RESUMEN
The use of mechanical circulatory support (MCS) devices is a viable therapeutic treatment option for patients with congestive heart failure. Ventricular assist devices, cavopulmonary assist devices, and total artificial heart pumps continue to gain acceptance as viable treatment strategies for both adults and pediatric patients as bridge-to-transplant, bridge-to-recovery, and longer-term circulatory support alternatives. We present a review of the current and future MCS devices for patients having congenital heart disease (CHD) with biventricular or univentricular circulations. Several devices that are specifically designed for patients with complex CHD are in the development pipeline undergoing rigorous animal testing as readiness experiments in preparation for future clinical trials. These advances in the development of new blood pumps for patients with CHD will address a significant unmet clinical need, as well as generally improve innovation of the current state of the art in MCS technology.
Asunto(s)
Circulación Asistida , Oxigenación por Membrana Extracorpórea , Cardiopatías Congénitas/terapia , Corazón Artificial , Animales , Circulación Asistida/instrumentación , Circulación Asistida/métodos , Niño , Diseño de Equipo , Oxigenación por Membrana Extracorpórea/instrumentación , Oxigenación por Membrana Extracorpórea/métodos , Cardiopatías Congénitas/patología , Cardiopatías Congénitas/cirugía , Ventrículos Cardíacos/patología , Ventrículos Cardíacos/cirugía , Humanos , Pediatría/instrumentación , Pediatría/métodos , Función VentricularRESUMEN
Single ventricle anomalies are a challenging set of congenital heart defects that require lifelong clinical management due to progressive decline of cardiovascular function. Few therapeutic devices are available for these patients, and conventional blood pumps are not designed for the unique anatomy of the single ventricle physiology. To address this unmet need, we are developing an axial flow blood pump with a protective cage or stent for Fontan patients. This study investigates the 3-D particle image velocimetry measurements of two cage designs being deployed in a patient-specific Fontan anatomy. We considered a control case without a pump, impeller placed in the inferior vena cava, and two cases where the impeller has two protective stents with unique geometric characteristics. The experiments were evaluated at a cardiac output of 3 L/min, a fixed vena caval flow split of 40%/60%, a fixed pulmonary arterial flow split of 50%/50%, and for operating speeds of 1000-4000 rpm. The introduction of the cardiovascular stents had a substantial impact on the flow conditions leaving the pump and entering the cavopulmonary circulation. The findings indicated that rotational speeds above 4000 rpm for this pump could result in irregular flows in this specific circulatory condition. Although retrograde flow into the superior vena cava was not measured, the risk of this occurrence increases with higher pump speeds. The against-with stent geometry outperformed the other configurations by generating higher pressures and more energetic flows. These results provide further support for the viability of mechanical cavopulmonary assistance as a therapeutic treatment strategy for Fontan patients.
Asunto(s)
Procedimiento de Fontan/instrumentación , Cardiopatías Congénitas/cirugía , Ventrículos Cardíacos/anomalías , Corazón Auxiliar , Reología/métodos , Stents , Diseño de Equipo , Seguridad de Equipos , Hemodinámica/fisiología , Humanos , Modelos Cardiovasculares , Sensibilidad y Especificidad , Atresia Tricúspide/cirugíaRESUMEN
Mechanical assistance of the Fontan circulation is hypothesized to enhance ventricular preload and improve cardiac output; however, little is known about the fluid dynamics. This study is the first to investigate the three-dimensional flow conditions of a blood pump in an anatomic Fontan. Laser measurements were conducted having an axial flow impeller in the inferior vena cava. Experiments were performed for a physiologic cardiac output, pulmonary arterial flows, and pump speeds of 1000-4000 rpm. The impeller had a modest effect on the flow conditions entering the total cavopulmonary connection at low pump speeds, but a substantial impact on the velocity at higher speeds. The higher speeds of the pump disrupted the recirculation region in the center of the anastomosis, which could be advantageous for washout purposes. No retrograde velocities in the superior vena cava were measured. These findings indicate that mechanical assistance is a viable therapeutic option for patients having dysfunctional single ventricle physiology.
