Adverse childhood experiences, the risk of pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) have a profound negative impact on health. However, the strength of the association between ACEs and pregnancy complications and adverse pregnancy outcomes is not well quantified or understood.

OBJECTIVE

To conduct a systematic review and meta-analysis of the association between ACEs and risk of pregnancy complications and adverse pregnancy outcomes.

SEARCH STRATEGY

A comprehensive search was conducted using PubMed, Embase, CINAHL, PsycINFO, ClinicalTrials.gov and Google scholar up to July 2022.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. Meta-analysis using the quality-effects model on the reported odds ratio (OR) was conducted. Heterogeneity and inconsistency were examined using the I2 statistics.

RESULTS

32 studies from 1508 met a priori inclusion criteria for systematic review, with 21 included in the meta-analysis. Pooled analyses showed that exposure to ACEs increased the risk of pregnancy complications (OR 1.37, 95% CI 1.20 to 1.57) and adverse pregnancy outcomes (OR 1.31, 95% CI 1.17 to 1.47). In sub-group analysis, maternal ACEs were associated with gestational diabetes mellitus (OR 1.39, 95% CI 1.11 to 1.74), antenatal depression (OR 1.59, 95% CI 1.15 to 2.20), low offspring birth weight (OR 1.27, 95% CI 1.02 to 1.47), and preterm delivery (OR 1.41, 95% CI 1.16 to 1.71).

CONCLUSION

The results suggest that exposure to ACEs increases the risk of pregnancy complications and adverse pregnancy outcomes. Preventive strategies, screening and trauma-informed care need to be examined to improve maternal and child health.

Perceived Impact of Digital Health Maturity on Patient Experience, Population Health, Health Care Costs, and Provider Experience: Mixed Methods Case Study

BACKGROUND

Health care organizations understand the importance of new technology implementations; however, the best strategy for implementing successful digital transformations is often unclear. Digital health maturity assessments allow providers to understand the progress made toward technology-enhanced health service delivery. Existing models have been criticized for their lack of depth and breadth because of their technology focus and neglect of meaningful outcomes.

OBJECTIVE

We aimed to examine the perceived impacts of digital health reported by health care staff employed in health care organizations across a spectrum of digital health maturity.

METHODS

A mixed methods case study was conducted. The digital health maturity of public health care systems (n=16) in Queensland, Australia, was examined using the quantitative Digital Health Indicator (DHI) self-assessment survey. The lower and upper quartiles of DHI scores were calculated and used to stratify sites into 3 groups. Using qualitative methods, health care staff (n=154) participated in interviews and focus groups. Transcripts were analyzed assisted by automated text-mining software. Impacts were grouped according to the digital maturity of the health care worker's facility and mapped to the quadruple aims of health care: improved patient experience, improved population health, reduced health care cost, and enhanced provider experience.

RESULTS

DHI scores ranged between 78 and 193 for the 16 health care systems. Health care systems in the high-maturity category (n=4, 25%) had a DHI score of ≥166.75 (the upper quartile); low-maturity sites (n=4, 25%) had a DHI score of ≤116.75 (the lower quartile); and intermediate-maturity sites (n=8, 50%) had a DHI score ranging from 116.75 to 166.75 (IQR). Overall, 18 perceived impacts were identified. Generally, a greater number of positive impacts were reported in health care systems of higher digital health maturity. For patient experiences, higher maturity was associated with maintaining a patient health record and tracking patient experience data, while telehealth enabled access and flexibility across all digital health maturity categories. For population health, patient journey tracking and clinical risk mitigation were reported as positive impacts at higher-maturity sites, and telehealth enabled health care access and efficiencies across all maturity categories. Limited interoperability and organizational factors (eg, strategy, policy, and vision) were universally negative impacts affecting health service delivery. For health care costs, the resource burden of ongoing investments in digital health and a sustainable skilled workforce was reported. For provider experiences, the negative impacts of poor usability and change fatigue were universal, while network and infrastructure issues were negative impacts at low-maturity sites.

CONCLUSIONS

This is one of the first studies to show differences in the perceived impacts of digital maturity of health care systems at scale. Higher digital health maturity was associated with more positive reported impacts, most notably in achieving outcomes for the population health aim.

Evaluating Digital Health Capability at Scale Using the Digital Health Indicator

Background  Health service providers must understand their digital health capability if they are to drive digital transformation in a strategic and informed manner. Little is known about the assessment and benchmarking of digital maturity or capability at scale across an entire jurisdiction. The public health care system across the state of Queensland, Australia has an ambitious 10-year digital transformation strategy.

Objective  The aim of this research was to evaluate the digital health capability in Queensland to inform digital health strategy and investment.

