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1.
JAMA Netw Open ; 6(12): e2346829, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-38064213

RESUMO

Importance: Obesity may affect the clinical course of Kawasaki disease (KD) in children and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Objective: To compare the prevalence of obesity and associations with clinical outcomes in patients with KD or MIS-C. Design, Setting, and Participants: In this cohort study, analysis of International Kawasaki Disease Registry (IKDR) data on contemporaneous patients was conducted between January 1, 2020, and July 31, 2022 (42 sites, 8 countries). Patients with MIS-C (defined by Centers for Disease Control and Prevention criteria) and patients with KD (defined by American Heart Association criteria) were included. Patients with KD who had evidence of a recent COVID-19 infection or missing or unknown COVID-19 status were excluded. Main Outcomes and Measures: Patient demographic characteristics, clinical features, disease course, and outcome variables were collected from the IKDR data set. Using body mass index (BMI)/weight z score percentile equivalents, patient weight was categorized as normal weight (BMI <85th percentile), overweight (BMI ≥85th to <95th percentile), and obese (BMI ≥95th percentile). The association between adiposity category and clinical features and outcomes was determined separately for KD and MIS-C patient groups. Results: Of 1767 children, 338 with KD (median age, 2.5 [IQR, 1.2-5.0] years; 60.4% male) and 1429 with MIS-C (median age, 8.7 [IQR, 5.3-12.4] years; 61.4% male) were contemporaneously included in the study. For patients with MIS-C vs KD, the prevalence of overweight (17.1% vs 11.5%) and obesity (23.7% vs 11.5%) was significantly higher (P < .001), with significantly higher adiposity z scores, even after adjustment for age, sex, and race and ethnicity. For patients with KD, apart from intensive care unit admission rate, adiposity category was not associated with laboratory test features or outcomes. For patients with MIS-C, higher adiposity category was associated with worse laboratory test values and outcomes, including a greater likelihood of shock, intensive care unit admission and inotrope requirement, and increased inflammatory markers, creatinine levels, and alanine aminotransferase levels. Adiposity category was not associated with coronary artery abnormalities for either MIS-C or KD. Conclusions and Relevance: In this international cohort study, obesity was more prevalent for patients with MIS-C vs KD, and associated with more severe presentation, laboratory test features, and outcomes. These findings suggest that obesity as a comorbid factor should be considered at the clinical presentation in children with MIS-C.


Assuntos
COVID-19 , Síndrome de Linfonodos Mucocutâneos , Criança , Estados Unidos/epidemiologia , Humanos , Masculino , Pré-Escolar , Feminino , COVID-19/epidemiologia , Síndrome de Linfonodos Mucocutâneos/complicações , Síndrome de Linfonodos Mucocutâneos/epidemiologia , SARS-CoV-2 , Estudos de Coortes , Sobrepeso , Obesidade/complicações , Obesidade/epidemiologia
2.
Pediatr Cardiol ; 2023 Dec 29.
Artigo em Inglês | MEDLINE | ID: mdl-38157048

RESUMO

Kawasaki disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 show clinical overlap and both lack definitive diagnostic testing, making differentiation challenging. We sought to determine how cardiac biomarkers might differentiate KD from MIS-C. The International Kawasaki Disease Registry enrolled contemporaneous KD and MIS-C pediatric patients from 42 sites from January 2020 through June 2022. The study population included 118 KD patients who met American Heart Association KD criteria and compared them to 946 MIS-C patients who met 2020 Centers for Disease Control and Prevention case definition. All included patients had at least one measurement of amino-terminal prohormone brain natriuretic peptide (NTproBNP) or cardiac troponin I (TnI), and echocardiography. Regression analyses were used to determine associations between cardiac biomarker levels, diagnosis, and cardiac involvement. Higher NTproBNP (≥ 1500 ng/L) and TnI (≥ 20 ng/L) at presentation were associated with MIS-C versus KD with specificity of 77 and 89%, respectively. Higher biomarker levels were associated with shock and intensive care unit admission; higher NTproBNP was associated with longer hospital length of stay. Lower left ventricular ejection fraction, more pronounced for MIS-C, was also associated with higher biomarker levels. Coronary artery involvement was not associated with either biomarker. Higher NTproBNP and TnI levels are suggestive of MIS-C versus KD and may be clinically useful in their differentiation. Consideration might be given to their inclusion in the routine evaluation of both conditions.

3.
J Am Heart Assoc ; 12(20): e030377, 2023 10 17.
Artigo em Inglês | MEDLINE | ID: mdl-37830333

RESUMO

Background The success of cardiac auscultation varies widely among medical professionals, which can lead to missed treatments for structural heart disease. Applying machine learning to cardiac auscultation could address this problem, but despite recent interest, few algorithms have been brought to clinical practice. We evaluated a novel suite of Food and Drug Administration-cleared algorithms trained via deep learning on >15 000 heart sound recordings. Methods and Results We validated the algorithms on a data set of 2375 recordings from 615 unique subjects. This data set was collected in real clinical environments using commercially available digital stethoscopes, annotated by board-certified cardiologists, and paired with echocardiograms as the gold standard. To model the algorithm in clinical practice, we compared its performance against 10 clinicians on a subset of the validation database. Our algorithm reliably detected structural murmurs with a sensitivity of 85.6% and specificity of 84.4%. When limiting the analysis to clearly audible murmurs in adults, performance improved to a sensitivity of 97.9% and specificity of 90.6%. The algorithm also reported timing within the cardiac cycle, differentiating between systolic and diastolic murmurs. Despite optimizing acoustics for the clinicians, the algorithm substantially outperformed the clinicians (average clinician accuracy, 77.9%; algorithm accuracy, 84.7%.) Conclusions The algorithms accurately identified murmurs associated with structural heart disease. Our results illustrate a marked contrast between the consistency of the algorithm and the substantial interobserver variability of clinicians. Our results suggest that adopting machine learning algorithms into clinical practice could improve the detection of structural heart disease to facilitate patient care.