Asunto(s)
Procedimiento de Fontan/métodos , Corazón Auxiliar , Hemodinámica/fisiología , Modelos Cardiovasculares , Diseño de Equipo , Humanos , HidrodinámicaRESUMEN
Limited treatment options for patients having dysfunctional single ventricle physiology motivate the necessity for alternative therapeutic options. To address this unmet need, we are developing a collapsible axial flow blood pump. This study investigated the impact of geometric simplicity to facilitate percutaneous placement and maintain optimal performance. Three new pump designs were numerically evaluated. A transient simulation explored the impact of respiration on blood flow conditions over the entire respiratory cycle. Prototype testing of the top performing pump design was completed. The top performing Rec design generated the highest pressure rise range of 2-38 mm Hg for flow rates of 1-4 L/min at 4000-7000 RPM, exceeding the performance of the other two configurations by more than 26%. The blood damage indices for the new pump designs were determined to be below 0.5% and predicted hemolysis levels remained low at less than 7 × 10(-5) g/100 L. Prototype testing of the Rec design confirmed numerical predictions to within an average of approximately 22%. These findings demonstrate that the pumps are reasonably versatile in operational ability, meet pressure-flow requirements to support Fontan patients, and are expected to have low levels of blood trauma.
Asunto(s)
Diseño Asistido por Computadora , Procedimiento de Fontan/métodos , Cardiopatías Congénitas/cirugía , Corazón Auxiliar , Diseño de Prótesis , Adolescente , Adulto , Niño , Preescolar , Análisis de Falla de Equipo , Seguridad de Equipos , Femenino , Procedimiento de Fontan/efectos adversos , Cardiopatías Congénitas/diagnóstico , Humanos , Masculino , Modelos Cardiovasculares , Medición de RiesgoRESUMEN
A mechanical blood pump specifically designed to increase pressure in the great veins would improve hemodynamic stability in adolescent and adult Fontan patients having dysfunctional cavopulmonary circulation. This study investigates the impact of axial-flow blood pumps on pressure, flow rate, and energy augmentation in the total cavopulmonary circulation (TCPC) using a patient-specific Fontan model. The experiments were conducted for three mechanical support configurations, which included an axial-flow impeller alone in the inferior vena cava (IVC) and an impeller with one of two different protective stent designs. All of the pump configurations led to an increase in pressure generation and flow in the Fontan circuit. The increase in IVC flow was found to augment pulmonary arterial flow, having only a small impact on the pressure and flow in the superior vena cava (SVC). Retrograde flow was neither observed nor measured from the TCPC junction into the SVC. All of the pump configurations enhanced the rate of power gain of the cavopulmonary circulation by adding energy and rotational force to the fluid flow. We measured an enhancement of forward flow into the TCPC junction, reduction in IVC pressure, and only minimally increased pulmonary arterial pressure under conditions of pump support.
Asunto(s)
Procedimiento de Fontan/instrumentación , Corazón Auxiliar , Adolescente , Adulto , Algoritmos , Diseño de Equipo , Hemodinámica , Humanos , Arteria Pulmonar/cirugía , Vena Cava Inferior/cirugía , Vena Cava Superior/cirugía , Adulto JovenRESUMEN
Patients with Fontan palliation and single-ventricle physiology encounter multiple comorbidities including plastic bronchitis, a disease characterised by the plugging of small and large airways by rubbery, white casts. To date, no controlled clinical trials have demonstrated effective treatment of plastic bronchitis. We report the application of aerosolised heparin, which has published success in non-cardiac-related pulmonary disease, for this complication in a Fontan patient.
Asunto(s)
Bronquitis/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Procedimiento de Fontan , Defectos del Tabique Interventricular/cirugía , Ventrículos Cardíacos/cirugía , Heparina/uso terapéutico , Estenosis de la Válvula Pulmonar/cirugía , Administración por Inhalación , Aerosoles , Bronquitis/complicaciones , Preescolar , Femenino , Defectos del Tabique Interventricular/complicaciones , Ventrículos Cardíacos/anomalías , Humanos , Estenosis de la Válvula Pulmonar/complicaciones , Resultado del TratamientoRESUMEN
This retrospective study included children aged ≤18 years who had durable ventricular assist devices (VADs) as a bridge to transplantation from the United Network Organ Sharing (UNOS) database between 2011 and 2020. We evaluated 90 day waitlist mortality and 1 year posttransplant mortality after VAD implantation in children stratified by race/ethnicity: Black, White, and Others. The VAD was used in a higher proportion of Black children listed for heart transplantation (HT) (26%) versus Other (25%) versus White (22%); p < 0.01. Black children had Medicaid health insurance coverage (67%) predominantly at the time of listing for HT. There was no significant overall difference in waitlist survival among the three groups supported with VAD at the time of listing (log-rank p = 0.4). On the other hand, the 90 day waitlist mortality after the VAD implantation at listing and while listed was the lowest among Black (6%) compared with White (13%) and Other (14%) ( p < 0.01). The multivariate regression analysis showed that Other race (hazard ratio [HR], 2.29; p < 0.01), Black race (HR, 2.13; p < 0.01), use of mechanical ventilation (HR, 1.72; p = 0.01), and Medicaid insurance (HR, 1.54; p = 0.04) were independently associated with increased 1 year posttransplant mortality. In conclusion, Black children had more access to durable VAD support than White children. The 90 day waitlist mortality was significantly lower in Black children compared with White and Other after VAD implantation. However, Black and Other racial/ethnic children with VAD at transplant had higher 1 year posttransplant mortality than White children. Future studies to elucidate the reasons for these disparities are needed.
