Ross procedure or mechanical aortic valve, which is the best lifetime option for an 18-year-old? A decision analysis.

Objectives: Identifying the optimal solution for young adults requiring aortic valve replacement (AVR) is challenging, given the variety of options and their lifetime complication risks, impacts on quality of life, and costs. Decision analytic techniques make comparisons incorporating these measures. We evaluated lifetime valve-related outcomes of mechanical aortic valve replacement (mAVR) versus the Ross procedure (Ross) using decision tree microsimulations modeling. Methods: Transition probabilities, utilities, and costs derived from published reports were entered into a Markov model decision tree to explore progression between health states for hypothetical 18-year-old patients. In total, 20,000 Monte Carlo microsimulations were performed to model mortality, quality-adjusted-life-years (QALYs), and health care costs. The incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analyses was performed to identify transition probabilities at which the preferred strategy switched from baseline. Results: From modeling, average 20-year mortality was 16.3% and 23.2% for Ross and mAVR, respectively. Average 20-year freedom from stroke and major bleeding was 98.6% and 94.6% for Ross, and 90.0% and 82.2% for mAVR, respectively. Average individual lifetime (60 postoperative years) utility (28.3 vs 23.5 QALYs) and cost ($54,233 vs $507,240) favored Ross over mAVR. The average ICER demonstrated that each QALY would cost $95,345 more for mAVR. Sensitivity analysis revealed late annual probabilities of autograft/left ventricular outflow tract disease and homograft/right ventricular outflow tract disease after Ross, and late death after mAVR, to be important ICER determinants. Conclusions: Our modeling suggests that Ross is preferred to mAVR, with superior freedom from valve-related morbidity and mortality, and improved cost-utility for young adults requiring aortic valve surgery.

Community Readiness Assessment of the "Take TIME for Your Child's Health" Intervention.

Take TIME (Tobacco-free, Injury-free, Moving daily, Eating healthy) was an early intervention strategy targeting community readiness to support healthy lifestyles for young children in Uxbridge, Canada. This study aimed to assess the effectiveness of Take TIME using the Community Readiness Model adapted for childhood obesity prevention. Six interviews were completed in Uxbridge, before and after the intervention, with purposively selected community leaders in education, political, business, religious, not-for-profit, and healthcare fields. Each interview was rated independently by two scorers. Interview content was scored (scale from 1 to 9, with 1 being no awareness and 9 being a high level of community ownership) according to the Community Readiness Model criteria on six dimensions, with overall readiness calculated as the mean score of all dimensions. T-tests compared readiness by time-point and between communities. Overall community readiness significantly improved (p = 0.03) in Uxbridge from pre-intervention (3.63 ± 1.14 vague awareness) to post-intervention (5.21 ± 0.97 preparation). Seven interviews were also completed with leaders in the matched town of Rockwood, Canada which served as the control community. Rockwood readiness was close to the Uxbridge post-intervention score (5.35 ± 1.11). Results indicated increased awareness and leadership support post-intervention in Uxbridge, but further improvements in community knowledge, formalized efforts, and additional leadership support are desired. Take TIME increased community readiness to support healthy lifestyles for young children and may be useful to other communities at similar stages, given its theoretical alignment with the community readiness model. Future research should investigate the impact of Take TIME in demographically diverse communities and appropriate interventions to move communities from the preparation to the action stage.

The Healthy Eating Assessment Tool (HEAT): A Simplified 10-Point Assessment of CHILD-2 Dietary Compliance for Children and Adolescents with Dyslipidemia.