Assuntos
Aprendizado Profundo , Cardiopatias , Adulto , Humanos , Sopros Cardíacos/diagnóstico , Cardiopatias/diagnóstico por imagem , Auscultação Cardíaca , Algoritmos
4.
Front Cardiovasc Med ; 10: 1211619, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37636313

RESUMO

Left atrial appendage aneurysm (LAAA) is a rare cardiac pathology that is often identified in adulthood. There are a myriad of presentations related to atrial appendage enlargement, but most are asymptomatic. Pediatric cases of LAAA are extremely rare. We report a case of an incidental giant LAAA found in a healthy 6-year-old boy. He was successfully treated with surgical resection. A review of the literature shows that the presentation of LAAA in pediatrics likely involves cardiac or respiratory symptoms but can also be incidental findings. Similar to adults, diagnosis requires cardiac imaging, with echocardiography being the mainstay. Surgical intervention is indicated in symptomatic and most asymptomatic patients to prevent complications. More research is warranted into the optimal timing of surgery and alternative surgical approaches for complex cases.

5.
Pediatr Nephrol ; 38(8): 2741-2751, 2023 08.
Artigo em Inglês | MEDLINE | ID: mdl-36692729

RESUMO

BACKGROUND: The diagnosis of hypertension and hypertension-induced target organ injury by the 2022 American Heart Association (AHA) ambulatory blood pressure threshold as compared with 2014 AHA and 2016 European Society of Hypertension (ESH) thresholds has not been evaluated. METHODS: In a cross-sectional study (n = 291, aged 5-18 years, at a tertiary care outpatient clinic), we compared 2022 AHA with 2014 AHA and ESH thresholds (revised with 2018 adult ESH thresholds where applicable) to diagnose ambulatory hypertension (AH), and detect ambulatory arterial stiffness index (AASI) and left ventricular target organ injury (LVTOI). RESULTS: The 2022 AHA threshold diagnosed significantly more AH (53%) than the 2014 AHA (42%, p < 0.01) and ESH (36%, p < 0.001) thresholds. The 2022 AHA threshold demonstrated only a moderate agreement with the 2014 AHA (kappa (k) = 0.77) and ESH (k = 0.66) thresholds to diagnose AH. Adjusted logistic regression analysis found that only the 2022 AHA threshold predicted elevated AASI significantly (odds ratio 2.40, 95% CI 1.09, 5.25, p = 0.02; AUC 0.61, p < 0.01). In those with elevated AASI, more participants had AH by the 2022 AHA threshold (72%) than the 2014 AHA (46%, p = 0.02) and ESH (48%, p = 0.03) thresholds. AH defined by the 2022 AHA threshold continued to maintain higher odds, larger AUC, and higher sensitivity to identify LVTOI than the 2014 AHA and ESH thresholds; however, the difference did not reach a statistically significant level. CONCLUSIONS: AH defined by the 2022 AHA threshold diagnoses more children with hypertension and identifies more children with hypertension-induced target organ injury than the 2014 AHA and ESH thresholds. A higher resolution version of the Graphical abstract is available as Supplementary information.


Assuntos
Monitorização Ambulatorial da Pressão Arterial , Hipertensão , Adulto , Estados Unidos , Humanos , Criança , American Heart Association , Estudos Transversais , Hipertensão/diagnóstico , Pressão Sanguínea
6.
Rev Cardiovasc Med ; 24(3): 85, 2023 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-39077485

RESUMO

Background: The population of adults with congenital heart defects (ACHD) is growing. The leading cause of premature death in these patients is heart failure (HF). However, there is still limited information on the predictive factors for HF in ACHD patients. Objectives: This study re-examined a group of patients with repaired or palliated congenital heart defects (CHD) that were initially studied in 2003. A follow-up period of 15 years has allowed us to identify and evaluate predictors for the development of HF in ACHD. Methods: All patients with repaired or palliated CHD who participated in the initial study (n = 364) were invited for a follow-up examination. The effects of maximum oxygen uptake ( VO 2max ) during exercise stress testing, the cardiac biomarker N-terminal pro brain natriuretic peptide (NT-proBNP), and QRS complex on the development of HF during the follow-up period were investigated. Results: From May 2017 to April 2019, 249 of the initial 364 (68%) patients participated in the follow-up study. Of these, 21% were found to have mild CHD, 60% had moderate CHD, and 19% had complex CHD. Significant predictors for the development of HF were: NT-proBNP level > 1.7 times the upper normal limit, VO 2max < 73% of predicted values, and QRS complex duration > 120 ms. Combination of these three parameters resulted in the highest area-under-the-curve of 0.75, with a sensitivity of 75% and specificity of 63% for predicting the development of HF. Conclusions: In this cohort of ACHD patients, the combination of VO 2max% , NT-proBNP, and QRS duration was predictive of HF development over a 15-year follow-up period. Enhanced surveillance of these parameters in patients with ACHD may be beneficial for the prevention of HF and early intervention.