Asunto(s)
Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Estados Unidos , Humanos , Niño , Etnicidad , Estudios Retrospectivos , Modelos de Riesgos Proporcionales , Listas de Espera , Insuficiencia Cardíaca/cirugíaRESUMEN
We aimed to study the disparity in the clinical profile and outcomes of hospitalized Multisystem Inflammatory Syndrome in Children (MIS-C) patients at our center. The second goal was to examine the temporal association with preceding SARS-CoV-2 infection by race/ethnicity in our community in Mississippi. We found the racial disparity in the prevalence of MIS-C exceeded its temporal association with SARS-CoV-2 infections. We included 51 consecutive MIS-C patients hospitalized, whose median age was 9 (interquartile range [IQR] 5-12) years, 58% were male, 71% were black, 25% were white, and 4% belonged to other groups. We found a delay between onset of symptoms and hospitalization in black patients compared with white patients with a median of 2 (IQR 0-7) vs median of 0 (0-5) urgent care visits (P = .022), respectively. Black patients were hospitalized longer (median 8, IQR 2-39 days) than whites (median 5, IQR 3-14 days), P = .047. A total of 38.9% of blacks and 23.1% of whites were admitted to intensive care unit (P = .498); 36.1% of blacks had severe cardiac involvement vs 23.1% of white patients, P = .531. Future studies of MIS-C are required to improve health equity for children.
Asunto(s)
COVID-19 , SARS-CoV-2 , Niño , Preescolar , Femenino , Humanos , Masculino , COVID-19/complicaciones , COVID-19/epidemiología , Etnicidad , Mississippi/epidemiologíaRESUMEN
This numerical study examined the performance of an intravascular axial flow blood pump for mechanical hemodynamic support of patients in the setting of Fontan failure, which presently has few treatment options. Three anatomically accurate geometries of the total cavopulmonary connection (TCPC) were generated using patients' magnetic resonance imaging data. These patient-specific geometries, as well as an idealized version with cylindrical vessels, were computationally analyzed with and without a pump in the inferior vena cava. Pressure flow characteristics, energy gain calculations, and blood damage analyses were performed for each model. The pump produced pressures of 1-14 mm Hg for 1500-4000 revolutions per minute, flow rates of 1-4 L/min, and pulmonary artery pressures of 8-24 mm Hg. Comparison of pump performance among the four models showed minimal intermodel differences (<5% deviation) in the pressure rise generated by the pump, the IVC pressure, and the energy imparted to the system by the pump. Blood damage analysis showed maximum fluid scalar stress values of 372 Pa or less, and the blood damage index was less than 2% in all of the models. These results suggest that this axial flow blood pump performs consistently in a variety of TCPC vessel geometries with low risk of blood trauma.
Asunto(s)
Procedimiento de Fontan/instrumentación , Corazón Auxiliar , Simulación por Computador , Diseño de Equipo , Hemodinámica , Humanos , Imagen por Resonancia Magnética , Modelos Anatómicos , Modelos Cardiovasculares , Arteria Pulmonar/anatomía & histología , Arteria Pulmonar/fisiología , Arteria Pulmonar/cirugía , Vena Cava Inferior/anatomía & histología , Vena Cava Inferior/fisiología , Vena Cava Inferior/cirugíaRESUMEN
The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.