Methods  The Healthcare Information and Management Systems Society Digital Health Indicator (DHI) was used via a cross-sectional survey design to assess four core dimensions of digital health transformation: governance and workforce; interoperability; person-enabled health; and predictive analytics across an entire jurisdiction simultaneously. The DHI questionnaire was completed by each health care system ( n  = 16) within Queensland in February to July 2021. DHI is scored 0 to 400 and dimension score is 0 to 100.

Results  The results reveal a variation in DHI scores reflecting the diverse stages of health care digitization across the state. The average DHI score across sites was 143 (range 78–193; SD35.3) which is similar to other systems in the Oceania region and global public systems but below the global private average. Governance and workforce was on average the highest scoring dimension (x̅= 54), followed by interoperability (x̅ = 46), person-enabled health (x̅ = 36), and predictive analytics (x̅ = 30).

Conclusion  The findings were incorporated into the new digital health strategy for the jurisdiction. As one of the largest single simultaneous assessments of digital health capability globally, the findings and lessons learnt offer insights for policy makers and organizational managers.

Understanding consumer preference for vascular access safety and quality measurement: an international survey

ObjectivesThe aim of this study was to examine patient perceptions regarding vascular access quality measurement.MethodsA web-based, cross-sectional survey was performed using a convenience sample of healthcare consumers with vascular access experience, recruited from September 2019 to June 2020. Survey respondents were asked to rate the perceived importance of 50 vascular access data items, including patient demographics, clinical and device characteristics, and insertion, management and complication data. Data were ranked using a five-point Likert scale (1, least important; 5, most important), and are reported as median values. Respondents proposed additional items and explored broader perspectives using free-text responses, which were analysed using inductive thematic analysis.ResultsIn all, 68 consumers completed the survey. Participants were primarily female (82%), aged 40-49 years (29%) and living in Australia or New Zealand (84%). All respondents indicated that measuring the quality of vascular access care was important. Of the 50 items, 37 (74%) were perceived as 'most important' (median score 5), with measures of quality (i.e. outcomes and complications) rated highly (e.g. thrombosis and primary blood stream infection). Participants proposed 16 additional items. 'Gender' received the lowest perceived importance score (median score 3). Two themes emerged from the qualitative analysis of broader perspectives: (1) measurement of vascular access device complication severity and associated factors; and (2) patient experience.ConclusionMeasuring vascular access quality and safety is important to consumers. Outcome and complication measures were rated 'most important', with respondents identifying a need for increased monitoring of their overall vascular access journey through the health system.What is known about the topic?The use of vascular access devices is common among hospitalised patients. Quality surveillance is not standardised, with no incorporation of patient preference.What does this paper add?We identify the data items consumers perceive as valuable to measure related to their vascular access journey; most importantly, consumers perceived the collecting of vascular access data as important.What are the implications for practitioners?Health services can use these data to develop platforms to monitor the quality and safety of vascular access care.

Managing the Digital Disruption Associated with COVID-19-Driven Rapid Digital Transformation in Brisbane, Australia

BACKGROUND

The COVID-19 pandemic has forced rapid digital transformation of many health systems. These innovations are now entering the literature, but there is little focus on the resulting disruption.

OBJECTIVE

We describe the implementation of digital innovations during the COVID-19 response of Australia's largest health service, Metro North (in Brisbane, Queensland), the challenges of the subsequent digital disruption, how these were managed, and lessons learned.

METHODS

Prior to the COVID-19 pandemic, the Australian state of Queensland created the Queensland Digital Clinical Charter, which provides guidance for the development of digital health programs. The guidelines utilize three horizons: digitizing workflows, leveraging digital data to transform clinical care, and reimagining new and innovative models of care. The technical response to COVID-19 in Metro North is described across these horizons. The rapid digital response caused significant disruption to health care delivery; management of the disruption and the outcomes are detailed. This is a participatory action research project, with members of the research team assisting with leading the implementation project informing the case report content.

RESULTS

Several digital innovations were introduced across Metro North during the COVID-19 response. This resulted in significant disruption creating digital hypervigilance, digital deceleration, data discordance, and postdigital "depression." Successful management of the digital disruption minimized the negative effects of rapid digital transformation, and contributed to the effective management of the pandemic in Queensland.

CONCLUSION

The rapid digital transformation in Metro North during COVID-19 was successful in several aspects; however, ongoing challenges remain. These include the need to improve data sharing and increase interoperability. Importantly, the innovations need to be evaluated to ensure that Metro North can capitalize on these changes and incorporate them into long-term routine practice. Moving forward, it will be essential to manage not only the pandemic, but increasingly, the resultant digital disruption.

Investigation of the neural basis of expectation-based analgesia in the human brainstem and spinal cord by means of functional magnetic resonance imaging

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Expectation of lower pain results in lower perceived pain in healthy humans.

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This expectation analgesia is mediated by descending regulation of the spinal cord.

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Connectivity analyses showed effects of expecting lower pain prior to stimulation.

