-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [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: 11/21/2022]
Abstract
OBJECTIVES We wanted to establish optimum protein and glucose intakes during total parenteral nutrition by using a constant caloric but changing protein intake in critically ill, ventilated, anuric patients on continuous renal replacement therapy and measuring amino acid and glucose losses across the hemofilter. METHODS Eleven consecutive, critically ill patients (eight male, age, 43.5 +/- 21.8 y; Acute Physiology and Chronic Health Evaluation II score, 20.5 +/- 7.0; Acute Physiology and Chronic Health Evaluation risk of death: 36.5% +/- 23.0 and 6 +/- 1 impaired organ systems) entered this study. Patients were fed by continuous infusion of a total parenteral mixture consisting of Synthamin (a mixture of essential and non-essential amino acids), 50% dextrose, and intralipid (long-chain triglycerides) to meet caloric requirements as predicted by Schofield's equation corrected by stress factors. The amount of protein infused was varied (1 to 2.5 g. kg(-1). d(-1)) by increments of 0.25 g. kg(-1). d(-1). Patients were stabilized on each feeding regimen for at least 24 h before paired samples of blood and dialysate were taken for amino acid and glucose measurements. Continuous renal replacement therapy was performed by using a blood pump with a blood flow of 100 to 175 mL/min. Dialysate was pumped in and out counter-currently to the blood flow at 2 L/h. A biocompatible polyacrylonitrile hemofilter was used in all cases. RESULTS With protein intakes below 2.5 g. kg(-1). d(-1), blood levels of 14% to 57% of the measured amino acids were below the lower limits of the normal range. At 2.5 g. kg(-1). d(-1), all measured amino acids were within the normal range. Amino acid balance became more positive as protein input increased (P = 0.0001). Glucose and amino acid losses were dependent on blood concentration. Overall, 17% (range, 13% to 24%) of infused amino acids and 4% of infused glucose were lost in the dialysate. CONCLUSIONS This study of critically ill, ventilated, anuric patients on continuous renal replacement therapy suggested that increases in protein and glucose are required to account for the increased losses across the hemofilter. A protein intake of 2.5 g. kg(-1). d(-1) appeared to optimize nitrogen balance and correct amino acid deficiencies.
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Abstract
BACKGROUND Changes in neurocognitive function after cardiopulmonary bypass (CPB) are difficult to assess in children with congenital cardiovascular malformations in part because identification of a suitable control group of children is difficult. METHODS AND RESULTS We evaluated neurocognitive function in subjects aged 3 to 17 years both before and after surgical repair of an atrial septal defect (ASD). Eighteen subjects underwent testing within a median of 3 days (range, 1 to 27) before surgery and 5.8 months (range, 5.5 to 9) after surgery. The Differential Ability Scales was administered to subjects in a single testing session. All subjects were considered to be healthy, and they had no activity limitations. The mean General Conceptual Ability (GCA) scores (analogous to IQ) for the group were in the normal range before and after ASD repair. No significant difference was detected between the GCA scores before and after surgery. The GCA score was 90.8+/-18.6 before surgery and 93.1+/-16.3 after surgery. CONCLUSIONS Use of CPB was not associated with changes in cognitive function in our subjects who underwent repair of an ASD.
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Shaddy RE, Curtin EL, Sower B, Tani LY, Burr J, LaSalle B, Boucek MM, Mahony L, Hsu DT, Pahl E, Burch GH, Schlencker-Herceg R. The Pediatric Randomized Carvedilol Trial in Children with Heart Failure: rationale and design. Am Heart J 2002; 144:383-9. [PMID: 12228773 DOI: 10.1067/mhj.2002.124402] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Carvedilol is a medication with both beta-receptor and alpha-receptor blocking properties that has been approved for the treatment of heart failure in adults. Little is known about its safety, efficacy, pharmacokinetics, and dosing profile in children. METHODS The primary objective of this study is to evaluate the efficacy of carvedilol administered twice daily for 8 months in terms of its effect compared with placebo on a composite measure of clinical outcomes in children with symptomatic systemic ventricular systolic dysfunction and heart failure. The secondary objectives are to determine the effect of carvedilol on individual components of a composite of clinical outcomes (hospitalizations for worsening heart failure, all-cause mortality and cardiovascular hospitalizations, all cause mortality, heart failure symptoms, and patient and physician global assessment); determine the effect of carvedilol on echocardiographic indices of ventricular function and remodeling; characterize the pharmacokinetics of carvedilol in pediatric patients with heart failure; characterize the effects carvedilol on neurohormonal systems; and provide data for the selection of an optimal titration schedule and daily dose of carvedilol in children with heart failure. This study will enroll 150 children between birth and 17 years of age with chronic symptomatic heart failure caused by systemic ventricular systolic dysfunction. CONCLUSION This study will determine whether carvedilol improves symptoms in children with heart failure as a result of systemic ventricular systolic dysfunction. The study also will provide information on echocardiographic changes of ventricular performance and neurohormonal levels in children with heart failure before and after treatment with carvedilol, in addition to pharmacokinetics of carvedilol in children.