7.
Clin Hypertens ; 28(1): 34, 2022 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-36376947

RESUMO

BACKGROUND: The agreement between the commonly used ambulatory blood pressure (ABP) thresholds to diagnose ambulatory hypertension in children (patient's 24-h mean ABP classified by 24-h 95th ABP percentile threshold, American Heart Association [AHA] threshold, or patient's day and night mean ABP classified by day-night 95th ABP percentile thresholds) is not known. We evaluated the agreement among 24-h ABP threshold, AHA threshold, and day-night ABP thresholds to diagnose ambulatory hypertension, white coat hypertension (WCH) and masked hypertension (MH). METHODS: In a cross-sectional study design, we analyzed ABP recordings from 450 participants with suspected hypertension from a tertiary care outpatient hypertension clinic. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. RESULTS: The 24-h ABP threshold and day-night ABP thresholds classified 19% ABP (95% confidence interval [CI], 0.15-0.23) differently into ambulatory normotension/hypertension (kappa [κ], 0.58; 95% CI, 0.51-0.66). Ambulatory hypertension diagnosed by 24-h ABP threshold in 27% participants (95% CI, 0.22-0.32) was significantly lower than that by day-night ABP thresholds in 44% participants (95% CI, 0.37-0.50; P < 0.001). The AHA threshold had a stronger agreement with 24-h ABP threshold than with day-night ABP thresholds for classifying ABP into ambulatory normotension/hypertension (k 0.94, 95% CI 0.91-0.98 vs. k 0.59, 95% CI 0.52-0.66). The diagnosis of ambulatory hypertension by the AHA threshold (26%; 95% CI, 0.21-0.31) was closer to that by 24-h ABP threshold (27%, P = 0.73) than by day-night ABP thresholds (44%, P < 0.001). Similar agreement pattern persisted among these ABP thresholds for diagnosing WCH and MH. CONCLUSIONS: The 24-h ABP threshold classifies a lower proportion of ABP as ambulatory hypertension than day-night ABP thresholds. The AHA threshold exhibits a stronger agreement with 24-h ABP than with day-night ABP thresholds for diagnosing ambulatory hypertension, WCH and MH. Our findings are relevant for a consistent interpretation of hypertension by these ABP thresholds in clinical practice.

8.
Clin Res Cardiol ; 111(8): 900-911, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35229166

RESUMO

OBJECTIVES: The population of adults with congenital heart defects (ACHD) is continuously growing. Data on morbidity and mortality of ACHD are limited. This longitudinal observational study examined a group of ACHD with surgically corrected or palliated congenital heart defects (CHD) during a 15-year period. METHODS: ACHD that had participated in the initial study were invited for a follow-up examination. Mortality and hospitalization data were compared with a healthy control group. RESULTS: From 05/2017 to 04/2019 a total of 249/364 (68%) ACHD participated in the follow-up study: 21% had mild, 60% moderate and 19% severe CHD. During the observational period, 290 health incidents occurred (cardiac catheterization 37%, cardiovascular surgery 27%, electrophysiological study/ablation 20%, catheter interventional treatment 14%, non-cardiac surgery 3%). Events were more frequent in ACHD with moderate (53%) and severe (87%) compared to those with mild CHD (p < 0.001). 24 individuals died at a median age of 43 years during the observation period. 29% of them had moderate and 71% severe CHD corresponding to a mortality rate of 0%, 0.29% and 1.68% per patient-year in ACHD with mild, moderate and severe CHD. Long-term survival was significantly reduced in patients with severe CHD in comparison to individuals with mild and moderate CHD (p < 0.001). CONCLUSION: After correction or palliation of CHD, there was remarkable ongoing morbidity and mortality in ACHD patients over the 15-year observation period, particularly in individuals with moderate and severe CHD when compared with the general population. Thus, life-long special care is required for all surgically corrected or palliated ACHD patients.


Assuntos
Cardiopatias Congênitas , Adulto , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Hospitalização , Humanos , Morbidade
9.
CJC Pediatr Congenit Heart Dis ; 1(4): 174-183, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37969928