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Expectation analgesia involves regions linked to arousal and autonomic regulation.

Purpose

The expected intensity of pain resulting from a noxious stimulus has been observed to have a strong influence on the pain that is perceived. The neural basis of pain reduction, as a result of expecting lower pain, was investigated using functional magnetic resonance imaging (fMRI) in the brainstem and spinal cord.

Methods

Functional MRI studies were carried out in a region spanning the brainstem and cervical spinal cord in healthy participants. Participants were familiarized with a noxious heat stimulus and study procedures in advance, and were informed during each trial that either a heat calibrated to produce moderate pain (Base state), or a temperature 1 °C lower (Low state), would be applied to their hand. However, the Base temperature was applied in every trial.

Results

Pain ratings were significantly reduced as a result of expecting lower temperatures. FMRI results demonstrate blood oxygenation-level dependent (BOLD) signal variations in response to participants being informed of the stimulus to expect, in advance of stimulation, and in response to stimulation. Significant coordination of BOLD signals was also detected across specific brainstem and spinal cord regions, with connectivity strengths that varied significantly with the study condition, and with individual pain ratings. The results identify regions that are known to be involved with arousal and autonomic regulation.

Conclusions

Expectation-based analgesia is mediated by descending regulation of spinal cord nociceptive responses. This regulation appears to be related to arousal and autonomic regulation, consistent with the cognitive/affective dimension of pain.

Queensland Digital Health Clinical Charter: a clinical consensus statement on priorities for digital health in hospitals

Digital transformation of Australian hospitals is occurring rapidly. Although the clinical community has had limited ability to influence high-level decision making and investments into digital health technologies, as these technologies increasingly transform the way patients are cared for, the clinical community must influence the digital health agenda and be an integral part of the decision-making process. This case study details the process and lessons learnt during the development of the state-wide consensus statement detailing the clinical requirements for digital health initiatives to form the Queensland Digital Health Clinical Charter. To the best of our knowledge, Queensland is the first Australian jurisdiction to create a Digital Clinical Charter to be specifically referenced in the investment in and governance of digital health in hospitals. By developing this clinical charter for digital health, and in articulating the needs of clinicians, a clinical framework will be added to both the decision-making process around the investments in digital health and the definition and realisation of the expected benefits from these sizable investments.

Moving Faster than the COVID-19 Pandemic: The Rapid, Digital Transformation of a Public Health System

Background  Queensland, Australia has been successful in containing the COVID-19 pandemic. Underpinning that response has been a highly effective virus containment strategy which relies on identification, isolation, and contact tracing of cases. The dramatic emergence of the COVID-19 pandemic rendered traditional paper-based systems for managing contact tracing no longer fit for purpose. A rapid digital transformation of the public health contact tracing system occurred to support this effort.

Objectives  The objectives of the digital transformation were to shift legacy systems (paper or standalone electronic systems) to a digitally enabled public health system, where data are centered around the consumer rather than isolated databases. The objective of this paper is to outline this case study and detail the lessons learnt to inform and give confidence to others contemplating digitization of public health systems in response to the COVID-19 pandemic.

Methods  This case study is set in Queensland, Australia. Universal health care is available. A multidisciplinary team was established consisting of clinical informaticians, developers, data strategists, and health information managers. An agile “pair-programming” approach was undertaken to application development and extensive change efforts were made to maximize adoption of the new digital workflows. Data governance and flows were changed to support rapid management of the pandemic.

Results  The digital coronavirus application (DCOVA) is a web-based application that securely captures information about people required to quarantine and creates a multiagency secure database to support a successful containment strategy.

Conclusion  Most of the literature surrounding digital transformation allows time for significant consultation, which was simply not possible under crisis conditions. Our observation is that staff was willing to adopt new digital systems because the reason for change (the COVID-19 pandemic) was clearly pressing. This case study highlights just how critical a unified purpose, is to successful, rapid digital transformation.

How is health information technology changing the way we deliver NHS hospital care?

As NHS England and the health system makes further investments in the deployment of health information technology (HIT) across NHS sites, this review article considers some of the benefits HIT can provide in secondary care, including the potential of creating innovation ecosystems.

Assessment of the Training Needs of Paediatric Residents in Developing a Curriculum in Gastroenterology

BACKGROUND: Well defined and focused objectives are essential for effective learning. Paediatric residents are expected to meet the educational objectives as set out by the Royal College of Physicians and Surgeons of Canada (RCPSC). For rotation in paediatric gastroenterology, it is unclear how the objectives and list of key clinical conditions was originally developed and which of them are most important for general practice. With increasing educational commitments, residents have limited time to acquire all the essential skills needed for clinical practice.

OBJECTIVES: To identify topics in gastroenterology which are of most importance in general pediatric practice. This would enable development of a concise and focused curriculum for pediatric residents doing rotation in gastroenterology.

