Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences.

OBJECTIVE: We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence. METHODS: Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM. RESULTS: Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]). CONCLUSION: Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.

Comparative analysis of nitrogen concentrations and sources within a coastal urban bayou watershed: A multi-tracer approach.

Fate and transport of nitrogen (N) in urban coastal watersheds continues to draw research interest due to serious impacts of N pollution and complexities with N sources and transport pathways. In this study, we used multiple tracers for source identification of N pollution (15N isotope in nitrate and chemical sewage tracers in water) and waters (using isotopes of 18O and 2H in water) in a coastal northwest Florida U.S.A. urban bayou fed by two contrasting streams, namely Jackson Creek traversing a dense residential area and Jones Creek flowing mainly through a wetland preserve. Results showed that the slightly higher δ15N-NO3 - values in Jones Creek and the bayou were insufficient to distinguish N sources; yet the different chemical sewage tracer concentrations (e.g., sucralose, carbamazepine and sulfamethoxazole) clearly demonstrated the major N source from leaking septic tanks in the Jackson Creek sub-basin but not in the Jones Creek sub-basin. The higher concentrations of nitrate, which constituted over 98% of dissolved inorganic N in Jackson Creek, support active nitrification in sandy soils and steep terrain while higher δ15N-NO3 - and much lower nitrate in Jones Creek are likely associated with denitrification in dense vegetative wetland and riparian zones. Episodic high nitrate concentrations and δ18O values in Jackson Creek preceded by periods of little rainfall indicated that the creek was sustained by subsurface flow with a steady input of nitrate. This study demonstrated the connection of land use and stormwater runoff generation to the forms of N entering urban waterways, the utility of N sourcing approaches, and the value of watershed-scale assessments for developing strategies to limit N loadings in urban settings.