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Affiliation(s)
- Robert E Shaddy
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA.
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Baig AA, Kozak KM, Cox ER, Zoladz JR, Mahony L, White DJ. Laboratory studies on the chemical whitening effects of a sodium hexametaphosphate dentifrice. J Clin Dent 2002; 13:19-24. [PMID: 11507927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Laboratory studies were developed to permit the evaluation of chemical actions of toothpaste components in the non-abrasive prevention and removal of tea stains. Powdered hydroxyapatites were used as substrates for adsorption of tea chromogens. Pre-treatment with a sodium hexametaphosphate dentifrice (Crest Dual Action Whitening) reduced tea adsorption to powdered apatite, while post-treatments of pre-stained powder resulted in desorption of tea components. These results exemplified the chemical actions of condensed calcium phosphate surface active builders toward dental stain removal and prevention. A cycling synamel chip model permitted the study of stain prevention, including salivary pellicle formation and chlorhexidine enhancement of dental staining by tea chromogens. Staining was evaluated by image analysis of color development. Under these conditions, condensed phosphate dentifrices were observed to produce superior prevention of stain accumulations, with Crest Dual Action Whitening dentifrice providing stain prevention superior to a variety of commercial dentifrices, including Colgate Total, Aquafresh Whitening, Colgate Tartar Control Whitening, Mentadent Baking Soda and Peroxide Whitening, Close-Up Whitening, Crest Tartar Control and Crest Regular Cavity Protection.
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Affiliation(s)
- Arif A Baig
- Procter & Gamble Company, Health Care Research Center, Mason, OH, USA.
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Pugia ML, Middel CJ, Seward SW, Pollock JL, Hall RC, Lowe L, Mahony L, Henderson NE. Comparison of acute swelling and function in subjects with lateral ankle injury. J Orthop Sports Phys Ther 2001; 31:384-8. [PMID: 11451309 DOI: 10.2519/jospt.2001.31.7.384] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Prospective correlational study involving a convenience sample. OBJECTIVES To investigate the relationships among figure-of-eight girth measurements and functional level in patients with acute lateral ankle sprains to determine the appropriate use of these clinical measures. BACKGROUND Research has shown that subjective scales of perceived athletic ability and measurements of swelling are useful in assessing clinical improvement following an acute ankle sprain; however, the relationship between ankle swelling and level of function is not known. METHODS AND MEASURES Twenty-nine subjects (20 men, 9 women) varying in age from 18-59 years of age (mean age, 30.8 +/- 11.37) with acute lateral ankle sprains were included in this study. Each subject was evaluated by 1 of 3 raters for ankle girth, weight-bearing status, and functional level as determined by a modified Ankle Osteoarthritis Scale (AOS) and the Foot and Ankle Ability Index (FAAI). This study also investigated the relationship between these measures and the sport subscale of the FAAI (FAAI sport). This is an 8-item subscale which includes questions on running, jumping, landing, quick starts and stops, cutting or lateral movements, low impact activities, ability to perform an activity with normal technique, and ability to participate in desired sports. RESULTS No significant correlations were found between figure-of-eight girth measurements and functional level. However, we did find moderate to good correlations between the FAAI vs. weight-bearing (rho = 0.73), FAAI vs. AOS (rho = -0.79), FAAI sport vs. weight-bearing (rho = 0.68), FAAI vs. FAAI Sport (rho = 0.73), weight-bearing vs. AOS (rho = -0.57), and FAAI Sport vs. AOS (rho = -0.50). CONCLUSIONS The figure-of-eight method is highly reliable and is appropriate for measuring ankle swelling; however, it does not correlate with functional level as determined by the modified AOS, FAAI, or observed weight-bearing status during gait. Therefore, clinicians should refrain from making assumptions about function based on ankle swelling.
