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Mussatto KA, Van Rompay MI, Trachtenberg FL, Pemberton V, Young-Borkowski L, Uzark K, Hollenbeck-Pringle D, Dunbar-Masterson C, Infinger P, Walter P, Sawin K. Family Function, Quality of Life, and Well-Being in Parents of Infants With Hypoplastic Left Heart Syndrome. J Fam Nurs 2021; 27:222-234. [PMID: 33535863 PMCID: PMC8594631 DOI: 10.1177/1074840720987309] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Survival for hypoplastic left heart syndrome (HLHS) has improved dramatically. Little is known about early family function, quality of life (QOL), or well-being/adjustment for parents of infants with HLHS. Parent/family outcomes over time, predictors, and differences in 143 mothers and 72 fathers were examined. Parents reported better family function compared with published norms, but 26% experienced family dysfunction. QOL and well-being were significantly lower than adult norms. QOL scores generally declined over time, whereas self-reported well-being improved. Responses from mothers and fathers showed different trends, with mothers having worse scores on most measures and at most time points. Being a single parent was a risk factor for poorer family function, but not for lower individual QOL or well-being. Family characteristics, stress, and coping skills were predictive of outcomes. Parents' psychosocial responses to the challenges of life with infants with HLHS change over time. Individually tailored psychosocial support is needed.
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Affiliation(s)
| | | | | | | | | | - Karen Uzark
- C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | | | | | | | | | - Kathleen Sawin
- Milwaukee School of Engineering, WI, USA
- Children's Hospital of Wisconsin, Milwaukee, USA
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2
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Hamstra MS, Pemberton VL, Dagincourt N, Hollenbeck-Pringle D, Trachtenberg FL, Cnota JF, Atz AM, Cappella E, De Nobele S, Grima J, King M, Korsin R, Lambert LM, MacNeal MK, Markham LW, MacCarrick G, Sylvester DM, Walter P, Xu M, Lacro RV. Recruitment, retention, and adherence in a clinical trial: The Pediatric Heart Network's Marfan Trial experience. Clin Trials 2020; 17:684-695. [PMID: 32820647 DOI: 10.1177/1740774520945988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS The Pediatric Heart Network Marfan Trial was a randomized trial comparing atenolol versus losartan on aortic root dilation in 608 children and young adults with Marfan syndrome. Barriers to enrollment included a limited pool of eligible participants, restrictive entry criteria, and a diverse age range that required pediatric and adult expertise. Retention was complicated by a 3-year commitment to a complex study and medication regimen. The Network partnered with the Marfan Foundation, bridging the community with the research. The aims of this study are to report protocol and medication adherence and associated predictive factors, and to describe recruitment and retention strategies. METHODS Recruitment, retention, and adherence to protocol activities related to the primary outcome were measured. Retention was measured by percentage of enrolled participants with 3-year outcome data. Protocol adherence was calculated by completion rates of study visits, ambulatory electrocardiography (Holter monitoring), and quarterly calls. Medication adherence was assessed by the number of tablets or the amount of liquid in bottles returned. Centers were ranked according to adherence (high, medium, and low tertiles). Recruitment, retention, and adherence questionnaires were completed by sites. Descriptive statistics summarized recruitment, retention, and adherence, as well as questionnaire results. Regression modeling assessed predictors of adherence. RESULTS Completion rates for visits, Holter monitors, and quarterly calls were 99%, 94%, and 96%, respectively. Primary outcome data at 3 years were obtained for 88% of participants. The mean percentage of medication taken was estimated at 89%. Site and age were associated with all measures of adherence. Young adult and African American participants had lower levels of adherence. Higher adherence sites employed more strategies; had more staffing resources, less key staff turnover, and more collaboration with referring providers; utilized the Foundation's resources; and used a greater number of strategies to recruit, retain, and promote protocol and medication adherence. CONCLUSION Overall adherence was excellent for this trial conducted within a National Institutes of Health-funded clinical trial network. Strategies specifically targeted to young adults and African Americans may have been beneficial. Many strategies employed by higher adherence sites are ones that any site could easily use, such as greeting families at non-study hospital visits, asking for family feedback, providing calendars for tracking schedules, and recommending apps for medication reminders. Additional key learnings include adherence differences by age, race, and site, the value of collaborative learning, and the importance of partnerships with patient advocacy groups. These lessons could shape recruitment, retention, and adherence to improve the quality of future complex trials involving rare conditions.