Traditional dietary assessment tools used to determine achievement of cholesterol-lowering dietary targets, defined in the Cardiovascular Health Integrated Lifestyle Diet (CHILD-2), are time intensive. We sought to determine the utility of the Healthy Eating Assessment Tool (HEAT), a simplified 10-point dietary assessment tool, in relation to meeting dietary cut points of the CHILD-2, as well as its association with markers of adiposity and lipid variables. We performed a 2-year single-center, prospective cross-sectional study of pediatric patients with dyslipidemia. HEAT score associations with meeting CHILD-2 fat targets were modest. Only patients with the highest HEAT scores (good 43%, excellent 64%) met the CHILD-2 cut point of <25% total fat calories (p = 0.03), with a non-significant trend for limiting the percentage of daily saturated fat to <8% (excellent 64%), and no association with cholesterol intake. There were more consistent associations with markers of adiposity (body mass index z-score r = -0.31, p = <0.01 and waist-to-height ratio r = -0.31, p = <0.01), and there was no independent association with lipid levels. While fat-restricted diets are safe, they are not particularly effective for treatment of dyslipidemia or for weight management alone. The HEAT may be a more useful and simplified way of assessing and tracking broader dietary goals in clinical practice.

Registry-based trials: a potential model for cost savings?

BACKGROUND/AIMS: Registry-based trials have emerged as a potentially cost-saving study methodology. Early estimates of cost savings, however, conflated the benefits associated with registry utilisation and those associated with other aspects of pragmatic trial designs, which might not all be as broadly applicable. In this study, we sought to build a practical tool that investigators could use across disciplines to estimate the ranges of potential cost differences associated with implementing registry-based trials versus standard clinical trials. METHODS: We built simulation Markov models to compare unique costs associated with data acquisition, cleaning, and linkage under a registry-based trial design versus a standard clinical trial. We conducted one-way, two-way, and probabilistic sensitivity analyses, varying study characteristics over broad ranges, to determine thresholds at which investigators might optimally select each trial design. RESULTS: Registry-based trials were more cost effective than standard clinical trials 98.6% of the time. Data-related cost savings ranged from $4300 to $600,000 with variation in study characteristics. Cost differences were most reactive to the number of patients in a study, the number of data elements per patient available in a registry, and the speed with which research coordinators could manually abstract data. Registry incorporation resulted in cost savings when as few as 3768 independent data elements were available and when manual data abstraction took as little as 3.4 seconds per data field. CONCLUSIONS: Registries offer important resources for investigators. When available, their broad incorporation may help the scientific community reduce the costs of clinical investigation. We offer here a practical tool for investigators to assess potential costs savings.

Self-reported functional health status following interrupted aortic arch repair: A Congenital Heart Surgeons' Society Study.

OBJECTIVES: Improved survival after congenital heart surgery has led to interest in functional health status. We sought to identify factors associated with self-reported functional health status in adolescents and young adults with repaired interrupted aortic arch. METHODS: Follow-up of survivors (aged 13-24 years) from a 1987 to 1997 inception cohort of neonates included completion of functional health status questionnaires (Child Health Questionnaire-CF87 [age <18 years, n = 51] or the Short Form [SF]-36 [age ≥18 years, n = 66]) and another about 22q11 deletion syndrome (22q11DS) features (n = 141). Factors associated with functional health status domains were determined using multivariable linear regression analysis. RESULTS: Domain scores of respondents were significantly greater than norms in 2 of 9 Child Health Questionnaire-CF87 and 4 of 10 SF-36 domains and only lower in the physical functioning domain of the SF-36. Factors most commonly associated with lower scores included those suggestive of 22q11DS (low calcium levels, recurrent childhood infections, genetic testing/diagnosis, abnormal facial features, hearing deficits), the presence of self-reported behavioral and mental health problems, and a greater number of procedures. Factors explained between 10% and 70% of domain score variability (R2 = 0.10-0.70, adj-R2 = 0.09-0.66). Of note, morphology and repair type had a minor contribution. CONCLUSIONS: Morbidities associated with 22q11DS, psychosocial issues, and recurrent medical issues affect functional health status more than initial morphology and repair in this population. Nonetheless, these patients largely perceive themselves as better than their peers. This demonstrates the chronic nature of interrupted aortic arch and suggests the need for strategies to decrease reinterventions and for evaluation of mental health and genetic issues to manage associated deteriorations.

Prelisting predictions of early postoperative survival in infant heart transplantation using classification and regression tree analysis.