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Affiliation(s)
- M L Pugia
- US Army-Baylor University Graduate Program in Physical Therapy, Fort Sam Houston, Tex. USA.
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47
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Abstract
Three neonates presented with malignant hypertension during the first week of life; 2 of them had congestive heart failure. Although none had indwelling umbilical artery catheters, unilateral renovascular lesions were diagnosed by nuclear perfusion scans. Angiotensin-converting enzyme inhibitor therapy produced rapid recovery. Hypertension must be included in the differential diagnosis of infants presenting with congestive heart failure and acidosis. Ultrasonography is not sensitive enough to exclude renovascular lesions. We emphasize the importance of early diagnosis and treatment.
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Affiliation(s)
- J M Saland
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, USA
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Abstract
We performed a retrospective cohort study to assess the relation between administration of angiotensin-converting enzyme inhibitors and duration of pleural drainage in the early postoperative period in patients who underwent a modified Fontan operation at our institution from 1990 through 1996. This study failed to show that administration of captopril decreased the duration of pleural drainage in patients after a modified Fontan operation.
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Affiliation(s)
- N Heragu
- University of Texas Southwestern Medical Center at Dallas, 75235-9063, USA
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Garcia JA, Zellers TM, Weinstein EM, Mahony L. Usefulness of Doppler echocardiography in diagnosing right ventricular coronary arterial communications in patients with pulmonary atresia and intact ventricular septum and comparison with angiography. Am J Cardiol 1998; 81:103-4. [PMID: 9462620 DOI: 10.1016/s0002-9149(97)00855-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Direct and indirect evidence of right ventricular coronary arterial communications has been detected by use of 2-dimensional and Doppler echocardiography in patients with pulmonary atresia and intact ventricular septum. We describe additional consistent and reproducible Doppler echocardiographic findings that were useful for identifying patients in whom abnormal coronary arterial flow patterns were detected angiographically.
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Affiliation(s)
- J A Garcia
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 75235-9063, USA
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Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors improve exercise capacity in adults with congestive heart failure by decreasing systemic vascular resistance and improving ventricular diastolic function. Patients who have undergone the Fontan procedure have decreased cardiac output, increased systemic vascular resistance, abnormal diastolic function, and decreased exercise capacity compared with normal people. METHODS AND RESULTS To test the hypothesis that afterload reduction therapy alters hemodynamic variables and augments exercise capacity in patients after a Fontan procedure, we compared the results of graded exercise with maximal effort from 18 subjects (14.5+/-6.2 years of age, 4 to 19 years after Fontan procedure) in a randomized, double-blind, placebo-controlled crossover trial using enalapril (0.2 to 0.3 mg x kg[-1] x d[-1], maximum 15 mg). Each treatment was administered for 10 weeks. Diastolic filling patterns at rest were assessed by Doppler determination of the systemic atrioventricular valve flow velocity at the conclusion of each therapy. No difference was detected in resting heart rate, blood pressure, or cardiac index. Diastolic filling patterns were also similar. Exercise duration was not different (6.4+/-2.6 [enalapril] versus 6.7+/-2.6 minutes [placebo]). The mean percent increase in cardiac index from rest to maximum exercise was slightly but significantly decreased in subjects after 10 weeks of enalapril therapy (102+/-34% [enalapril] versus 125+/-34% [placebo]; P<.02). At maximal exercise, cardiac index (3.5+/-0.9 [enalapril] versus 3.8+/-0.9 L x min[-1] x m2 [placebo]), oxygen consumption (18.3+/-9 [enalapril] versus 20.5+/-7 mL x min[-1] x kg[-1] [placebo]), minute ventilation (57.5+/-17 [enalapril] versus 55.4+/-19 L/min [placebo]), and total work (247+/-181 [enalapril] versus 261+/-197 W [placebo]) were not different. CONCLUSIONS We conclude that enalapril administration for 10 weeks does not alter abnormal systemic vascular resistance, resting cardiac index, diastolic function, or exercise capacity in patients who have undergone a Fontan procedure.
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Affiliation(s)
- A A Kouatli
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 75235-9063, USA
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