RESUMO

Background: The impact of adjunctive anti-inflammatory treatment on outcomes for patients with Kawasaki disease (KD) and coronary artery aneurysms (CAAs) is unknown. Methods: Using data from the International KD Registry in patients with ≥ medium CAA we evaluate associations of treatment with outcomes and major adverse cardiac events (MACE). Results: Medium or large CAA was present in 527 (32%) patients. All were treated with intravenous immunoglobulin (IVIG), 70% were male, and the median age was 1.3 years (interquartile range: 0.4-4.0 years). The most common acute therapies included single IVIG alone in 243 (46%), multiple IVIG in 100 (19%), multiple IVIG + corticosteroids in 75 (14%), and multiple IVIG + infliximab + corticosteroids in 44 (8%) patients. Patients who received therapy beyond single IVIG had a larger CA z-score at baseline (P < 0.001) and a higher rate of bilateral CAA (P < 0.001). Compared with IVIG alone, early adjunctive treatments (within 3 days of initial IVIG) were not associated with time to CAA regression or MACE, whereas later adjunctive therapy was associated with MACE and longer time to CAA regression. Patients receiving IVIG plus steroids vs IVIG alone had a trend towards shorter time to CAA regression and lower risk of MACE (P = 0.07). A larger CAA z-score at baseline was the strongest predictor of an increase in the CAA z-score over follow-up, lower likelihood of CAA regression, and higher risk of MACE. Conclusions: Persistence of CAA and MACE are more strongly associated with baseline severity CAA than with acute adjuvant anti-inflammatory therapy. Patients who received late adjunctive therapy are at higher risk for worse outcomes.


Contexte: L'incidence d'un traitement anti-inflammatoire d'appoint chez les patients atteints de la maladie de Kawasaki (MK) compliquée d'anévrismes coronariens est inconnue. Méthodologie: À partir de données provenant du registre international de la maladie de Kawasaki portant sur les patients ayant subi des anévrismes coronariens modérés ou importants, nous avons évalué l'incidence des différents traitements sur les résultats cliniques et les événements cardiovasculaires indésirables majeurs (ECIM). Résultats: Des anévrismes coronariens modérés ou importants ont été relevés chez 527 patients (32 %). Tous les patients recevaient des immunoglobulines administrées par voie intraveineuse (IgIV); 70 % d'entre eux étaient de sexe masculin, et leur âge médian était de 1,3 an (écart interquartile : de 0,4 an à 4,0 ans). Les traitements d'urgence les plus fréquents comprenaient un seul traitement par IgIV chez 243 patients (46 %), plusieurs traitements par IgIV chez 100 patients (19 %), une association de plusieurs traitements IgIV et de corticostéroïdes chez 75 patients (14 %) et une association de plusieurs traitements IgIV, de corticostéroïdes et d'infliximab chez 44 patients (8 %). Les patients ayant reçu un traitement autre qu'un seul traitement IgIV présentaient des scores z initiaux plus élevés pour le diamètre des artères coronaires (P < 0,001) et un taux plus élevé d'anévrismes coronariens bilatéraux (P < 0,001). En comparaison d'un traitement par IgIV seulement, les traitements d'appoint précoces (administrés dans les trois jours suivant le début du traitement par IgIV) n'ont pas eu d'incidence sur la durée avant la régression des anévrismes coronariens ni sur la survenue d'ECIM, alors que les traitements d'appoint plus tardifs ont été associés à un risque plus élevé d'ECIM et à une régression plus tardive des anévrismes coronariens. Les patients ayant reçu une association d'IgIV et de corticostéroïdes avaient tendance à présenter une régression plus rapide des anévrismes coronariens et un plus faible risque d'ECIM que ceux recevant uniquement un traitement par IgIV (P = 0,07). Un score z initial plus élevé pour un anévrisme coronarien était le facteur prédictif le plus puissant d'une augmentation du score z pendant la période de suivi, d'une probabilité plus faible de régression de l'anévrisme et d'un risque plus élevé d'ECIM. Conclusions: La gravité initiale de l'anévrisme coronarien est plus fortement associée à la persistance de l'anévrisme et à la survenue d'ECIM que le recours à un traitement anti-inflammatoire d'urgence en appoint. Les patients recevant un traitement d'appoint tardif étaient par ailleurs plus susceptibles de présenter des résultats défavorables.

10.
CJC Pediatr Congenit Heart Dis ; 1(4): 200-202, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37969933

RESUMO

The arterial switch operation is the gold-standard treatment for dextro-transposition of the great arteries. Long-term follow-up data are beginning to reveal its natural history and associated late complications, including various reoperations for those complications. Given the unique anatomy and the increasing longevity of these patients, there is a need for effective surgical repair options to address aneurysmal and degenerative changes in both neoaortic and pulmonic roots. Thereby, we describe our technique and the novel considerations for prosthetic choice with reconstruction of both the neoaortic root and pulmonary artery, with satisfactory postoperative results.


La détransposition artérielle constitue le traitement de référence dans les cas de dextro-transposition des gros vaisseaux. De nouvelles données, issues du suivi à long terme, nous permettent de mieux comprendre l'évolution naturelle à la suite de cette intervention et les complications tardives qui y sont associées, y compris les diverses interventions à réaliser pour les corriger. Étant donné les caractéristiques anatomiques uniques de ces patients et l'augmentation de leur espérance de vie, il est nécessaire de proposer des options efficaces de réparations chirurgicales pour remédier aux changements anévrismaux et dégénératifs des racines néoaortique et pulmonaire. Ainsi, nous décrivons la technique que nous avons utilisée et les nouveaux éléments qui entrent en ligne de compte dans le choix d'une prothèse pour une reconstruction de la racine néoaortique et de l'artère pulmonaire, avec des résultats postopératoires jugés satisfaisants.