Infants listed for heart transplantation experience high waitlist and early post-transplant mortality, and thus, optimal allocation of scarce donor organs is required. Unfortunately, the creation and validation of multivariable regression models to identify risk factors and generate individual-level predictions are challenging. We sought to explore the use of data mining methods to generate a prediction model. CART analysis was used to create a model which, at the time of listing, would predict which infants listed for heart transplantation would survive at least 3 months post-transplantation. A total of 48 infants were included; 13 died while waiting, and six died within 3 months of heart transplant. CART analysis identified RRT, blood urea nitrogen, and hematocrit as terminal nodes with alanine transaminase as an intermediate node predicting death. No patients listed on RRT (n = 10) survived and only three of 12 (25%) patients listed on ECLS survived >3 months post-transplant. CART analysis overall accuracy was 83%, with sensitivity of 95% and specificity 76%. This study shows that CART analysis can be used to generate accurate prediction models in small patient populations. Model validation will be necessary before incorporation into decision-making algorithms used to determine transplant candidacy.

Determining the accuracy of predictive energy expenditure (PREE) equations in severely obese adolescents.

BACKGROUND & AIMS: Severe obesity in children and adolescents is now a serious global health concern. Accurate measurements of resting energy expenditure (REE) is a key foundation for successful obesity treatment. Clinical dietitians rely heavily on measured or calculated REE to tailor dietary interventions. Indirect calorimetry (IC) is the gold standard for measuring REE. However, predictive resting energy expenditure (PREE) equations are commonly used when IC is unavailable due to cost or practicality. PREE equations differ based on variables such as age, gender, weight, and height and selecting the most accurate PREE for an individual is crucial to avoid over or underestimation of energy requirements. Published studies investigating the accuracy of PREE equations in obese children and adolescents have reported inconsistent findings, which likely result from heterogeneity in the patient populations studied. Accordingly, this study aimed to (a) assess the accuracy of the published PREE equations in a group of severely obese (SO) adolescents using IC measurement, and (b) determine if there is a BMI threshold at which the PREE equations become less accurate. METHODS: SO adolescents were studied using IC. REE was calculated using nine commonly used PREE equations. Generalized linear regression equations were used to compare absolute and relative differences between calculated and measured REE (MREE) for each PREE equation. Accuracy was calculated as the percentage of subjects with PREE values within 10 percent of MREE. RESULTS: 226 SO adolescents (mean ± SD age: 15.9 ± 1.9 years; weight: 126.9 ± 24.5 kg; BMI: 44.9 ± 8.1 kg/m2) participated. Mean MREE was 2163 ± 443 kcal/d. PREE calculated by the Mifflin equation was the only equation without a statistically significant bias compared to MREE (mean bias of -23 ± 307 kcal/d; p = 0.26). Mifflin was also the most accurate with 61% of individuals within ±10% of MREE. PREE equations accuracy was not associated with degree of BMI elevation (31-69 kg/m2). CONCLUSIONS: In adolescents with severe obesity, the Mifflin equation best predicts REE. This should be the equation applied when using PREE to optimize nutritional care in this population.

Assessment of Quality of Life in Young Patients with Single Ventricle after the Fontan Operation.

OBJECTIVES: To assess self-reported quality of life (QOL) in a large multicenter cohort of adolescent and young adults surviving Fontan. STUDY DESIGN: Cross-sectional. The Pediatric Quality of Life Inventory (PedsQL) was administered to 408 survivors of Fontan ages 13-25 years enrolled in the Pediatric Heart Network Fontan Follow-up Study. Subjects also completed either the Child Health Questionnaire (age <19 years) or Short Form Health Survey (age ≥ 19 years). PedsQL data were compared with matched controls without a chronic health condition. Correlations between the measures were examined. RESULTS: Mean PedsQL scores for subjects receiving Fontan were significantly lower than those for the control group for physical and psychosocial QOL (P < .001). Overall, 45% of subjects receiving Fontan had scores in the clinically significant impaired range for physical QOL with 30% in the impaired range for psychosocial QOL. For each 1 year increase in age, the physical functioning score decreased by an average of 0.76 points (P = .004) and the emotional functioning score decreased by an average of 0.64 points (P = .03). Among subjects ≥19 years of age, the physical functioning score decreased by an average of 2 points for each year increase in age (P = .02). PedsQL scale scores were significantly correlated with conceptually related Child Health Questionnaire (P < .001) and Short Form Health Survey scores (P < .001). CONCLUSIONS: Survivors of Fontan are at risk for significantly impaired QOL which may decline with advancing age. Routine assessment of QOL is essential to inform interventions to improve health outcomes. The PedsQL allowed QOL assessment from pediatrics to young adulthood. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00132782.