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Affiliation(s)
- Michelle S Hamstra
- Heart Institute Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | | - James F Cnota
- Heart Institute Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | - Martha King
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | | | - Linda M Lambert
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | | | - Larry W Markham
- The Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | | | | | - Patricia Walter
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mingfen Xu
- Duke University School of Medicine, Durham, NC, USA
| | - Ronald V Lacro
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Lambert LM, McCrindle BW, Pemberton VL, Hollenbeck-Pringle D, Atz AM, Ravishankar C, Campbell MJ, Dunbar-Masterson C, Uzark K, Rolland M, Trachtenberg FL, Menon SC. Longitudinal study of anthropometry in Fontan survivors: Pediatric Heart Network Fontan study. Am Heart J 2020; 224:192-200. [PMID: 32428726 DOI: 10.1016/j.ahj.2020.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/02/2019] [Accepted: 03/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Growth abnormalities in single-ventricle survivors may reduce quality of life (QoL) and exercise capacity. METHODS This multicenter, longitudinal analysis evaluated changes in height and body mass index (BMI) compared to population norms and their relationship to mortality, ventricular morphology, QoL, and exercise capacity in the Pediatric Heart Network Fontan studies. RESULTS Fontan 1 (F1) included 546 participants (12 ± 3.4 years); Fontan 2 (F2), 427 (19 ± 3.4 years); and Fontan 3 (F3), 362 (21 ± 3.5 years), with ~60% male at each time point. Height z-score was -0.67 ± -1.27, -0.60 ± 1.34, and- 0.43 ± 1.14 at F1-F3, lower compared to norms at all time points (P ≤ .001). BMI z-score was similar to population norms. Compared to survivors, participants who died had lower height z-score (P ≤ .001). Participants with dominant right ventricle (n = 112) had lower height z-score (P ≤ .004) compared to dominant left (n = 186) or mixed (n = 64) ventricular morphologies. Higher height z-score was associated with higher Pediatric Quality of Life Inventory for the total score (slope = 2.82 ± 0.52; P ≤ .001). Increase in height z-score (F1 to F3) was associated with increased oxygen consumption (slope = 2.61 ± 1.08; P = .02), whereas, for participants >20 years old, an increase in BMI (F1 to F3) was associated with a decrease in oxygen consumption (slope = -1.25 ± 0.33; P ≤ .001). CONCLUSIONS Fontan survivors, especially those with right ventricular morphology, are shorter when compared to the normal population but have similar BMI. Shorter stature was associated with worse survival. An increase in height z-score over the course of the study was associated with better QoL and exercise capacity; an increase in BMI was associated with worse exercise capacity.
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Affiliation(s)
- Linda M Lambert
- University of Utah/Primary Children's Hospital, Salt Lake City, UT.
| | | | | | | | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC
| | | | | | | | - Karen Uzark
- University of Michigan/CS Mott Children's Hospital, Ann Arbor, MI
| | - Martha Rolland
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Shaji C Menon
- University of Utah/Primary Children's Hospital, Salt Lake City, UT
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4
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Balmes JR, Arjomandi M, Bromberg PA, Costantini MG, Dagincourt N, Hazucha MJ, Hollenbeck-Pringle D, Rich DQ, Stark P, Frampton MW. Ozone effects on blood biomarkers of systemic inflammation, oxidative stress, endothelial function, and thrombosis: The Multicenter Ozone Study in oldEr Subjects (MOSES). PLoS One 2019; 14:e0222601. [PMID: 31553765 PMCID: PMC6760801 DOI: 10.1371/journal.pone.0222601] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 09/02/2019] [Indexed: 02/01/2023] Open
Abstract
The evidence that exposure to ozone air pollution causes acute cardiovascular effects is mixed. We postulated that exposure to ambient levels of ozone would increase blood markers of systemic inflammation, prothrombotic state, oxidative stress, and vascular dysfunction in healthy older subjects, and that absence of the glutathione S-transferase Mu 1 (GSTM1) gene would confer increased susceptibility. This double-blind, randomized, crossover study of 87 healthy volunteers 55-70 years of age was conducted at three sites using a common protocol. Subjects were exposed for 3 h in random order to 0 parts per billion (ppb) (filtered air), 70 ppb, and 120 ppb ozone, alternating 15 min of moderate exercise and rest. Blood was obtained the day before, approximately 4 h after, and approximately 22 h after each exposure. Linear mixed effect and logistic regression models evaluated the impact of exposure to ozone on pre-specified primary and secondary outcomes. The definition of statistical significance was p<0.01. There were no effects of ozone on the three primary markers of systemic inflammation and a prothrombotic state: C-reactive protein, monocyte-platelet conjugates, and microparticle-associated tissue factor activity. However, among the secondary endpoints, endothelin-1, a potent vasoconstrictor, increased from pre- to post-exposure with ozone concentration (120 vs 0 ppb: 0.07 pg/mL, 95% confidence interval [CI] 0.01, 0.14; 70 vs 0 ppb: -0.03 pg/mL, CI -0.09, 0.04; p = 0.008). Nitrotyrosine, a marker of oxidative and nitrosative stress, decreased with increasing ozone concentrations, with marginal significance (120 vs 0 ppb: -41.5, CI -70.1, -12.8; 70 vs 0 ppb: -14.2, CI -42.7, 14.2; p = 0.017). GSTM1 status did not modify the effect of ozone exposure on any of the outcomes. These findings from healthy older adults fail to identify any mechanistic basis for the epidemiologically described cardiovascular effects of exposure to ozone. The findings, however, may not be applicable to adults with cardiovascular disease.