11.
J Pediatr ; 240: 164-170.e1, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34474088

RESUMO

OBJECTIVE: To evaluate practice variation in pharmacologic management in the International Kawasaki Disease Registry (IKDR). STUDY DESIGN: Practice variation in intravenous immunoglobulin (IVIG) therapy, anti-inflammatory agents, statins, beta-blockers, antiplatelet therapy, and anticoagulation was described. RESULTS: We included 1627 patients from 30 IKDR centers with maximum coronary artery aneurysm (CAA) z scores 2.5-4.99 in 848, 5.0-9.99 in 349, and ≥10.0 (large/giant) in 430 patients. All centers reported IVIG and acetylsalicylic acid (ASA) as primary therapy and use of additional IVIG or steroids as needed. In 23 out of 30 centers, (77%) infliximab was also used; 11 of these 23 centers reported using it in <10% of their patients, and 3 centers used it in >20% of patients. Nonsteroidal anti-inflammatory agents were used in >10% of patients in only nine centers. Beta-blocker (8.8%, all patients) and abciximab (3.6%, all patients) were mainly prescribed in patients with large/giant CAAs. Statins (2.7%, all patients) were mostly used in one center and only in patients with large/giant CAAs. ASA was the primary antiplatelet modality for 99% of patients, used in all centers. Clopidogrel (18%, all patients) was used in 24 centers, 11 of which used it in >50% of their patients with large/giant CAAs. CONCLUSIONS: In the IKDR, IVIG and ASA therapy as primary therapy is universal with common use of a second dose of IVIG for persistent fever. There is practice variation among centers for adjunctive therapies and anticoagulation strategies, likely reflecting ongoing knowledge gaps. Randomized controlled trials nested in a high-quality collaborative registry may be an efficient strategy to reduce practice variation.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Aspirina/uso terapêutico , Imunoglobulinas Intravenosas/uso terapêutico , Fatores Imunológicos/uso terapêutico , Síndrome de Linfonodos Mucocutâneos/tratamento farmacológico , Pré-Escolar , Aneurisma Coronário/etiologia , Feminino , Humanos , Lactente , Masculino , Síndrome de Linfonodos Mucocutâneos/complicações , Padrões de Prática Médica , Sistema de Registros , Estudos Retrospectivos
12.
J Clin Hypertens (Greenwich) ; 23(11): 1947-1956, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34668643

RESUMO

The agreement between the traditionally-used ambulatory blood pressure (ABP)-load thresholds in children and recently-recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated. In this cross-sectional study on 450 outpatient participants, the authors evaluated the agreement between previously used ABP-load 25%, 30%, 40%, 50% thresholds and the AHA/ESH thresholds for diagnosing AH, WCH, and MH. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. The AHA threshold diagnosed ambulatory normotension/hypertension closest to ABP load 50% in 88% (95% CI 0.79, 0.96) participants (k 0.67, 95% CI 0.59, 0.75) and the ESH threshold diagnosed ambulatory normotension/hypertension closest to ABP load 40% in 86% (95% CI 0.77, 0.94) participants (k 0.66, 95% CI 0.59, 0.74). In contrast, the AHA/ESH thresholds had a relatively weaker agreement with ABP load 25%/30%. Therefore, the diagnosis of AH was closest between the AHA threshold and ABP load 50% (difference 3%, 95% CI -2.6%, 8.6%, p = .29) and between the ESH threshold and ABP load 40% (difference 4%, 95% CI -2.1%, 10.1%, p = .19) than between the AHA/ESH and ABP load 25%/30% thresholds. A similar agreement pattern persisted between the AHA/ESH and various ABP load thresholds for diagnosing WCH and MH. The AHA and ESH thresholds diagnosed AH, WCH, and MH closest to ABP load 40%/50% than ABP load 25%/30%. Future outcome-based studies are needed to guide the optimal use of these ABP thresholds in clinical practice.


Assuntos
Hipertensão , Hipertensão Mascarada , Pediatria , Hipertensão do Jaleco Branco , American Heart Association , Pressão Sanguínea , Monitorização Ambulatorial da Pressão Arterial , Criança , Estudos Transversais , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão Mascarada/diagnóstico , Hipertensão Mascarada/epidemiologia , Hipertensão do Jaleco Branco/diagnóstico
13.
Appl Physiol Nutr Metab ; 46(9): 1038-1046, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34139129

RESUMO

There is a need for improved understanding of how different cerebrovascular reactivity (CVR) protocols affect vascular cross-sectional area (CSA) to reduce error in CVR calculations when measures of vascular CSA are not feasible. In human participants, we delivered ∼±4 mm Hg end-tidal partial pressure of CO2 (PETCO2) relative to baseline through controlled delivery, and measured changes in middle cerebral artery (MCA) CSA (7 Tesla magnetic resonance imaging (MRI)), blood velocity (transcranial Doppler and Phase contrast MRI), and calculated CVR based on a 3-minute steady-state (+4 mm Hg PETCO2) and a ramp (-3 to +4 mm Hg of PETCO2). We observed that (1) the MCA did not dilate during the ramp protocol (slope for CSA across time P > 0.05; R2 = 0.006), but did dilate by ∼7% during steady-state hypercapnia (P < 0.05); and (2) MCA blood velocity CVR was not different between ramp and steady-state hypercapnia protocols (ramp: 3.8 ± 1.7 vs. steady-state: 4.0 ± 1.6 cm/s/mm Hg), although calculated MCA blood flow CVR was ∼40% greater during steady-state hypercapnia than during ramp (P < 0.05) with the discrepancy due to MCA CSA changes during steady-state hypercapnia. We propose that a ramp model, across a delta of -3 to +4 mm Hg PETCO2, may provide an alternative approach to collecting CVR measures in young adults with transcranial Doppler when CSA measures are not feasible. Novelty: We optimized a magnetic resonance imaging sequence to measure dynamic middle cerebral artery (MCA) cross-sectional area (CSA). A ramp model of hypercapnia elicited similar MCA blood velocity reactivity as the steady-state model while maintaining MCA CSA.