Lower socioeconomic status, adiposity and negative health behaviours in youth: a cross-sectional observational study.

OBJECTIVE: Understanding obesity and its modifiable risk factors in youth is key to addressing the burden of cardiovascular disease later in life. Our aim was to examine the associations among adiposity, negative health behaviours and socioeconomic status in youth from the Niagara Region. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional observational study of 3467 grade 9 students during their mandatory health and physical education class to investigate the association between socioeconomic status (postal code), self-reported health behaviour and adiposity in the Niagara Region, Ontario, Canada. RESULTS: Median household income was $63,696 and overall percentage below the after-tax low-income cut-off was 4.2%. Negative health behaviours (especially skipped meals, lower fruit and vegetable consumption, higher screen time) were associated with lower income neighbourhoods, however, the absolute effect was small. Those participants in the lowest income quintile had a significantly greater body mass index z-score than those in the highest (0.72±1.19 vs 0.53±1.12), but the overall trend across quintiles was not statistically significant. A similar trend was noted for waist-to-height ratio. The lowest income neighbourhoods according to after-tax low-income cut-off had small but statistically significant associations with higher adiposity compared with the middle or highest income neighbourhoods. CONCLUSIONS: Obesity prevention efforts should target modifiable behaviours, with particular attention to adolescents from lower income families and neighbourhoods.

Survival data and predictors of functional outcome an average of 15 years after the Fontan procedure: the pediatric heart network Fontan cohort.

OBJECTIVE: Multicenter longitudinal outcome data for Fontan patients surviving into adulthood are lacking. The aim of this study was to better understand contemporary outcomes in Fontan survivors by collecting follow-up data in a previously well-characterized cohort. DESIGN: Baseline data from the Fontan Cross-Sectional Study (Fontan 1) were previously obtained in 546 Fontan survivors aged 11.9 ± 3.4 years. We assessed current transplant-free survival status in all subjects 6.8 ± 0.4 years after the Fontan 1 study. Anatomic, clinical, and surgical data were collected along with socioeconomic status and access to health care. RESULTS: Thirty subjects (5%) died or underwent transplantation since Fontan 1. Subjects with both an elevated (>21 pg/mL) brain natriuretic peptide and a low Child Health Questionnaire physical summary score (<44) measured at Fontan 1 were significantly more likely to die or undergo transplant than the remainder, with a hazard ratio of 6.2 (2.9-13.5). Among 516 Fontan survivors, 427 (83%) enrolled in this follow-up study (Fontan 2) at 18.4 ± 3.4 years of age. Although mean scores on functional health status questionnaires were lower than the general population, individual scores were within the normal range in 78% and 88% of subjects for the Child Health Questionnaire physical and psychosocial summary score, and 97% and 91% for the SF-36 physical and mental aggregate score, respectively. Since Fontan surgery, 119 (28%) had additional cardiac surgery; 55% of these (n = 66) in the interim between Fontan 1 and Fontan 2. A catheter intervention occurred in 242 (57%); 32% of these (n = 78) after Fontan 1. Arrhythmia requiring treatment developed in 118 (28%) after Fontan surgery; 58% of these (n = 68) since Fontan 1. CONCLUSIONS: We found 95% interim transplant-free survival for Fontan survivors over an average of 7 years of follow-up. Continued longitudinal investigation into adulthood is necessary to better understand the determinants of long-term outcomes and to improve functional health status.

Healthcare transition for youth with heart disease: a clinical trial.