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Affiliation(s)
- John R. Balmes
- Department of Medicine, University of California at San Francisco, San Francisco, CA, United States of America
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Mehrdad Arjomandi
- Department of Medicine, University of California at San Francisco, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Philip A. Bromberg
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
- Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, NC, United States of America
| | | | | | - Milan J. Hazucha
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
- Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, NC, United States of America
| | | | - David Q. Rich
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Paul Stark
- New England Research Institute, Watertown, MA, United States of America
| | - Mark W. Frampton
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
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5
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Arjomandi M, Balmes JR, Frampton MW, Bromberg P, Rich DQ, Stark P, Alexis NE, Costantini M, Hollenbeck-Pringle D, Dagincourt N, Hazucha MJ. Respiratory Responses to Ozone Exposure. MOSES (The Multicenter Ozone Study in Older Subjects). Am J Respir Crit Care Med 2019; 197:1319-1327. [PMID: 29232153 DOI: 10.1164/rccm.201708-1613oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Acute respiratory effects of low-level ozone exposure are not well defined in older adults. OBJECTIVES MOSES (The Multicenter Ozone Study in Older Subjects), although primarily focused on acute cardiovascular effects, provided an opportunity to assess respiratory responses to low concentrations of ozone in older healthy adults. METHODS We performed a randomized crossover, controlled exposure study of 87 healthy adults (59.9 ± 4.5 yr old; 60% female) to 0, 70, and 120 ppb ozone for 3 hours with intermittent exercise. Outcome measures included spirometry, sputum markers of airway inflammation, and plasma club cell protein-16 (CC16), a marker of airway epithelial injury. The effects of ozone exposure on these outcomes were evaluated with mixed-effect linear models. A P value less than 0.01 was chosen a priori to define statistical significance. MEASUREMENTS AND MAIN RESULTS The mean (95% confidence interval) FEV1 and FVC increased from preexposure values by 2.7% (2.0-3.4) and 2.1% (1.3-2.9), respectively, 15 minutes after exposure to filtered air (0 ppb). Exposure to ozone reduced these increases in a concentration-dependent manner. After 120-ppb exposure, FEV1 and FVC decreased by 1.7% (1.1-2.3) and 0.8% (0.3-1.3), respectively. A similar concentration-dependent pattern was still discernible 22 hours after exposure. At 4 hours after exposure, plasma CC16 increased from preexposure levels in an ozone concentration-dependent manner. Sputum neutrophils obtained 22 hours after exposure showed a marginally significant increase in a concentration-dependent manner (P = 0.012), but proinflammatory cytokines (IL-6, IL-8, and tumor necrosis factor-α) were not significantly affected. CONCLUSIONS Exposure to ozone at near ambient levels induced lung function effects, airway injury, and airway inflammation in older healthy adults. Clinical trial registered with www.clinicaltrials.gov (NCT01487005).
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Affiliation(s)
- Mehrdad Arjomandi
- 1 San Francisco Veterans Affairs Medical Center, San Francisco, California.,2 Department of Medicine, University of California at San Francisco, San Francisco, California
| | - John R Balmes
- 2 Department of Medicine, University of California at San Francisco, San Francisco, California.,3 Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California
| | - Mark W Frampton
- 4 Department of Medicine.,5 Department of Environmental Medicine, and
| | - Philip Bromberg
- 6 Department of Medicine and.,7 Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, North Carolina
| | - David Q Rich
- 4 Department of Medicine.,5 Department of Environmental Medicine, and.,8 Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Paul Stark
- 9 New England Research Institute, Watertown, Massachusetts; and
| | - Neil E Alexis
- 10 Department of Pediatrics, School of Medicine, and.,7 Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - Milan J Hazucha
- 6 Department of Medicine and.,7 Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, North Carolina
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6
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Prospero CJ, Trachtenberg FL, Pemberton VL, Pasquali SK, Anderson BR, Ash KE, Bainton J, Dunbar-Masterson C, Graham EM, Hamstra MS, Hollenbeck-Pringle D, Jacobs JP, Jacobs ML, John R, Lambert LM, Oster ME, Swan E, Waldron A, Nathan M. Lessons learned in the use of clinical registry data in a multi-centre prospective study: the Pediatric Heart Network Residual Lesion Score Study. Cardiol Young 2019; 29:930-938. [PMID: 31204627 PMCID: PMC6715515 DOI: 10.1017/s1047951119001148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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 Using existing data from clinical registries to support clinical trials and other prospective studies has the potential to improve research efficiency. However, little has been reported about staff experiences and lessons learned from implementation of this method in pediatric cardiology. OBJECTIVES We describe the process of using existing registry data in the Pediatric Heart Network Residual Lesion Score Study, report stakeholders' perspectives, and provide recommendations to guide future studies using this methodology. METHODS The Residual Lesion Score Study, a 17-site prospective, observational study, piloted the use of existing local surgical registry data (collected for submission to the Society of Thoracic Surgeons-Congenital Heart Surgery Database) to supplement manual data collection. A survey regarding processes and perceptions was administered to study site and data coordinating center staff. RESULTS Survey response rate was 98% (54/55). Overall, 57% perceived that using registry data saved research staff time in the current study, and 74% perceived that it would save time in future studies; 55% noted significant upfront time in developing a methodology for extracting registry data. Survey recommendations included simplifying data extraction processes and tailoring to the needs of the study, understanding registry characteristics to maximise data quality and security, and involving all stakeholders in design and implementation processes. CONCLUSIONS Use of existing registry data was perceived to save time and promote efficiency. Consideration must be given to the upfront investment of time and resources needed. Ongoing efforts focussed on automating and centralising data management may aid in further optimising this methodology for future studies.