Asunto(s)
Costos de la Atención en Salud , Accesibilidad a los Servicios de Salud/organización & administración , Pediatría/métodos , Pediatría/organización & administración , Calidad de la Atención de Salud/organización & administración , Telemedicina/métodos , Telemedicina/organización & administración , Adolescente , Niño , Preescolar , Disparidades en Atención de Salud , Humanos , Lactante , Recién Nacido , Atención Dirigida al Paciente/economía , Atención Dirigida al Paciente/organización & administración , Pediatría/economía , Pediatría/normas , Telemedicina/economía , Telemedicina/normas , Estados UnidosRESUMEN
BACKGROUND: Pediatric physicians regularly face the problem of uncertain procedural anticoagulation in children, especially in neonates. We sought to evaluate the safety, plasma concentration (pharmacokinetics, PK), pharmacodynamics (PD), and dosing guidelines of bivalirudin when used as a procedural anticoagulant in pediatric percutaneous intravascular procedures. METHODS AND RESULTS: Pediatric subjects undergoing percutaneous intravascular procedures for congenital heart disease were enrolled and received the current weight-based dose used in percutaneous coronary interventions (0.75 mg/kg bolus, 1.75 mg/kg/hr infusion). Blood samples for PK/PD analyses were drawn, and safety was evaluated by monitoring bleeding and thrombosis events. A total of 110 patients (11 neonates, 33 infants, 32 young children, and 34 older children) were enrolled; 106 patients received the protocol dose. The PK/PD response of bivalirudin was predictable and behaved in a manner similar to that in adults. Weight-normalized bivalirudin clearance rates were more rapid in neonates and decreased with increasing age. Bivalirudin concentrations were slightly lower in neonates, with a trend to an increase with age. Activating clotting time response was consistent with adult studies and prolonged in all age groups, and there was reasonable correlation between activating clotting time and bivalirudin plasma concentrations across all age groups. There were few major bleeding (2 of 110, 1.8%) or thrombotic events (9 of 110, 8.2%) reported. CONCLUSIONS: PK/PD response of bivalirudin in the pediatric population is predictable and behaves in a manner similar to that in adults. Using adult dosing, bivalirudin safely provided the expected anticoagulant effect in the pediatric population undergoing intravascular procedures for congenital heart disease.
Asunto(s)
Anticoagulantes/administración & dosificación , Cateterismo Cardíaco , Cardiopatías Congénitas , Hirudinas/administración & dosificación , Fragmentos de Péptidos/administración & dosificación , Trombosis/prevención & control , Adolescente , Factores de Edad , Anticoagulantes/efectos adversos , Anticoagulantes/sangre , Anticoagulantes/farmacocinética , Niño , Preescolar , Femenino , Cardiopatías Congénitas/sangre , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/terapia , Hemorragia/inducido químicamente , Hirudinas/efectos adversos , Hirudinas/sangre , Hirudinas/farmacocinética , Humanos , Lactante , Recién Nacido , Masculino , Fragmentos de Péptidos/efectos adversos , Fragmentos de Péptidos/sangre , Fragmentos de Péptidos/farmacocinética , Estudios Prospectivos , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/sangre , Proteínas Recombinantes/farmacocinética , Medición de Riesgo , Factores de Riesgo , Trombosis/sangre , Trombosis/etiología , Resultado del Tratamiento , Estados UnidosRESUMEN
This study investigated the performance of a magnetically levitated, intravascular axial flow blood pump for mechanical circulatory support of the thousands of Fontan patients in desperate need of a therapeutic alternative. Four models of the extracardiac, total cavopulmonary connection (TCPC) Fontan configuration were evaluated to formulate numerical predictions: an idealized TCPC, a patient-specific TCPC per magnetic resonance imaging data, and each of these two models having a blood pump in the inferior vena cava (IVC). A lumped parameter model of the Fontan physiology was used to specify boundary conditions. Pressure-flow characteristics, energy gain calculations, scalar stress levels, and blood damage estimations were executed for each model. Suction limitation experiments using the Sylgard elastomer tubing were also conducted. The pump produced pressures of 1-16 mm Hg for 2000-6000 rpm and flow rates of 0.5-4.5 L/min. The pump inlet or IVC pressure was found to decrease at higher rotational speeds. Maximum scalar stress estimations were 3 Pa for the nonpump models and 290 Pa for the pump-supported cases. The blood residence times for the pump-supported cases were shorter (0.9 s) as compared with the nonsupported configurations (2.5 s). However, the blood damage indices were higher (1.5%) for the anatomic model with pump support. The pump successfully augmented pressure in the TCPC junction and increased the hydraulic energy of the TCPC as a function of flow rate and rotational speed. The suction experiments revealed minimal deformation (<3%) at 9000 rpm. The findings of this study support the continued design and development of this blood pump.