OBJECTIVES: Adolescents with heart disease have complex health needs and require lifelong cardiology follow-up. Interventions to facilitate paediatric to adult healthcare transition are recommended, although outcomes are unknown. We sought to determine the impact of a transition intervention on improving knowledge and self-management skills among this population. METHODS: We conducted a clinical trial of 15-17 year olds with moderate or complex congenital heart disease (CHD) or cardiomyopathy. Participants were systematically allocated to either usual care (controls) or a 1 h nurse-led one-on-one teaching session about their heart. Allocation was determined by week of attendance in the cardiology clinic. The primary outcome was change in Transition Readiness Assessment Questionnaire (TRAQ) score at 6 months, possible scores ranging from 1 (low) to 5 (optimal). Cardiac knowledge (MyHeart score, range 0-100) was a secondary outcome. Analysis was intention to treat. RESULTS: Of 58 participants (48% female), 52 had CHD and 6 had cardiomyopathy. 27 were allocated to the intervention group; 3 declined the intervention and received usual care. When comparing the intervention group with the usual care group at 6 months postintervention, the mean self-management TRAQ score was 3.59 (±0.83) vs. 3.16 (±1.05), respectively (p=0.048, adjusted for baseline score); the mean self-advocacy TRAQ score was 4.38 (±0.56) vs. 4.01 (±0.95) (p=0.18) and the mean MyHeart score was 75% (±15) vs. 61% (±25) (p=0.019). CONCLUSIONS: A 1 h nurse-led transition intervention resulted in a significant improvement in self-management and cardiac knowledge scores. An educational intervention should be routine for youth with congenital or acquired heart disease. TRIAL REGISTRATION NUMBER: NCT01286480.

Role of the waist/height ratio in the cardiometabolic risk assessment of children classified by body mass index.

OBJECTIVES: The aim of this study was to determine the utility of waist/height ratio (WHtR) in the specification of cardiometabolic risk in children already stratified by body mass index (BMI). BACKGROUND: Reflective of its association with cardiometabolic risk, BMI is a commonly used indirect indicator of adiposity in children. The WHtR, a marker of central adiposity, has been advocated as a possibly superior indicator of cardiometabolic risk. METHODS: Cross-sectional analysis of 5 National Health and Nutrition Examination Surveys from 1999 to 2008 (ages 5 to 18 years of age). The BMI percentile categories (normal, overweight, and obese) were further stratified on the basis of WHtR (<0.5, 0.5 to <0.6, ≥ 0.6). Outcome measures were lipid and glycemic profiles, C-reactive protein, liver transaminases, prevalence of hypertension, and metabolic syndrome. RESULTS: Data were available for 14,493 subjects. Overweight and obese subjects with a WHtR <0.5 had a cardiometabolic risk approaching that of subjects with a normal BMI percentile category. Increasing WHtR was significantly associated with increased cardiometabolic risk in overweight and obese subjects, with the greatest associations observed in the obese population. Of obese subjects with WHtR ≥ 0.6, 26% had elevated non-high-density lipoprotein levels, 18% had elevated C-reactive protein levels, 69% had an elevated homeostatic model assessment-insulin resistance, and 32% had metabolic syndrome. CONCLUSIONS: The WHtR further specifies cardiometabolic risk within classifications stratification on the basis of BMI percentile. A significant proportion of obese children with increased WHtRs have abnormal cardiometabolic risk factor levels. The WHtR should be included in the routine screening and assessment of overweight and obese children, and those with an elevated WHtR should undergo a further cardiometabolic risk assessment.

Foetal echocardiographic assessment of borderline small left ventricles can predict the need for postnatal intervention.

