Adverse family social circumstances and outcome in pediatric cardiac transplant recipients at a UK center.

BACKGROUND: Socioeconomic disadvantage is known to prejudice certain health-related outcomes. METHODS: Our objective was to establish whether adverse social circumstances are linked to rejection events after pediatric cardiac transplant in a UK context. A retrospective observational cohort study was conducted including 78 of 85 children who underwent cardiac transplantation between 2001 and 2005. RESULTS: Family social circumstances included: 36 (46%) unemployed/manual occupation; 29 (37%) non-home owners; 16 (21%) single parents; income support in 31 (40%); and 2 or more further children in 34 (44%). Adverse social risk factors were evenly distributed throughout the cohort in terms of other demographic variables. The rate for a first rejection event was 0.10 (95% confidence interval [CI] 0.07 to 0.15) episode per patient per year, and for late rejection was 0.04 (95% CI 0.02 to 0.07) episode per patient per year. There was some evidence that children from non-home-owning families (hazard ratio [HR] 0.31, 95% CI 0.11 to 0.82, p = 0.02) and those on income support (HR 0.43, 95% CI 0.18 to 1.04, p = 0.06) had reduced risk of early/all first-time rejection episodes. Other social risk factors were unrelated to early rejection. No relationship was found between any social factor and late rejection episodes or low immunosuppression levels at clinic visits 3, 6 or 12 months post-transplant. CONCLUSIONS: Children from more adverse circumstances were not predisposed to rejection episodes. To date, there is no evidence to support a policy of declining children for transplantation on psychosocial grounds in the UK.

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE).

BACKGROUND: We previously reported that 20% of women with chest pain but without obstructive coronary artery disease (CAD) had stress-induced reduction in myocardial phosphocreatine-adenosine triphosphate ratio by phosphorus-31 nuclear magnetic resonance spectroscopy (abnormal MRS), consistent with myocardial ischemia. The prognostic implications of these findings are unknown. METHODS AND RESULTS: Women referred for coronary angiography for suspected myocardial ischemia underwent MRS handgrip stress testing and follow-up evaluation. These included (1) n=60 with no CAD/normal MRS, (2) n=14 with no CAD/abnormal MRS, and (3) n=352 a reference group with CAD. Cardiovascular events were death, myocardial infarction, heart failure, stroke, other vascular events, and hospitalization for unstable angina. Cumulative freedom from events at 3 years was 87%, 57%, and 52% for women with no CAD/normal MRS, no CAD/abnormal MRS, and CAD, respectively (P<0.01). After adjusting for CAD and cardiac risk factors, a phosphocreatine-adenosine triphosphate ratio decrease of 1% increased the risk of a cardiovascular event by 4% (P=0.02). The higher event rate in women with no CAD/abnormal MRS was primarily due to hospitalization for unstable angina, which is associated with repeat catheterization and higher healthcare costs. CONCLUSIONS: Among women without CAD, abnormal MRS consistent with myocardial ischemia predicted cardiovascular outcome, notably higher rates of anginal hospitalization, repeat catheterization, and greater treatment costs. Further evaluation into the underlying pathophysiology and possible treatment options for women with evidence of myocardial ischemia but without CAD is indicated.