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Affiliation(s)
- Carol J. Prospero
- Nemours Cardiac Center, Alfred I. duPont Hospital for
Children, Wilmington, DE USA
| | | | | | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics,
University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI USA
| | - Brett R. Anderson
- Division of Pediatric Cardiology, New York
Presbyterian/Morgan Stanley Children’s Hospital, New York, NY USA
| | - Kathleen E. Ash
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jessica Bainton
- Division of Pediatric Cardiology, The Hospital for Sick
Children, Toronto, ON Canada
| | | | - Eric M. Graham
- Division of Pediatric Cardiology, Medical University of
South Carolina, Charleston, SC USA
| | - Michelle S. Hamstra
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | | | - Jeffrey P. Jacobs
- Department of Surgery, Johns Hopkins All
Children’s Hospital, Saint Petersburg, FL USA
| | - Marshall L. Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and
Vascular Institute, Baltimore, MD USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas
Children’s Hospital, Houston, TX USA
| | - Linda M. Lambert
- Division of Pediatric Cardiothoracic Surgery, University
of Utah, Salt Lake City, UT USA
| | - Matthew E. Oster
- Division of Pediatric Cardiology, Emory University School
of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Elizabeth Swan
- Division of Pediatric Cardiology, Riley Hospital for
Children, Indianapolis, IN USA
| | - Abigail Waldron
- Division of Cardiology,
Children’s Hospital Philadelphia, Philadelphia, PA USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children’s
Hospital, Boston, MA USA
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7
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Lee B, Hollenbeck-Pringle D, Goldman V, Biondi E, Alverson B. Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients? Hosp Pediatr 2019; 9:162-169. [PMID: 30709907 DOI: 10.1542/hpeds.2018-0139] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 06/09/2023]
Abstract
OBJECTIVES The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels. METHODS This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital. RESULTS Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost. CONCLUSIONS Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.
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Affiliation(s)
- Brian Lee
- Hasbro Children's Hospital, Providence, Rhode Island;
- Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | | | - Victoria Goldman
- Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Eric Biondi
- Johns Hopkins Children's Center, Baltimore, Maryland
| | - Brian Alverson
- Hasbro Children's Hospital, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
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8
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Handisides JC, Hollenbeck-Pringle D, Uzark K, Trachtenberg FL, Pemberton VL, Atz TW, Bradley TJ, Cappella E, De Nobele S, Groh GKT, Hamstra MS, Korsin R, Levine JC, Lindauer B, Liou A, Mac Neal MK, Markham LW, Morrison T, Mussatto KA, Olson AK, Pierpont MEM, Pyeritz RE, Radojewski EA, Roman MJ, Xu M, Lacro RV. Health-Related Quality of Life in Children and Young Adults with Marfan Syndrome. J Pediatr 2019; 204:250-255.e1. [PMID: 30270167 PMCID: PMC6800200 DOI: 10.1016/j.jpeds.2018.08.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/25/2018] [Accepted: 08/21/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess health-related quality of life (HRQOL) in a large multicenter cohort of children and young adults with Marfan syndrome participating in the Pediatric Heart Network Marfan Trial. STUDY DESIGN The Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales were administered to 321 subjects with Marfan syndrome (5-25 years). PedsQL scores were compared with healthy population norms. The impact of treatment arm (atenolol vs losartan), severity of clinical features, and number of patient-reported symptoms on HRQOL was assessed by general linear models. RESULTS Mean PedsQL scores in children (5-18 years) with Marfan syndrome were lower than healthy population norms for physical (P ≤ .003) and psychosocial (P < .001) domains; mean psychosocial scores for adults (19-25 years) were greater than healthy norms (P < .001). HRQOL across multiple domains correlated inversely with frequency of patient-reported symptoms (r = 0.30-0.38, P < .0001). Those <18 years of age with neurodevelopmental disorders (mainly learning disability, attention-deficit/hyperactivity disorder) had lower mean PedsQL scores (5.5-7.4 lower, P < .04). A multivariable model found age, sex, patient-reported symptoms, and neurodevelopmental disorder to be independent predictors of HRQOL. There were no differences in HRQOL scores by treatment arm, aortic root z score, number of skeletal features, or presence of ectopia lentis. CONCLUSIONS Children and adolescents with Marfan syndrome were at high risk for impaired HRQOL. Patient-reported symptoms and neurodevelopmental disorder, but not treatment arm or severity of Marfan syndrome-related physical findings, were associated with lower HRQOL.