BACKGROUND: We sought to prospectively determine foetal echocardiographic factors associated with neonatal interventions in borderline hypoplastic left ventricles. METHODS: Foetuses were included who had a left ventricle that was 2-4 standard deviations below normal for length or diameter and had forward flow across the mitral and aortic valves. Factors associated with an intervention in the first month of life or no need for intervention were sought using univariate and multivariate logistic regression models. RESULTS: From 2005 to 2008, 47 foetuses meeting the criteria had an additional diagnosis (+foetal coarctation/+transverse arch hypoplasia): atrioventricular septal defect 7 (+2/+0), double outlet right ventricle 2 (+0/+0), Shone's complex 19 (+9/+4), and ventricular disproportion 19 (+13/+11; 4 both). There were seven pregnancies terminated, three foetal demises, and five had compassionate care. There were 32 livebirths that either had a biventricular repair (n = 20, n = 2 dead), univentricular palliation (n = 2, both alive), or no intervention (n = 9). Overall survival of livebirths to 6 months of age was 79%. Factors associated with early intervention on first foetal echocardiogram were: obstructed or retrograde arch flow (p = 0.08, odds ratio 3.3), coarctation (p = 0.05, odds ratio 11.4), and left ventricle outflow obstruction (p = 0.05, odds ratio 12.5). Neonatal factors included: Shone's diagnosis (p = 0.02, odds ratio 4.9), bicuspid aortic valve (p = 0.005, odds ratio 11.7), and larger tricuspid valve z-score (p = 0.05, odds ratio 3.6). A neonatal factor associated with no intervention was a larger mitral valve z-score (mean 23.8 versus 24.2 intervention group, p = 0.04, odds ratio 2.8). DISCUSSION: The need for early intervention in foetuses with borderline hypoplastic left ventricle can be predicted by foetal echocardiography.

Role of waist measures in characterizing the lipid and blood pressure assessment of adolescents classified by body mass index.

OBJECTIVE: To determine if the interaction of waist circumference percentile and waist to height ratio(WHtR) with body mass index (BMI) may serve to provide further risk specification in the lipid and blood pressure assessment of adolescents beyond BMI classification. DESIGN: Population-based, cross-sectional study. Data collected during the 2009-2010 academic school year. SETTING: Geographically and administratively defined Niagara Region, Ontario, Canada. Data collected in school, during subjects' mandatory physical education class. Part of the Heart Niagara Inc Healthy Heart Schools' Program. PARTICIPANTS: Entire population of grade 9 (14- and 15-year-old) students in the Niagara Region, Ontario.Four thousand eight hundred eighty-four students enrolled in grade 9 during the study period, of which 4104 participated (51% male) and 3248 (79%) had complete data. MAIN OUTCOME MEASURES: Nonfasting lipid values and blood pressure categories in subjects categorized based on BMI/waist circumference percentile and BMI/WHtR. RESULTS: The associations between blood pressure, lipid profile, and measures of adiposity (BMI alone, BMI/waist circumference percentile, and BMI/WHtR) were statistically significant but had a limited strength and were not statistically significant from each other. For overweight and obese subjects, increased WHtR categories were associated with worsened lipid profile and increased odds of hypertension both relative to subjects with both normal BMI and normal WHtR and subjects with normal WHtR within each BMI category. CONCLUSION: Waist measures should be included in the screening and assessment of overweight and obese adolescents.

Factors associated with low moderate-to-vigorous physical activity levels in pediatric patients with Kawasaki disease.

BACKGROUND/METHODS: We sought to determine functional health status and physical activity determinants in 27 patients with Kawasaki disease (KD; 20 males, 11 ± 3 years old). Patient physical activity data were compared with a population-based study of healthy children (Canadian Health Measures Survey). RESULTS: KD patients performed less moderate-to-vigorous physical activity (MVPA) than healthy children (males, 27 vs 61 min/d, P < .001; females, 10 vs 47 min/d, P < .001). Male KD patients performed more MVPA than female KD patients (median = 27; quartiles [Q1 15, Q3 26] min/d vs 10 [Q1 7, Q3 11] min/day, P = .009). Lower MVPA in KD patients was significantly associated with female gender; lower child self-efficacy score; lower Child Health Questionnaire (CHQ-PF50) scores for role functioning behavioral issues, physical functioning, and family cohesion; and higher CHQ-PF50 scores for self-esteem and family activity limitations. CONCLUSION: Physical activity counseling should be a focus of management for children with a history of KD.

Assessment of myocardial deformation in children using Digital Imaging and Communications in Medicine (DICOM) data and vendor independent speckle tracking software.