Assuntos
Velocidade do Fluxo Sanguíneo , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiologia , Vasodilatação , Adulto , Circulação Cerebrovascular , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Ultrassonografia Doppler Transcraniana , Adulto Jovem
14.
Front Pediatr ; 9: 669453, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34055700

RESUMO

Renal infarction is a rare finding in children. Associations between SARS-CoV-2 infections and thromboembolic events including renal infarcts have been described in adults. Although a similar association in children has not yet been described with this pandemic, the pediatric literature is still evolving with the recognition of new manifestations including the post-infectious Multisystem Inflammatory Syndrome in Children (MIS-C). We report the rare event of multiple renal infarcts in a 6-year-old boy manifesting several features of MIS-C 9 weeks following a self-limiting febrile illness characteristic of COVID-19. An underlying Factor V Leiden mutation was identified in this child but felt to be insufficient on its own to explain his clinical presentation. As SARS-CoV-2 testing was delayed, the failure to identify viral RNA or antibodies may not exclude the virus' potential role in precipitating the infarct in this host. Given that renal infarcts have been described in adult patients with COVID-19, reporting this perplexing case where SARS-CoV-2 may have played a role, may help identify this potential complication.

15.
PLoS One ; 16(2): e0246169, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33606726

RESUMO

BACKGROUND: Patients of congenital heart disease surgery have good prospects for reaching old age. Against the backdrop of increasing life expectancies, the question of how well such patients are mastering daily routines and their working life emerges. In our study, the educational and occupational performance of patients over 15 years was examined. METHODS: Intergenerational social mobility (changes in social positions from the parental generation to the generation of children) was examined in terms of education, and intragenerational social mobility (changes in positions within the same generation, i.e., in individuals over their life courses) was examined in terms of occupational positions. Comparisons were made between patients and a control group drawn from the German Socio-Economic Panel (SOEP). Controls were drawn from respondents who participated in the 2004 and 2018 SOEP surveys. RESULTS: The data were from 244 out of 360 patients (68%) with complete social data from the first survey (2003-2004) and who were included in the follow-up (2017-2019), and 238 controls were drawn from the SOEP. At the time of the second survey, subjects' ages ranged from 28 to 59 years of age (M = 40.1 years). Intergenerational educational mobility did not differ between cases and controls. For intragenerational social mobility, downward changes were more frequent among controls. This latter finding may be explained by patients retiring earlier than the general population. Retirement rates increased over time, particularly among patients with severe congenital malformations. Unemployment rates were also higher among patients. CONCLUSIONS: Taken together, although a considerable proportion of patients with congenital heart disease retired prematurely or never entered the labour force, their educational and occupational careers proceeded more favourably than expected.


Assuntos
Cardiopatias Congênitas/cirurgia , Mobilidade Social/estatística & dados numéricos , Adulto , Estudos de Casos e Controles , Criança , Escolaridade , Emprego/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aposentadoria/estatística & dados numéricos
16.
Pediatr Cardiol ; 42(3): 676-684, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33439285

RESUMO

In the 2017 American Heart Association (AHA) Kawasaki disease (KD) guidelines, risk levels (RLs) for long-term management are defined by both maximal and current coronary artery (CA) dimensions normalized as z-scores. We sought to determine the degree to which current recommended practice differs from past actual practice, highlighting areas for knowledge translation efforts. The International KD Registry (IKDR) included 1651 patients with CA aneurysms (z-score > 2.5) from 1999 to 2016. Patients were classified by AHA RL using maximum CA z-score (RL 3 = small, RL 4 = medium, RL 5 = large/giant) and subcategorized based on decreases over time. Medical management provided was compared to recommendations. Low-dose acetylsalicylic acid (ASA) use ranged from 86 (RL 3.1) to 95% (RL 5.1) for RLs where use was "indicated." Dual antiplatelet therapy (ASA + clopidogrel) use ranged from 16% for RL 5.2 to 9% for RL 5.4. Recommended anticoagulation (warfarin or low molecular weight heparin) use was 65% for RL 5.1, while 12% were on triple therapy (anticoagulation + dual antiplatelet). Optional statin use ranged from 2 to 8% depending on RL. Optional beta-blocker use was 2-25% for RL 5, and 0-5% for RLs 3 and 4 where it is not recommended. Generally, past practice was consistent with the latest AHA guidelines, taking into account the flexible wording of recommendations based on the limited evidence, as well as unmeasured patient-specific factors. In addition to strengthening the overall evidence base, knowledge translation efforts may be needed to address variation in thromboprophylaxis management.