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Affiliation(s)
| | | | - Karen Uzark
- C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | | | | | - Teresa W. Atz
- Medical University of South Carolina, Charleston, SC
| | - Timothy J. Bradley
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Jami C. Levine
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Bergen Lindauer
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT
| | | | | | - Larry W. Markham
- The Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | | | | | | | | | - Reed E. Pyeritz
- The Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Mingfen Xu
- Duke University School of Medicine, Durham, NC
| | - Ronald V. Lacro
- Boston Children’s Hospital, Harvard Medical School, Boston, MA
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9
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Rich DQ, Balmes JR, Frampton MW, Zareba W, Stark P, Arjomandi M, Hazucha MJ, Costantini MG, Ganz P, Hollenbeck-Pringle D, Dagincourt N, Bromberg PA. Cardiovascular function and ozone exposure: The Multicenter Ozone Study in oldEr Subjects (MOSES). Environ Int 2018; 119:193-202. [PMID: 29980042 DOI: 10.1016/j.envint.2018.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/08/2018] [Accepted: 06/12/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND To date, there have been relatively few studies of acute cardiovascular responses to controlled ozone inhalation, although a number of observational studies have reported significant positive associations between both ambient ozone levels and acute cardiovascular events and long-term ozone exposure and cardiovascular mortality. OBJECTIVES We hypothesized that short-term controlled exposure to low levels of ozone in filtered air would induce autonomic imbalance, repolarization abnormalities, arrhythmia, and vascular dysfunction. METHODS This randomized crossover study of 87 healthy volunteers 55-70 years of age was conducted at three sites using a common protocol, from June 2012 to April 2015. Subjects were exposed for 3 h in random order to 0 ppb (filtered air), 70 ppb ozone, and 120 ppb ozone, alternating 15 min of moderate exercise with 15 min of rest. A suite of cardiovascular endpoints was measured the day before, the day of, and up to 22 h after each exposure. Mixed effect linear and logit models evaluated the impact of exposure to ozone on pre-specified primary and secondary outcomes. Site and time were included in the models. RESULTS We found no significant effects of ozone exposure on any of the primary or secondary measures of autonomic function, repolarization, ST segment change, arrhythmia, or vascular function (systolic blood pressure and flow-mediated dilation). CONCLUSIONS In this multicenter study of older healthy women and men, there was no convincing evidence for acute effects of 3-h, relatively low-level ozone exposures on cardiovascular function. However, we cannot exclude the possibility of effects with higher ozone concentrations, more prolonged exposure, or in subjects with underlying cardiovascular disease. Further, we cannot exclude the possibility that exposure to ambient ozone and other pollutants in the days before the experimental exposures obscured or blunted cardiovascular biomarker response to the controlled ozone exposures.
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Affiliation(s)
- David Q Rich
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States of America; Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America; Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, United States of America.
| | - John R Balmes
- Department of Medicine, University of California at San Francisco, San Francisco, CA, United States of America; Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Mark W Frampton
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America; Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Wojciech Zareba
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Paul Stark
- New England Research Institute, Watertown, MA, United States of America
| | - Mehrdad Arjomandi
- Department of Medicine, University of California at San Francisco, San Francisco, CA, United States of America; San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Milan J Hazucha
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America; Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, NC, United States of America
| | | | - Peter Ganz
- Department of Medicine, University of California at San Francisco, San Francisco, CA, United States of America
| | | | | | - Philip A Bromberg
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America; Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, NC, United States of America
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Newburger JW, Sleeper LA, Gaynor JW, Hollenbeck-Pringle D, Frommelt PC, Li JS, Mahle WT, Williams IA, Atz AM, Burns KM, Chen S, Cnota J, Dunbar-Masterson C, Ghanayem NS, Goldberg CS, Jacobs JP, Lewis AB, Mital S, Pizarro C, Eckhauser A, Stark P, Ohye RG. Transplant-Free Survival and Interventions at 6 Years in the SVR Trial. Circulation 2018; 137:2246-2253. [PMID: 29437119 DOI: 10.1161/circulationaha.117.029375] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups. METHODS Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial. RESULTS Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, P=0.25) or with all available follow-up of 7.1±1.6 years (log-rank P=0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (P=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; P=0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; P=0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, P<0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures. CONCLUSIONS By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- Jane W Newburger
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.).
| | - Lynn A Sleeper
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.)
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Jennifer S Li
- North Carolina Consortium, Duke University, Durham (J.S.L.).,East Carolina University, Greenville, NC (J.S.L.).,Wake Forest University, Winston-Salem, NC (J.S.L.)
| | - William T Mahle
- Children's Healthcare of Atlanta and Emory University, GA (W.T.M.)
| | - Ismee A Williams
- Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia College of Physicians and Surgeons, NY (I.A.W.)
| | - Andrew M Atz
- Medical University of South Carolina, Charleston (A.M.A.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (KM.B.)
| | - Shan Chen
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - James Cnota
- Cincinnati Children's Medical Center, OH (J.C.)
| | | | - Nancy S Ghanayem
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Caren S Goldberg
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
| | | | | | - Seema Mital
- Hospital for Sick Children, Toronto, Ontario, Canada (S.M.)
| | | | - Aaron Eckhauser
- Primary Children's Hospital and the University of Utah, Salt Lake City (A.E.)