Asunto(s)
Circulación Asistida/instrumentación , Procedimiento de Fontan/instrumentación , Vena Cava Inferior/cirugía , Circulación Asistida/métodos , Simulación por Computador , Diseño de Equipo , Procedimiento de Fontan/métodos , Hemodinámica , Humanos , Modelos Cardiovasculares , Succión/instrumentaciónRESUMEN
This review discusses the potential drug and device therapies for pediatric heart failure (HF) due to reduced systolic function. It is important to realize that most drugs that are used in pediatric HF are extrapolated from adult cardiology practices or consensus guidelines based on expert opinion rather than on evidence from controlled clinical trials. It is difficult to conclude whether the drugs that are well established in adult HF trials are also beneficial for children because of tremendous heterogeneity in the mechanism of HF in children and variations in the pharmacokinetics and pharmacodynamics of drugs from birth to adolescence. The lessons learned from adult trials can guide pediatric cardiologists to design clinical trials of the newer drugs that are in the pipeline to study their efficacy and safety in children with HF. This paper's focus is that the reader should specifically think through the pathophysiological mechanism of HF and the mode of action of drugs for the selection of appropriate pharmacotherapy. We review the drug and device trials in adults with HF to highlight the knowledge gap that exists in the pediatric HF population.
RESUMEN
This is a cross-sectional study of 29 published cases of acute myopericarditis following COVID-19 mRNA vaccination. The most common presentation was chest pain within 1-5 days after the second dose of mRNA COVID-19 vaccination. All patients had an elevated troponin. Cardiac magnetic resonance imaging revealed late gadolinium enhancement consistent with myocarditis in 69% of cases. All patients recovered clinically rapidly within 1-3 weeks. Most patients were treated with non-steroidal anti-inflammatory drugs for symptomatic relief, and 4 received intravenous immune globulin and corticosteroids. We speculate a possible causal relationship between vaccine administration and myocarditis. The data from our analysis confirms that all myocarditis and pericarditis cases are mild and resolve within a few days to few weeks. The bottom line is that the risk of cardiac complications among children and adults due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection far exceeds the minimal and rare risks of vaccination-related transient myocardial or pericardial inflammation.
RESUMEN
All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations.
Asunto(s)
Accesibilidad a los Servicios de Salud , Calidad de la Atención de Salud , Telemedicina , Adolescente , Niño , Servicios de Salud del Niño , Etnicidad , Humanos , Pediatras , Factores Raciales , Especialización , Estados UnidosRESUMEN
This study evaluated the performance of an intravascular, percutaneously-inserted, axial flow blood pump in an idealized total cavopulmonary connection (TCPC) model of a Fontan physiology. This blood pump, intended for placement in the inferior vena cava (IVC), is designed to augment pressure and blood flow from the IVC to the pulmonary circulation. Three different computational models were examined: (i) an idealized TCPC without a pump; (ii) an idealized TCPC with an impeller pump; and (iii) an idealized TCPC with an impeller and diffuser pump. Computational fluid dynamics analyses of these models were performed to assess the hydraulic performance of each model under varying physiologic conditions. Pressure-flow characteristics, fluid streamlines, energy augmentation calculations, and blood damage analyses were evaluated. Numerical predictions indicate that the pump with an impeller and diffuser blade set produces pressure generations of 1 to 16 mm Hg for rotational speeds of 2000 to 6000 rpm and flow rates of 1 to 4 L/min. In contrast, for the same flow range, the model with the impeller only in the IVC demonstrated pressure generations of 1 to 9 mm Hg at rotational speeds of 10,000 to 12,000 rpm. Influence of blood viscosity was found to be insignificant at low rotational speeds with minimal performance deviation at higher rotational speeds. Results from the blood damage index analyses indicate a low probability for damage with maximum damage index levels less than 1% and maximum fluid residence times below 0.6 s. The numerical predictions further indicated successful energy augmentation of the TCPC with a pump in the IVC. These results support the continued design and development of this cavopulmonary assist device.