Assuntos
Fidelidade a Diretrizes , Síndrome de Linfonodos Mucocutâneos/terapia , Tromboembolia Venosa/prevenção & controle , Adolescente , Anticoagulantes/administração & dosagem , Aspirina/administração & dosagem , Criança , Aneurisma Coronário/etiologia , Aneurisma Coronário/terapia , Feminino , Humanos , Masculino , Síndrome de Linfonodos Mucocutâneos/complicações , Sistema de Registros , Estudos Retrospectivos , Varfarina/administração & dosagem
17.
Am J Hypertens ; 34(2): 198-206, 2021 03 11.
Artigo em Inglês | MEDLINE | ID: mdl-33011756

RESUMO

BACKGROUND: The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known. METHODS: In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP). RESULTS: In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16). CONCLUSIONS: In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.


Assuntos
Monitorização Ambulatorial da Pressão Arterial , Hipertensão , Adolescente , Instituições de Assistência Ambulatorial , Monitorização Ambulatorial da Pressão Arterial/métodos , Criança , Pré-Escolar , Estudos Transversais , Hipertensão Essencial/diagnóstico , Europa (Continente) , Humanos , Hipertensão/diagnóstico , Hipertensão Mascarada/diagnóstico , Pediatria , Estudos Retrospectivos , Sociedades Médicas , Hipertensão do Jaleco Branco/diagnóstico
18.
CJC Open ; 2(6): 555-562, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33305216

RESUMO

BACKGROUND: Despite current physical activity (PA) guidelines, children spend an average of 1-3 hours/day playing video games. Some video games offer physically active components as part of gameplay. We sought to determine if these active video games (AVGs) can elicit at least moderate PA in children, identify game elements important for PA, and determine if they are fun to play. METHODS: Twenty children aged 8 to 16 years underwent cardiopulmonary exercise testing to determine their heart rate (HR) at ventilatory threshold. Participants played 2 different AVGs, and the gaming time that each participant's HR was above the HR thresholds for moderate and vigorous PA was determined. Gameplay elements that supported or inhibited active gameplay were also identified. Participants also completed questionnaires on physical activity, game engagement, and game experience. RESULTS: The Dance Central Spotlight and Kung-Fu for Kinect AVGs produced at least moderate PA, for a mean of 54.3% ± 29.5% and 87.8% ± 21.8% of gameplay time, respectively. Full-body movements, player autonomy, and self-efficacy were observed to be important elements of good AVG design. Although participants enjoyed these AVGs, they still preferred their favorite games (game engagement score of 1.82 ± 0.67 vs 0.95 ± 0.70 [Dance Central Spotlight] and 1.39 ± 0.37 [Kung Fu for Kinect]). CONCLUSIONS: AVGs can provide at least moderate PA and are enjoyable to play, but most popular video games do not incorporate active components. The implementation of government policies and a rating system concerning PA in video games may help address the widespread sedentary lifestyle of children.


CONTEXTE: Malgré les lignes directrices actuelles sur l'activité physique, les enfants passent en moyenne entre une et trois heures par jour à jouer à des jeux vidéo. Comme la jouabilité de certains jeux vidéo comporte des activités physiques, nous avons cherché à déterminer si les jeux vidéo dynamiques (JVD) pouvaient permettre aux enfants d'atteindre un degré d'activité physique au moins modéré, à cerner les éléments de jeu qui sont importants pour l'activité physique et à déterminer si ces jeux étaient amusants. MÉTHODOLOGIE: Nous avons soumis 20 enfants de 8 à 16 ans à des épreuves d'effort cardiopulmonaire pour déterminer leur fréquence cardiaque (FC) au seuil ventilatoire. Les participants ont joué à deux JVD différents et nous avons déterminé la durée pendant laquelle la FC de chaque participant était supérieure aux seuils de FC correspondant à une activité physique modérée et intense. Nous avons aussi cerné les éléments de la jouabilité qui favorisaient ou empêchaient la jouabilité dynamique. Les participants ont en outre rempli des questionnaires sur l'activité physique, l'intérêt des jeux et l'expérience de jeu. RÉSULTATS: Deux JVD, Dance Central Spotlight et Kung-Fu for Kinect, ont produit un degré d'activité physique au moins modéré pendant respectivement 54,3 % ± 29,5 % et 87,8 % ± 21,8 % de la durée de jouabilité. Nous avons constaté que les mouvements du corps entier, l'autonomie des joueurs et l'auto-efficacité étaient des éléments importants de la bonne conception d'un JVD. Les participants ont aimé ces JVD, mais ils préféraient toujours leurs jeux favoris (score d'intérêt à l'égard du jeu de 1,82 ± 0,67 vs 0,95 ± 0,70 [Dance Central Spotlight] et 1,39 ± 0,37 [Kung Fu for Kinect]). CONCLUSIONS: Les JVD semblent produire un degré d'activité physique au moins modéré et sont amusants, mais la plupart des jeux vidéo populaires ne font pas faire d'activité physique. La mise en œuvre de politiques gouvernementales et l'adoption d'un système de cotation concernant l'activité physique associée aux jeux vidéo pourraient permettre de s'attaquer au problème répandu que représente la sédentarité chez les enfants.