| | - Paul Stark
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - Richard G Ohye
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
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11
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Selamet Tierney ES, Hollenbeck-Pringle D, Lee CK, Altmann K, Dunbar-Masterson C, Golding F, Lu M, Miller SG, Molina K, Natarajan S, Taylor CL, Trachtenberg F, Colan SD. Reproducibility of Left Ventricular Dimension Versus Area Versus Volume Measurements in Pediatric Patients With Dilated Cardiomyopathy. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.006007. [PMID: 29133477 DOI: 10.1161/circimaging.116.006007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple echocardiographic methods are used to measure left ventricular size and function. Clinical management is based on individual evaluations and longitudinal trends. The Pediatric Heart Network VVV study (Ventricular Volume Variability) in pediatric patients with dilated cardiomyopathy has reported reproducibility of several of these measures, and how disease state and number of beats impact their reproducibility. In this study, we investigated the impact of observer and sonographer variation on reproducibility of dimension, area, and volume methods to determine the best method for both individual and sequential evaluations. METHODS AND RESULTS In 8 centers, echocardiograms were obtained on 169 patients prospectively. During the same visit, 2 different sonographers acquired the same imaging protocol on each patient. Each acquisition was analyzed by 2 different observers; first observer analyzed the first acquisition twice. Intraobserver, interobserver, interacquisition, and interobserver-acquisition (different observers and different acquisition) reproducibility were assessed on measurements of left ventricular end-diastolic dimension, area, and volume. Left ventricular shortening fraction, ejection fraction, mass, and fractional area change were calculated. Percent difference was calculated as (interobservation difference/mean)×100. Interobserver reproducibility for both acquisitions was better for both volume and dimension measurements (P≤0.002) compared with area measurements, whereas intraobserver, interacquisition (for both observers), and interobserver-acquisition reproducibilities (for both observer-acquisition sets) were best for volume measurements (P≤0.01). Overall, interobserver-acquisition percent differences were significantly higher than interobserver and interacquisition percent differences (P<0.001). CONCLUSIONS In pediatric patients with dilated cardiomyopathy, compared with dimension and area methods, left ventricular measurements by volume method have the best reproducibility in settings where assessment is not performed by the same personnel. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00123071.
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Affiliation(s)
- Elif Seda Selamet Tierney
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.).
| | - Danielle Hollenbeck-Pringle
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Caroline K Lee
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Karen Altmann
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Carolyn Dunbar-Masterson
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Fraser Golding
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Minmin Lu
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Stephen G Miller
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Kimberly Molina
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Shobha Natarajan
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Carolyn L Taylor
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Felicia Trachtenberg
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
| | - Steven D Colan
- From the Department of Pediatrics, Stanford University, Palo Alto, CA (E.S.S.T.); New England Research Institutes, Watertown, MA (D.H.-P., M.L., F.T.); Department of Pediatrics, St. Louis Children's Hospital, Washington University, MO (C.K.L.); Department of Pediatrics, New York Presbyterian Medical Center, Columbia University (K.A.); Department of Cardiology, Boston Children's Hospital, Harvard Medical School, MA (C.D.-M., S.D.C.); Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada (F.G.); Department of Pediatrics, Duke University School of Medicine, Durham, NC (S.G.M.); Department of Pediatrics, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City (K.M.); Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, CA (S.N.); and Department of Pediatrics, Medical University of South Carolina, Children's Hospital of South Carolina, Charleston (C.L.T.)
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Frampton MW, Balmes JR, Bromberg PA, Stark P, Arjomandi M, Hazucha MJ, Rich DQ, Hollenbeck-Pringle D, Dagincourt N, Alexis N, Ganz P, Zareba W, Costantini MG. Multicenter Ozone Study in oldEr Subjects (MOSES): Part 1. Effects of Exposure to Low Concentrations of Ozone on Respiratory and Cardiovascular Outcomes. Res Rep Health Eff Inst 2017; 2017:1-107. [PMID: 31898880 PMCID: PMC7266375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Exposure to air pollution is a well-established risk factor for cardiovascular morbidity and mortality. Most of the evidence supporting an association between air pollution and adverse cardiovascular effects involves exposure to particulate matter (PM). To date, little attention has been paid to acute cardiovascular responses to ozone, in part due to the notion that ozone causes primarily local effects on lung function, which are the basis for the current ozone National Ambient Air Quality Standards (NAAQS). There is evidence from a few epidemiological studies of adverse health effects of chronic exposure to ambient ozone, including increased risk of mortality from cardiovascular disease. However, in contrast to the well-established association between ambient ozone and various nonfatal adverse respiratory effects, the observational evidence for impacts of acute (previous few days) increases in ambient ozone levels on total cardiovascular mortality and morbidity is mixed. Ozone is a prototypic oxidant gas that reacts with constituents of the respiratory tract lining fluid to generate reactive oxygen species (ROS) that can overwhelm antioxidant defenses and cause local oxidative stress. Pathways by which ozone could cause cardiovascular dysfunction include alterations in autonomic balance, systemic inflammation, and oxidative stress. These initial responses could lead ultimately to arrhythmias, endothelial dysfunction, acute arterial vasoconstriction, and procoagulant activity. Individuals with impaired antioxidant defenses, such as those with the null variant of glutathione S-transferase mu 1 (GSTM1), may be at increased risk for acute health effects. The Multicenter Ozone Study in oldEr Subjects (MOSES) was a controlled human exposure study designed to evaluate whether short-term exposure of older, healthy individuals to ambient levels of ozone induces acute cardiovascular responses. The study was designed to test the a priori hypothesis that short-term exposure to ambient levels of ozone would induce acute cardiovascular responses through the following mechanisms: autonomic imbalance, systemic inflammation, and development of