DESIGN/METHODS: All paediatricians in the four Canadian Atlantic provinces were surveyed with a mailed questionnaire. The list consisted of 14 clinical conditions from the current RCPSC objectives with additional 6 generated after input from regional paediatric gastroenterologists. Information was collected on demographics including type and duration of pediatric practice. The participants ranked the conditions on a 4 point Likert scale (from Not Important to Very Important).

RESULTS: Of the 234 subjects, 132 (56%) responded. Of these, 57.5% were female, 48.8% were academic and 48% were general pediatricians. The majority (73.2%) were in practice >10 years and 75.6% felt that a rotation in gastroenterology should be mandatory in pediatric residency training. Celiac disease, gastroesophageal reflux and obesity were identified as Very Important conditions by 94.4%, 96.1% and 96.0% of the participants respectively. These are currently not in RCPSC list of clinical problems. Clinical situations encountered in long-term follow-up of survivors of liver transplantation (RCPSC objective) and chronic pancreatitis were considered Not Important by 61.3% and 58.3% of respondents respectively. Academic pediatricians placed significantly more importance on abdominal pain than non-academic pediatricians (p=0.029). Pediatricians in practice for <10 years identified issues encountered in long-term follow-up of liver transplantation (p=0.039) and celiac disease (p=0.015) as significantly more important than those in practice longer. There were no significant differences between general paediatricians and specialists in cross analysis of all other variables studied.

CONCLUSION: Needs assessment for paediatric residency curriculum development is important as it can identify gaps in RCPSC objectives. Input from general pediatricians should be sought systematically and on an ongoing basis in order to keep the curriculum current and focused.

Factors Influencing Adoption of New Technologies into Dental Practice: A Qualitative Study

The objective of this study was to explore factors affecting decisions to adopt new technologies into dental practice using a colorimetric rinse test for detection of periodontal disease as a model. Focus groups with key informants in Canadian dentistry and dental hygiene were conducted. A deductive approach used Rogers's diffusion of innovation theory as a framework for organizing codes and subcodes. Two members of the research team independently reviewed and analyzed the data using NVivo 10. The attributes of the technology itself emerged as primary influencers. Perceived relative advantages of the diagnostic mouth rinse over existing methods were potential time efficiency, low implementation cost, and utility of the tool. Low complexity, compatibility with existing routines/beliefs, and the potential for reinvention-the use of a technology for other than its intended purpose (i.e., patient education, monitoring of disease, screening tool in nondental settings)-were other important features enhancing adoption. An overarching concern was that any new technology benefit the patient. Contextual factors also play a role. Numerous communication channels, including opinion leaders, patients, marketing, continuing education courses, and strength of evidence, influenced clinicians, with peer interaction being a stronger influence than marketing. Similar themes arose from specialist, general dentist, and dental hygienist focus groups. Adopter characteristics also came into play: participants ranged in their self-reported innovativeness with many considering themselves "early adopters" of new technology. Findings of this study suggest that the innovation adoption process is not straightforward, but attributes of the innovation, contextual factors, and adopter characteristics play important roles in the process. Knowledge Transfer Statement: Various factors affect the adoption of new tools into clinical dental practice. These include attributes of the test or tool itself, the context of the settings in which the tool is introduced to practitioners, and the characteristics of the clinicians themselves. A qualitative study of dentists and dental hygienists investigated these factors. Situations in which dentists and hygienists interact with their peers and colleagues-through social networks, continuing education courses, conventions, or personal contact-were a major driver in the decision to adopt new technologies. However, even among "early adopters," most were reluctant to use new tests or tools unless they perceived a benefit to their patients or practice.

Design and delivery of an e-learning curriculum for physicians involved in the management of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) is a condition that affects more than 25 million individuals worldwide and causes premature disability and death. Despite advances in our understanding of this condition, education and training of health professionals has not kept pace with the rapid changes in diagnosis and treatment. The net effects of this gap between advancing knowledge and limited educational opportunity likely include clinically significant delays in both the diagnosis and commencement of effective evidence-based treatment - an unacceptable outcome for patients with a lethal condition.

AIM

The Actelion Clinical Excellence Programme (ACEP) is an e-learning postgraduate curriculum, the purpose of which is to educate and mentor healthcare professionals, both theoretically and practically, in the diagnosis and treatment of patients with all forms of PH. This article reports on the development and delivery of the programme and outcomes from its first year of operation.

RESULTS

Forty-three healthcare professionals from 22 institutions were enroled in the first iteration of the programme. In the 6 months from May to October 2011, participants successfully completed 285 lectures and/or activities. Overall, the programme was considered easily accessible, comprehensive in terms of both quality and quantity, provided an efficient means of self-paced learning, and was a highly regarded as reference source. Ninety-five per cent of participants said that they intended to change their clinical practice as a result of the information presented in the programme.