BACKGROUND: Analysis of myocardial deformation from data stored in Digital Imaging and Communications in Medicine format using vendor-independent software may be useful for clinical and research purposes but has not been evaluated in children. METHODS: Grayscale images were prospectively acquired on Vivid 7 (GE Healthcare) and iE33 (Philips Medical Systems) ultrasound systems in 49 children. Digital Imaging and Communications in Medicine and raw data were analyzed using vendor-independent software (Cardiac Performance Analysis, Tomtec Imaging Systems) and vendor-specific software (EchoPAC and QLAB) and results compared. In addition, vendor-independent software using images at 30 frames/sec were compared with images at the higher acquisition frame rate. RESULTS: Measurement of short-axis radial and circumferential strain (ε) and apical four-chamber longitudinal ε by vendor-independent software was possible in >92% of the children. Intraobserver and interobserver coefficients of variation for global circumferential and longitudinal ε ranged from 7.1% to 15.3% and for radial ε from 23.9% to 30.2%. Strain values were somewhat higher when using GE images at acquisition frame rates compared with ε values using GE images stored at 30 frames/sec. Strain values obtained by vendor-independent software were comparable with those obtained by vendor-specific software for longitudinal ε and higher for circumferential ε. Radial ε values obtained by vendor-independent software were lower than ε values by EchoPAC and higher than ε values by QLAB. CONCLUSIONS: Vendor-independent software-derived ε is feasible and potentially valuable for measuring myocardial deformation in research and in multicenter studies using images from different ultrasound systems, especially for longitudinal deformation. However, a systematic bias for circumferential ε and a high variability in radial ε measurements remain concerns.

Assessment and management of hypertension in children and adolescents.

The epidemic of overweight and obesity in youth is increasing the prevalence of prehypertension and hypertension among children and adolescents. The younger the child is at presentation and the more severe the blood pressure abnormality, the more likely a secondary cause of hypertension is to be present. Measurement of blood pressure in children requires adaptation to the age and size of the child. Interpretation must be related to normative values specific for age, sex, and height. Evaluation is primarily aimed at identifying secondary causes of hypertension, associated comorbidities, additional risk factors, and evidence of target-organ damage. Ambulatory blood pressure monitoring is emerging as a useful tool for evaluation of some patients, particularly for those with suspected 'white coat' hypertension. Management of prehypertension and hypertension is directed at the underlying cause, exacerbating factors, and the magnitude of the blood pressure abnormality. Healthy behavioral changes are a primary management tool for treating hypertension and, more particularly, prehypertension and for addressing other cardiovascular risk factors, such as obesity. Pharmacological management is reserved for patients with hypertension who do not respond to behavioral changes, have additional cardiovascular risk factors or diabetes, are symptomatic, or have developed target-organ damage.

Functional health status of adolescents after the Fontan procedure -- comparison with their siblings.

BACKGROUND: Studies have suggested that patients who have undergone the Fontan procedure experience lower functional health status and diminished exercise capacity compared with other children. OBJECTIVES: To compare the functional health status of Fontan patients with and without siblings, assess whether there are any differences between Fontan patients and their siblings, and determine associated factors. METHODS: A cross-sectional, single-centre, observational study was performed on Fontan patients 10 to 20 years of age, and their sibling closest in age, followed in a tertiary pediatric hospital. Functional health status was measured by the Child Health Questionnaire Child Form and the Pediatric Quality of Life Inventory. RESULTS: A total of 68 patients and 38 siblings were enrolled. Patients with siblings scored significantly lower on numerous domains of physical functional status than those without siblings. Compared with their matched siblings, Fontan patients reported significantly lower scores in all domains of the Pediatric Quality of Life Inventory and on physical (but not psychosocial) domains of the Child Health Questionnaire Child Form. Factors associated with increased patient-sibling differences included younger patient age, female sex, intracardiac lateral tunnel Fontan connection and lower ejection fraction at the time of study enrollment. CONCLUSIONS: Adolescents with Fontan physiology reported a lower functional health status in physical domains than their siblings, but had similar status in psychosocial domains. Having a sibling was associated with lower reported functional health status, suggesting an important effect of self-perceived physical limitations over true limitations.