a prothrombotic vascular state. We also postulated a priori the confirmatory hypothesis that exposure to ozone would induce airway inflammation, lung injury, and lung function decrements. Finally, we postulated the secondary hypotheses that ozone-induced acute cardiovascular responses would be associated with: (a) increased systemic oxidative stress and lung effects, and (b) the GSTM1-null genotype. METHODS The study was conducted at three clinical centers with a separate Data Coordinating and Analysis Center (DCAC) using a common protocol. All procedures were approved by the institutional review boards (IRBs) of the participating centers. Healthy volunteers 55 to 70 years of age were recruited. Consented participants who successfully completed the screening and training sessions were enrolled in the study. All three clinical centers adhered to common standard operating procedures (SOPs) and used common tracking and data forms. Each subject was scheduled to participate in a total of 11 visits: screening visit, training visit, and three sets of exposure visits, each consisting of the pre-exposure day, the exposure day, and the post-exposure day. The subjects spent the night in a nearby hotel the night of the pre-exposure day. On exposure days, the subjects were exposed for three hours in random order to 0 ppb ozone (clean air), 70 ppb ozone, and 120 ppm ozone, alternating 15 minutes of moderate exercise with 15 minutes of rest. A suite of cardiovascular and pulmonary endpoints was measured on the day before, the day of, and up to 22 hours after, each exposure. The endpoints included: (1) electrocardiographic changes (continuous Holter monitoring: heart rate variability [HRV], repolarization, and arrhythmia); (2) markers of inflammation and oxidative stress (C-reactive protein [CRP], interleukin-6 [IL-6], 8-isoprostane, nitrotyrosine, and P-selectin); (3) vascular function measures (blood pressure [BP], flow-mediated dilatation [FMD] of the brachial artery, and endothelin-1 [ET-1]; (4) venous blood markers of platelet activation, thrombosis, and microparticle-associated tissue factor activity (MP-TFA); (5) pulmonary function (spirometry); (6) markers of airway epithelial cell injury (increases in plasma club cell protein 16 [CC16] and sputum total protein); and (7) markers of lung inflammation in sputum (polymorphonuclear leukocytes [PMN], IL-6, interleukin-8 [IL-8], and tumor necrosis factor-alpha [TNF-α]). Sputum was collected only at 22 hours after exposure. The analyses of the continuous electrocardiographic monitoring, the brachial artery ultrasound (BAU) images, and the blood and sputum samples were carried out by core laboratories. The results of all analyses were submitted directly to the DCAC. The variables analyzed in the statistical models were represented as changes from pre-exposure to post-exposure (post-exposure minus pre-exposure). Mixed-effect linear models were used to evaluate the impact of exposure to ozone on the prespecified primary and secondary continuous outcomes. Site and time (when multiple measurements were taken) were controlled for in the models. Three separate interaction models were constructed for each outcome: ozone concentration by subject sex; ozone concentration by subject age; and ozone concentration by subject GSTM1 status (null or sufficient). Because of the issue of multiple comparisons, the statistical significance threshold was set a priori at P < 0.01. RESULTS Subject recruitment started in June 2012, and the first subject was randomized on July 25, 2012. Subject recruitment ended on December 31, 2014, and testing of all subjects was completed by April 30, 2015. A total of 87 subjects completed all three exposures. The mean age was 59.9 ± 4.5 years, 60% of the subjects were female, 88% were white, and 57% were GSTM1 null. Mean baseline body mass index (BMI), BP, cholesterol (total and low-density lipoprotein), and lung function were all within the normal range. We found no significant effects of ozone exposure on any of the primary or secondary endpoints for autonomic function, repolarization, ST segment change, or arrhythmia. Ozone exposure also did not cause significant changes in the primary endpoints for systemic inflammation (CRP) and vascular function (systolic blood pressure [SBP] and FMD) or secondary endpoints for systemic inflammation and oxidative stress (IL-6, P-selectin, and 8-isoprostane). Ozone did cause changes in two secondary endpoints: a significant increase in plasma ET-1 (P = 0.008) and a marginally significant decrease in nitrotyrosine (P = 0.017). Lastly, ozone exposure did not affect the primary prothrombotic endpoints (MP-TFA and monocyte-platelet conjugate count) or any secondary markers of prothrombotic vascular status (platelet activation, circulating microparticles [MPs], von Willebrand factor [vWF], or fibrinogen.). Although our hypothesis focused on possible acute cardiovascular effects of exposure to low levels of ozone, we recognized that the initial effects of inhaled ozone involve the lower airways. Therefore, we looked for: (a) changes in lung function, which are known to occur during exposure to ozone and are maximal at the end of exposure; and (b) markers of airway injury and inflammation. We found an increase in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) after exposure to 0 ppb ozone, likely due to the effects of exercise. The FEV₁ increased significantly 15 minutes after 0 ppb exposure (85 mL; 95% confidence interval [CI], 64 to 106; P < 0.001), and remained significantly increased from pre-exposure at 22 hours (45 mL; 95% CI, 26 to 64; P < 0.001). The increase in FVC followed a similar pattern. The increase in FEV₁ and FVC were attenuated in a dose-response manner by exposure to 70 and 120 ppb ozone. We also observed a significant ozone-induced increase in the percentage of sputum PMN 22 hours after exposure at 120 ppb compared to 0 ppb exposure (P = 0.003). Plasma CC16 also increased significantly after exposure to 120 ppb (P < 0.001). Sputum IL-6, IL-8, and TNF-α concentrations were not significantly different after ozone exposure. We found no significant interactions with sex, age, or GSTM1 status regarding the effect of ozone on lung function, percentage of sputum PMN, or plasma CC16. CONCLUSIONS In this multicenter clinical study of older healthy subjects, ozone exposure caused concentration-related reductions in lung function and presented evidence for airway inflammation and injury. However, there was no convincing evidence for effects on cardiovascular function. Blood levels of the potent vasoconstrictor, ET-1, increased with ozone exposure (with marginal statistical significance), but there were no effects on BP, FMD, or other markers of vascular function. Blood levels of nitrotyrosine decreased with ozone exposure, the opposite of our hypothesis. Our study does not support acute cardiovascular effects of low-level ozone exposure in healthy older subjects. Inclusion of only healthy older individuals is a major limitation, which may affect the generalizability of our findings. We cannot exclude the possibility of effects with higher ozone exposure concentrations or more prolonged exposure, or the possibility that subjects with underlying vascular disease, such as hypertension or diabetes, would show effects under these conditions.