CONCLUSION

ACEP represents a successful physician-industry partnership, which has resulted in a significant impact on clinical teaching and awareness of PH.

Epilepsy in the Twitter era: a need to re-tweet the way we think about seizures

Seizures have long been associated with misconceptions and stigma. Exponential growth in Internet use has seen the rapid expansion of social media, such as Twitter, for health promotion. In view of the popularity of Twitter, we sought to explore how seizures are being portrayed on this social networking website and to consider its potential for information dissemination. A 48-hour Twitter search was used as a preliminary data set to determine an appropriate classification scheme of "seizure"-related posts ("tweets"). Analysis was then conducted using "seizure" tweets from a 7-consecutive day sample period. Tweets were analyzed and coded by two independent reviewers. Predominant categories were Metaphorical (32%), Personal Accounts (31%), Informative (12%), and Ridicule/Joke (9%). This study supports the notion that stigmatization associated with seizures continues to flourish, as 41% of "seizure" tweets were derogatory in nature. Although Twitter could be used to disseminate accurate information on seizures and epilepsy, this study suggests that it is currently propagating negative attitudes toward seizures with potential for fueling stigma. In recent years there have been significant advancements in technology offering many new methods of sharing information. Social networking sites allow real-time communication while providing the opportunity for exchange of information and opinions. Twitter, a website launched in 2006, allows users to communicate through "tweets" limited to 140 characters. Twitter's popularity has drastically increased since its inception, with approximately 110 million tweets per day from 200 million users worldwide, as of January 2011 (http://blogs.forbes.com/oliverchiang/2011/01/19/twitter-hits-nearly-200m-users-110m-tweets-per-day-focuses-on-global-expansion/). Such social media facilitate communication about an array of health-related topics including seizures and epilepsy.

Atrial versus ventricular cannulation for a rotary ventricular assist device

The ventricular assist device inflow cannulation site is the primary interface between the device and the patient. Connecting these cannulae to either atria or ventricles induces major changes in flow dynamics; however, there are little data available on precise quantification of these changes. The objective of this investigation was to quantify the difference in ventricular/vascular hemodynamics during a range of left heart failure conditions with either atrial (AC) or ventricular (VC) inflow cannulation in a mock circulation loop with a rotary left VAD. Ventricular ejection fraction (EF), stroke work, and pump flow rates were found to be consistently lower with AC compared with VC over all simulated heart failure conditions. Adequate ventricular ejection remained with AC under low levels of mechanical support; however, the reduced EF in cases of severe heart failure may increase the risk of thromboembolic events. AC is therefore more suitable for class III, bridge to recovery patients, while VC is appropriate for class IV, bridge to transplant/destination patients.

Endothelin receptor antagonists are an effective long term treatment option in pulmonary arterial hypertension associated with congenital heart disease with or without trisomy 21

INTRODUCTION

Traditionally, treatment options for patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) are limited. Bosentan has been shown to improve pulmonary haemodynamics and exercise tolerance short term but long term clinical studies are lacking.

AIM

To report long term efficacy and safety data with endothelin receptor antagonists (ERA) in patients with PAH associated CHD.

METHODS

Prospective, open label, uncontrolled, single centre study of 53 patients (33 females, 17 Trisomy 21, mean age 34 ± 12 years) prescribed ERA (48 bosentan, 5 sitaxentan) from 2003 to August 2009. Outcome measurements of oxygen saturation (SaO2), WHO functional class, 6-minute walk test distance (6MWD) and adverse events were analysed.

RESULTS

Mean duration of therapy was 15 ± 13 months in 53 patients with CHD. Four patients failed ERA, seven died (five progressive RHF) and one delisted from transplantation. No abnormal liver transaminases occurred on bosentan, with one case on sitaxentan. After 3, 6, 12, 18 and 24 months of treatment a significant improvement was seen in WHO functional class (mean 3.15 vs 2.8 vs 2.5 vs 2.5 vs 2.4 vs 2.4; p<0.01) and 6MWD (344 ± 18 vs 392 ± 17 vs 411 ± 17 vs 420 ± 17 vs 442 ± 18 vs 417 ± 23: p<0.0005, p<0.01) compared with baseline. The Trisomy 21 and PAH-CHD showed a significant improvement in 6MWD at 6 and 12 months (263 ± 24 vs 348 ± 29 vs 360 ± 32, p<0.01, p<0.05) respectively. No changes in SaO2, BNP, RV or LV function were demonstrated during follow-up.

CONCLUSION

This large single centre study demonstrates that endothelin receptor antagonism is an effective and safe treatment in PAH associated CHD with or without Trisomy 21. The improvements in exercise tolerance are similar to reported benefits in other forms of PAH.

Endothelin receptor antagonists are an effective long term treatment option in pulmonary arterial hypertension associated with congenital heart disease with or without trisomy 21

INTRODUCTION

Traditionally, treatment options for patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) are limited. Bosentan has been shown to improve pulmonary haemodynamics and exercise tolerance short term but long term clinical studies are lacking.