19.
J Am Heart Assoc ; 9(15): e016440, 2020 08 04.
Artigo em Inglês | MEDLINE | ID: mdl-32750313

RESUMO

Background Coronary artery aneurysms (CAAs) may occur after Kawasaki disease (KD) and lead to important morbidity and mortality. As CAA in patients with KD are rare and heterogeneous lesions, prognostication and risk stratification are difficult. We sought to derive the cumulative risk and associated factors for cardiovascular complications in patients with CAAs after KD. Methods and Results A 34-institution international registry of 1651 patients with KD who had CAAs (maximum CAA Z score ≥2.5) was used. Time-to-event analyses were performed using the Kaplan-Meier method and Cox proportional hazard models for risk factor analysis. In patients with CAA Z scores ≥10, the cumulative incidence of luminal narrowing (>50% of lumen diameter), coronary artery thrombosis, and composite major adverse cardiovascular complications at 10 years was 20±3%, 18±2%, and 14±2%, respectively. No complications were observed in patients with a CAA Z score <10. Higher CAA Z score and a greater number of coronary artery branches affected were associated with increased risk of all types of complications. At 10 years, normalization of luminal diameter was noted in 99±4% of patients with small (2.5≤Z<5.0), 92±1% with medium (5.0≤Z<10), and 57±3% with large CAAs (Z≥10). CAAs in the left anterior descending and circumflex coronary artery branches were more likely to normalize. Risk factor analysis of coronary artery branch level outcomes was performed with a total of 893 affected branches with Z score ≥10 in 440 patients. In multivariable regression models, hazards of luminal narrowing and thrombosis were higher for patients with CAAs of the right coronary artery and left anterior descending branches, those with CAAs that had complex architecture (other than isolated aneurysms), and those with CAAs with Z scores ≥20. Conclusions For patients with CAA after KD, medium-term risk of complications is confined to those with maximum CAA Z scores ≥10. Further risk stratification and close follow-up, including advanced imaging, in patients with large CAAs is warranted.


Assuntos
Aneurisma Coronário/complicações , Síndrome de Linfonodos Mucocutâneos/complicações , Sistema de Registros , Criança , Pré-Escolar , Aneurisma Coronário/patologia , Vasos Coronários/patologia , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Medição de Risco
20.
Can J Cardiol ; 36(10): 1598-1607, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32621885

RESUMO

BACKGROUND: The substantial risk of thrombosis in large coronary artery aneurysms (CAAs) (maximum z-score ≥ 10) after Kawasaki disease (KD) mandates effective thromboprophylaxis. We sought to determine the effectiveness of anticoagulation (low-molecular-weight heparin [LMWH] or warfarin) for thromboprophylaxis in large CAAs. METHODS: Data from 383 patients enrolled in the International KD Registry (IKDR) were used. Time-to-event analysis was used to account for differences in treatment duration and follow-up. RESULTS: From diagnosis onward (96% received acetylsalicylic acid concomitantly), 114 patients received LMWH (median duration 6.2 months, interquartile range [IQR] 2.5-12.7), 80 warfarin (median duration 2.2 years, IQR 0.9-7.1), and 189 no anticoagulation. Cumulative incidence of coronary artery thrombosis with LMWH was 5.7 ± 3.0%, with warfarin 6.7 ± 3.7%, and with no anticoagulation 20.6 ± 3.0% (P < 0.001) at 2.5 years after the start of thromboprophylaxis (LMWH vs warfarin HR 1.5, 95% confidence interval [CI] 0.4-5.1; P = 0.56). A total of 51/63 patients with coronary artery thrombosis received secondary thromboprophylaxis (ie, thromboprophylaxis after a previous thrombus): 27 LMWH, 24 warfarin. There were no differences in incidence of further coronary artery thrombosis between strategies (HR 2.9, 95% CI 0.6-13.5; P = 0.19). Severe bleeding complications were generally rare (1.6 events per 100 patient-years) and were noted equally for patients on LMWH and warfarin (HR 2.3, 95% CI 0.6-8.9; P = 0.25). CONCLUSIONS: LMWH and warfarin appear to have equivalent effectiveness for preventing thrombosis in large CAAs after KD, although event rates for secondary thromboprophylaxis and safety outcomes were low. Based on our findings, all patients with CAA z-score ≥ 10 should receive anticoagulation, but the choice of agent might be informed by secondary risk factors and patient preferences.


Assuntos
Quimioprevenção , Aneurisma Coronário , Heparina de Baixo Peso Molecular , Síndrome de Linfonodos Mucocutâneos , Trombose , Varfarina , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Canadá/epidemiologia , Quimioprevenção/métodos , Quimioprevenção/estatística & dados numéricos , Pré-Escolar , Aneurisma Coronário/complicações , Aneurisma Coronário/tratamento farmacológico , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Incidência , Masculino , Síndrome de Linfonodos Mucocutâneos/complicações , Síndrome de Linfonodos Mucocutâneos/epidemiologia , Sistema de Registros/estatística & dados numéricos , Risco Ajustado , Trombose/epidemiologia , Trombose/etiologia , Trombose/prevenção & controle , Estados Unidos/epidemiologia , Varfarina/administração & dosagem , Varfarina/efeitos adversos
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