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Affiliation(s)
- M W Frampton
- University of Rochester Medical Center, Rochester, New York
| | | | | | - P Stark
- New England Research Institute, Watertown, Massachusetts
| | | | | | - D Q Rich
- University of Rochester Medical Center, Rochester, New York
| | | | - N Dagincourt
- New England Research Institute, Watertown, Massachusetts
| | - N Alexis
- University of North Carolina, Chapel Hill
| | - P Ganz
- University of California, San Francisco
| | - W Zareba
- University of Rochester Medical Center, Rochester, New York
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Nathan M, Jacobs ML, Gaynor JW, Newburger JW, Dunbar Masterson C, Lambert LM, Hollenbeck-Pringle D, Trachtenberg FL, White O, Anderson BR, Bell MC, Burch PT, Graham EM, Kaltman JR, Kanter KR, Mery CM, Pizarro C, Schamberger MS, Taylor MD, Jacobs JP, Pasquali SK. Completeness and Accuracy of Local Clinical Registry Data for Children Undergoing Heart Surgery. Ann Thorac Surg 2017; 103:629-636. [PMID: 27726857 PMCID: PMC5253303 DOI: 10.1016/j.athoracsur.2016.06.111] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 01/22/2016] [Revised: 05/27/2016] [Accepted: 06/06/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data routinely captured in clinical registries may be leveraged to enhance efficiency of prospective research. The quality of registry data for this purpose has not been studied, however. We evaluated the completeness and accuracy of perioperative data within congenital heart centers' local surgical registries. METHODS Within 12 Pediatric Heart Network (PHN) sites, we evaluated 31 perioperative variables (and their subcategories, totaling 113 unique fields) collected via sites' local clinical registries for submission to The Society of Thoracic Surgeons Database, compared with chart review by PHN research coordinators. Both used standard STS definitions. Data were collected on 10 subjects for 2 to 5 procedures/site and adjudicated by the study team. Completeness and accuracy (agreement of registry data with medical record review by PHN coordinator, adjudicated by the study team) were evaluated. RESULTS A total of 56,500 data elements were collected on 500 subjects. With regard to data completeness, 3.1% of data elements were missing from the registry, 0.6% from coordinator-collected data, and 0.4% from both. Overall, registry data accuracy was 98%. In total, 94.7% of data elements were both complete/non-missing and accurate within the registry, although there was variation across data fields and sites. Mean total time for coordinator chart review per site was 49.1 hours versus 7.0 hours for registry query. CONCLUSIONS This study suggests that existing surgical registry data constitute a complete, accurate, and efficient information source for prospective research. Variability across data fields and sites also suggest areas for improvement in some areas of data quality.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Department of Surgery and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Carolyn Dunbar Masterson
- Department of Cardiology, Boston Children's Hospital, Department of Surgery and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital/University of Utah, Salt Lake City, Utah
| | | | | | - Owen White
- CardioAccess Inc, Fort Lauderdale, Florida
| | - Brett R Anderson
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Hospital, Columbia Presbyterian University, New York, New York
| | | | - Phillip T Burch
- Division of Cardiothoracic Surgery, Primary Children's Hospital/University of Utah, Salt Lake City, Utah
| | - Eric M Graham
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Carlos M Mery
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Christian Pizarro
- Division of Pediatric Cardiothoracic Surgery, Nemours Cardiac Center and the Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Marcus S Schamberger
- Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University, Indianapolis, Indiana
| | - Michael D Taylor
- Division of Cardiology, Cincinatti Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, Florida
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, CS Mott Children's Hospital, Ann Arbor, Michigan
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Mahle WT, Nicolson SC, Hollenbeck-Pringle D, Gaies MG, Witte MK, Lee EK, Goldsworthy M, Stark PC, Burns KM, Scheurer MA, Cooper DS, Thiagarajan R, Ben Sivarajan V, Colan SD, Schamberger MS, Shekerdemian LS. Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med 2016; 17:939-947. [PMID: 27513600 PMCID: PMC5053873 DOI: 10.1097/pcc.0000000000000918] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING Ten children's hospitals. PATIENTS Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.
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Affiliation(s)
| | | | | | | | | | - Eva K Lee
- Georgia Institute of Technology, Atlanta, GA
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