Asunto(s)
Corazón Auxiliar , Diseño de Equipo , Hemodinámica , Humanos , Modelos CardiovascularesRESUMEN
BACKGROUND: Limited therapeutic options are available for Fontan patients with dysfunctional or failing single ventricle physiology. This study describes the evaluation of an alternative, non-invasive, at-home therapeutic compression treatment for Fontan patients. Our hypothesis is that routinely administered, externally applied compression treatments to the lower extremities will augment systemic venous return, improve ventricular preload, and thus enhance cardiac output in Fontan patients. METHODS: To initially evaluate this hypothesis, we employed the NormaTec pneumatic compression device (PCD) in a pilot clinical study (n=2). This device is composed of inflatable trouser compartments that facilitate circumferentially and uniformly applied pressure to a patient's lower extremities. Following an initial health screening, test subjects were pre-evaluated with a modified-Bruce treadmill exercise stress test, and baseline data on cardiorespiratory health was collected. After training, test subjects conducted 6 days of external compression therapy at-home. Subjects were then re-evaluated with a final treadmill stress test and data acquisition of new cardiorespiratory parameters. RESULTS: Both subjects demonstrated improvement in exercise duration time, peak oxygen volume, and ventilator threshold, as compared to the baseline evaluation. CONCLUSIONS: These findings are promising and provide the foundation for future studies that will focus on increasing study participation (sample size) to better assess the clinical benefit of compression therapy for Fontan patients.
RESUMEN
OBJECTIVE: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. METHODS: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey. RESULTS: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. CONCLUSION: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.
Asunto(s)
Citas y Horarios , Fuerza Laboral en Salud/tendencias , Pediatría/tendencias , Medicina del Adolescente/educación , Medicina del Adolescente/tendencias , Cardiología/educación , Cardiología/tendencias , Selección de Profesión , Cuidados Críticos , Endocrinología/educación , Endocrinología/tendencias , Femenino , Cirugía General/educación , Cirugía General/tendencias , Medicina Hospitalar/educación , Medicina Hospitalar/tendencias , Humanos , Masculino , Nefrología/educación , Nefrología/tendencias , Neurología , Ortopedia/educación , Ortopedia/tendencias , Otolaringología/educación , Otolaringología/tendencias , Medicina de Urgencia Pediátrica/tendencias , Pediatría/educación , Neumología/educación , Neumología/tendencias , Especialización , Estados Unidos , Carga de TrabajoRESUMEN
The use of telemedicine technologies by primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists (henceforth referred to as "pediatric physicians") has the potential to transform the practice of pediatrics. The purpose of this policy statement is to describe the expected and potential impact that telemedicine will have on pediatric physicians' efforts to improve access and physician workforce shortages. The policy statement also describes how the American Academy of Pediatrics can advocate for its members and their patients to best use telemedicine technologies to improve access to care, provide more patient- and family-centered care, increase efficiencies in practice, enhance the quality of care, and address projected shortages in the clinical workforce. As the use of telemedicine increases, it is likely to impact health care access, quality, and education and costs of care. Telemedicine technologies, applied to the medical home and its collaborating providers, have the potential to improve current models of care by increasing communication among clinicians, resulting in more efficient, higher quality, and less expensive care. Such a model can serve as a platform for providing more continuous care, linking primary and specialty care to support management of the needs of complex patients. In addition, telemedicine technologies can be used to efficiently provide pediatric physicians working in remote locations with ongoing medical education, increasing their ability to care for more complex patients in their community, reducing the burdens of travel on patients and families, and supporting the medical home. On the other hand, telemedicine technologies used for episodic care by nonmedical home providers have the potential to disrupt continuity of care and to create redundancy and imprudent use of health care resources. Fragmentation should be avoided, and telemedicine, like all primary and specialty services, should be coordinated through the medical home.
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Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de Salud , Pediatría/métodos , Telemedicina/métodos , Niño , Humanos , Médicos , Recursos HumanosRESUMEN
The incidence of foramen ovale restriction or closure is greater in fetuses with congenital heart defects (CHDs) and obligate atrial shunting and/or left atrial hypertension. Foramen ovale restriction or closure in fetuses with CHD can cause distress in utero or at birth. We suggest performing serial ultrasound assessment for at-risk fetuses with CHD to best assure fetal well-being plan the timing and mode of delivery, and develop management protocols for in utero and postnatal care. The future for these patients may be more optimistic as fetal intervention procedures are developed and mastered.