AIM

To report long term efficacy and safety data with endothelin receptor antagonists (ERA) in patients with PAH associated CHD.

METHODS

Prospective, open label, uncontrolled, single centre study of 53 patients (33 females, 17 Trisomy 21, mean age 34 ± 12 years) prescribed ERA (48 bosentan, 5 sitaxentan) from 2003 to August 2009. Outcome measurements of oxygen saturation (SaO2), WHO functional class, 6-minute walk test distance (6MWD) and adverse events were analysed.

RESULTS

Mean duration of therapy was 15 ± 13 months in 53 patients with CHD. Four patients failed ERA, seven died (five progressive RHF) and one delisted from transplantation. No abnormal liver transaminases occurred on bosentan, with one case on sitaxentan. After 3, 6, 12, 18 and 24 months of treatment a significant improvement was seen in WHO functional class (mean 3.15 vs 2.8 vs 2.5 vs 2.5 vs 2.4 vs 2.4; p<0.01) and 6MWD (344 ± 18 vs 392 ± 17 vs 411 ± 17 vs 420 ± 17 vs 442 ± 18 vs 417 ± 23: p<0.0005, p<0.01) compared with baseline. The Trisomy 21 and PAH-CHD showed a significant improvement in 6MWD at 6 and 12 months (263 ± 24 vs 348 ± 29 vs 360 ± 32, p<0.01, p<0.05) respectively. No changes in SaO2, BNP, RV or LV function were demonstrated during follow-up.

CONCLUSION

This large single centre study demonstrates that endothelin receptor antagonism is an effective and safe treatment in PAH associated CHD with or without Trisomy 21. The improvements in exercise tolerance are similar to reported benefits in other forms of PAH.

The BiVACOR rotary biventricular assist device: concept and in vitro investigation

The BiVACOR is a novel rotary Biventricular Assist Device (BiVAD) undergoing development to treat global end-stage heart failure. The design includes left and right vanes positioned on a shared rotating hub to form a double-sided magnetically and hydrodynamically suspended centrifugal impeller. The performance of the device was assessed in a pulsatile mock circulation loop replicating end-stage biventricular heart failure, and was shown to restore flow from pathological (2 L/min) to normal levels (5 L/min). A novel technique to balance the left/right outflow of the BiVAD was also investigated, for which a maximum relative left to right outflow differential of 1.8 L/min was achieved at normal physiologic afterloads. The in vitro results encourage device progression to in vivo animal studies. Successful development of this BiVAD will provide a suitably miniature device for patients who require biventricular assistance.

Human metapneumovirus in lung transplant recipients and comparison to respiratory syncytial virus

RATIONALE

Human metapneumovirus is a newly described virus isolated in 2001 from children with acute respiratory viral infection. It has subsequently been reported globally, although there are limited data in lung transplant recipients.

OBJECTIVES

To prospectively analyze whether human metapneumovirus was circulating in our adult lung transplant community and assess the morbidity of this infection and to compare the clinical presentation and outcome after intravenous ribavirin of human metapneumovirus with that of respiratory syncytial virus (RSV).

METHODS

Lung transplant patients with clinical features of respiratory viral infection underwent nasopharyngeal aspirates. Patients with a positive specimen for RSV or human metapneumovirus by reverse transcriptase-polymerase chain reaction analysis and graft dysfunction received intravenous ribavirin and pulse steroid therapy.

MEASUREMENTS AND MAIN RESULTS

Eighty-nine patients had 199 visits for aspirate studies. A viral cause was determined for 62 visits in 47 patients (19 human metapneumovirus, 18 RSV, 13 parainfluenza, 9 influenza A, 2 adenovirus, and 1 influenza B). A significant percentage of patients with metapneumovirus (63%) and RSV (72%) developed graft dysfunction, with average declines in FEV(1) of 30 +/- 12.4% and 25.9 +/- 11.2%, respectively. In these patients, bronchiolitis obliterans syndrome onset or progression occurred in no patients with human metapneumovirus compared with 5 of 13 (38%) patients with RSV at 6 months.

CONCLUSIONS

Human metapneumovirus is a leading cause of acute respiratory tract illness in lung transplant recipients. The incidence and clinical spectrum at presentation are similar to RSV, although the latter seems to be associated with a higher risk of chronic rejection. We recommend testing of nasopharyngeal aspirates for human metapneumovirus with polymerase chain reaction to assess local epidemiologic patterns.

Fast Track Recovery Following En Bloc Heart–Lung–Liver Transplantation in a Patient with Cystic Fibrosis Complicated by Severe Portal Hypertension

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Symptomatic and asymptomatic viral recrudescence in solid-organ transplant recipients and its relationship with the antigen-specific CD8(+) T-cell response

Using ex vivo antigen-specific T-cell analysis, we found that symptomatic cytomegalovirus recrudescence in transplant recipients was coincident with reduced expression of gamma interferon (IFN-gamma) by virus-specific CD8(+) T cells and an up-regulation of CD38 expression on these T cells, although there was no significant change in the absolute number of virus-specific cells (as assessed by major histocompatibility complex-peptide multimers). In contrast, HLA class I-matched transplant patients with asymptomatic viral recrudescence showed increased expansion of antigen-specific T cells and highly stable IFN-gamma expression by epitope-specific T cells. These studies suggest that a strong functional T-cell response plays a crucial role in defining the clinical outcome of acute viral recrudescence.

Ex vivo monitoring of human cytomegalovirus-specific CD8+ T-cell responses using QuantiFERON�-CMV

We have developed a novel diagnostic technology to monitor the human cytomegalovirus (HCMV)-specific CD8+ T-cell responses that is based on the detection of secreted interferon-gamma (IFN-gamma) in the whole blood (referred to as QuantiFERON -CMV). Evaluation of QuantiFERON -CMV in healthy individuals revealed that this technology was at least as sensitive and with some HCMV epitopes more sensitive than the ELISPOT for detecting ex vivo IFN-gamma. Results from QuantiFERON -CMV assays showed 97% (36/37 individuals) agreement with the anti-HCMV serology test in healthy individuals. Furthermore, we also show that this technology can be used to assess HCMV-specific T-cell responses in transplant patients. This study shows that QuantiFERON -CMV is a simple, reproducible, and reliable test for the detection of IFN-gamma in response to HCMV CD8+ T-cell epitopes, and may be a valuable diagnostic test for the detection of HCMV infection and a useful clinical tool for monitoring the immune response in immunosuppressed patients during therapy.

Review of bosentan in the management of pulmonary arterial hypertension

The dual endothelin receptor antagonist, bosentan, is an orally active therapy, which is effective in the treatment of pulmonary arterial hypertension (PAH). This review critically appraises the evidence for the efficacy of bosentan in idiopathic and familial PAH, in PAH associated with connective tissue disease and in PAH which may develop in association with other conditions. Data from the pivotal placebo controlled studies and their open labeled extensions as well as long term survival and quality of life data is presented. Data is also presented on the potential benefit of bosentan in patients with inoperable chronic thromboembolic pulmonary hypertension. The safety and tolerability of bosentan as well as drug interactions are discussed. Dosage recommendations in adults and pediatrics are presented. An algorithm is provided to guide the reader in monitoring potential increases in alanine and aspartate transaminase levels that may occur with bosentan use and the dose adjustments that are recommended as a result of any increase in the levels of these enzymes are shown. Finally, the role of bosentan as part of combination therapy in PAH is examined.

Is Obliterative Bronchiolitis in Lung Transplantation Associated With Microvascular Damage to Small Airways?

BACKGROUND

Acute rejection, a vascular-based disorder, has been identified as the major risk factor for obliterative bronchiolitis (OB), an airway-based pathology. This study investigated the hypothesis that changes to the microvascular blood supply of small airways were associated with the development of OB, thus providing a possible link between an acute vascular insult (acute rejection) and chronic airway changes (OB).

METHODS

Microvasculature of 695 small airways (99 patients) was assessed in post-mortem lung allograft specimens using monoclonal antibodies for von Willebrand factor and CD31. Group A consisted of 343 small airways from 58 patients with no evidence of OB. The remaining 41 patients had histological evidence of OB in some of their small airways and grouped as B, C, and D with some patients contributing to all three groups ie, their lung specimen had some small airways which were completely obliterated with OB, some airways which were partially obliterated and some small airways without any histological evidence of OB development. Thus group B consisted of 145 small airways (34 patients) without OB. Group C consisted of 171 small airways with partial luminal obstruction (36 patients). Group D consisted of 36 small airways (14 patients) with complete luminal obliteration.

RESULTS

Airway circumference (mean +/- standard deviation) was 2.36 +/- 0.37, 2.41 +/- 0.51, 2.49 +/- 0.51, and 2.57 +/- 0.79 mm, respectively (p = 0.40). Mean number of blood vessels per unit length of airway circumference was 4.12 +/- 1.1, 1.58 +/- 0.61, 2.42 +/- 1.06, and 4.42 +/- 1.46 vessels/mm, respectively (p < 0.001). Blood vessels with circumference greater than 0.2 mm were present in 100%, 64%, 39%, and 7% of small airways, respectively (p < 0.001). Univariate and multivariate analyses (donor and recipient age, sex, and cytomegalovirus status, recipient pretransplant diagnosis, ischemic times, acute rejection and infective episodes, postoperative survival days, recipient group [A to D], blood vessels per unit length, and airway circumference) confirmed that reduction in blood vessels per unit length was associated with the development of OB and was time-independent.

CONCLUSIONS

Obliterative bronchiolitis was preceded by a decrease in microvascular supply to the small airways (group B). The subsequent onset of airway scarring (groups C and D) was associated with an increased number of significantly smaller vessels, suggestive of neovascularization.

Comparison of mycophenolate mofetil and azathioprine for prevention of bronchiolitis obliterans syndrome in de novo lung transplant recipients

BACKGROUND

There are no data on the effects of mycophenolate mofetil (MMF) on the incidence of bronchiolitis obliterans syndrome (BOS) in lung-transplant patients. This study attempted to determine whether MMF reduces the incidence of BOS in de novo lung transplant recipients compared with azathioprine (AZA).

METHODS

This prospective, randomized, open-label, multicenter study compared the effects of MMF with AZA in combination with induction therapy, cyclosporine (Neoral) and corticosteroids in patients receiving their first lung transplant. Primary endpoint was incidence of BOS at 3 years. Secondary endpoints were incidence of acute rejection, time to first rejection event, and survival.

RESULTS

The incidence of acute rejection and the time to first rejection event at 1 and 3 years did not differ between groups (54.1% vs. 53.8% and 56.6% vs. 60.3% for MMF and AZA respectively). Survival at 1 year tended to be better in patients receiving MMF (88 vs. 80%, P = 0.07). At year 3, there was no difference in survival or in the incidence, severity or time to acquisition of BOS between the two groups. Treatment was generally well tolerated, however more patients withdrew from AZA treatment than from MMF (59.6% vs. 46.5%, P = 0.02). As a result, there was an imbalance in the observation times of the two groups (876 +/- 395 vs. 947 +/- 326 days).

CONCLUSIONS

No differences were seen in the incidence of acute rejection or BOS in lung transplant recipients treated with MMF or AZA. This null result may have been influenced by the shorter observation time for AZA patients.

A Complete Mock Circulation Loop for the Evaluation of Left, Right, and Biventricular Assist Devices

A new mock circulation loop was developed to replicate the necessary features of the systemic and pulmonic circulatory systems, including pulsatile left and right ventricles coupled with vascular compliances and resistances. A brief description of the mock loop construction is provided before results are presented confirming the recreation of perfusion rates and pressures found in the natural systemic and pulmonic vascular trees for a normal and failing heart at rest. This rig provides the ability to evaluate the hemodynamic effect of left, right, and biventricular assist devices in vitro. The small and compact mock circulation rig has the potential to reduce device evaluation costs by simulating the natural circulatory system, thus providing valuable device performance feedback prior to expensive in vivo animal trials.

Extended Ganciclovir Prophylaxis in Lung Transplantation

BACKGROUND

Positive cytomegaloviral status of the donor or of the recipient adversely affects survival and enhances the development of bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. The role of ganciclovir prophylaxis in cytomegalovirus infection in respect to obliterative bronchiolitis or to BOS development is not known.

METHODS

From the Papworth transplant database, we identified 146 patients who received organs from cytomegalovirus-positive donors. We classified patients into 3 groups as follows: Group 1 consisted of 42 patients who underwent transplantation between 1990 and 1992 when no prophylaxis was given; Group 2 consisted of 49 patients who underwent transplantation between 1992 and 1995 when 4 weeks of IV ganciclovir was given as prophylaxis; and Group 3 consisted of 55 patients who underwent transplantation between 1995 and 1998 when cytomegalovirus prophylaxis consisted of IV (1 week) followed by oral ganciclovir for a total of 3 months. Donor management, recipient management during and after surgery, and pharmacotherapy were uniform during the study period. We used survival and regression methods to compare these groups, adjusting for the transplantation type (single lung, double lung, or heart-lung) and for HLA typing.

RESULTS

We found a significant difference among all 3 groups in numbers of cytomegaloviral disease episodes in the 1st year after transplantation. The number of rejection episodes in the 3 groups during the 1st post-transplant year gradually decreased from Group 1 to Group 3. We identified no statistically significant benefit in the time to BOS occurrence or in actuarial survival.

CONCLUSION

Extended prophylaxis with IV and oral ganciclovir practically abolishes cytomegaloviral disease and is related to a decreased incidence of rejection episodes. However, ganciclovir prophylaxis is not related to a decreased incidence or progression of BOS or survival.

Lung transplant outcomes: a review of survival, graft function, physiology, health-related quality of life and cost-effectiveness

The success of lung transplantation has improved over time as evidenced by better long-term survival and functional outcomes. Despite the success of this procedure, there are numerous problems and complications that may develop over the life of a lung transplant recipient. With proper monitoring and treatment, the frequency and severity of these problems can be decreased. However, significant improvement for the overall outcomes of lung transplantation will only occur when better methods exist to prevent or effectively treat chronic rejection.