Interventions on residual lesions in patients with heterotaxy syndrome following orthotropic heart transplantation: A single-center experience.

BACKGROUND: Heterotaxy syndrome (HS) is a defect in lateralization which often results in complex intra and extracardiac abnormalities. Orthotropic heart transplantation (OHT) in HS involves intricate and individualized modifications to surgical technique. Post-OHT outcomes are worse in patients with HS, however, the impact of post-OHT residual lesions has not yet been characterized. METHODS: Patients with HS who underwent OHT at Ann & Robert H. Lurie Children's Hospital of Chicago between January 2012 and June 2023 were identified. Patients were excluded if follow-up data was not available due to follow up at a different institution of early mortality. Pre-OHT clinical data, surgical data, and post-OHT surgical and catheterization data were collected. RESULTS: Two early mortalities were excluded from analysis, leaving 15 patients in the study cohort. Median age at OHT was 3.7 years (range: 0.7-15.4). Nine out of 15 patients were diagnosed with residual lesions requiring intervention at a median of 188 days post transplantation. All interventions on residual lesions occurred via catheterization. Overall mortality rate was 27% (4/15) with all deaths occurring in patients with residual lesions (4/9 patients, 44%). 83% (10/12) of lesions were diagnosed via catheterization, and 83% (10/12) of lesions of occurred in the first year after transplant. CONCLUSIONS: Patients with HS are at high risk for residual lesions after OHT, which may contribute to increased mortality. Comprehensive invasive diagnostics were required to diagnose residual lesions, which were all addressed percutaneously.

Transforming Care for Older Adults Living with Complex Health Conditions in Ontario Post-Covid: Conference Proceedings and Recommendations.

The virtual conference 'Transforming Care: Supporting Older Adults Post-COVID in Ontario' was held in October 2021. It was organized by Specialized Geriatric Services (SGS) East and held over three half-days. The guiding themes included: The Need, The Innovation, and The Transformation. Over 500 participants heard from ~50 clinicians, researchers, administrators, older adults, care partners, and community partners. The pandemic uncovered and exacerbated existing issues and pushed us to explore new ways to support older adults living with complex health conditions. The following key priorities were identified: older adults and their care partners call for personalized care experiences, and a lifespan approach to care delivery; aging in the community remains the most common preference; an integrated community care system that supports aging at-home should be prioritized; care delivery by SGS interprofessional teams and specialists is paramount to providing comprehensive care; building health human resource capacity should be a system priority; and promising innovations should be scaled and spread. Evidence shows that we cannot return to status-quo; post-pandemic planning of both who we serve and how we serve needs to be anchored in system renewal, not just recovery. Renewal means integrating lessons learned during the pandemic into the redesign of our systems of care. Investments in innovative, upstream strategies that support home and community-based care, and target health promotion and prevention are necessary. The provincial and regional infrastructure of SGS has the expertise and capacity to assist Ontario Health Teams in responding to the evolving health and social needs of this population.

Early aspirin use and the development of cardiac allograft vasculopathy in pediatric heart transplant recipients: A pediatric heart transplant society analysis.

BACKGROUND: Cardiac allograft vasculopathy (CAV) remains a leading cause of graft loss in pediatric heart transplant (HTx) recipients. Adult literature suggests that aspirin (ASA) use in the early post-HTx period may reduce the risk of CAV. This study aimed to determine the impact of early ASA use on the development of CAV in pediatric HTx recipients. METHODS: All subjects <17 years of age at time of primary HTx who survived ≥3 years without evidence of CAV were identified for inclusion from the Pediatric Heart Transplant Society database (1996-2019). Early ASA use was defined as ASA started within the first 3 years post-HTx and was classified as continuous or intermittent. Frequency of ASA use was described across centers. Kaplan-Meier method assessed freedom from CAV and overall graft survival. Multiphase parametric hazard analyses and propensity score matched analysis were used to identify independent risk factors. RESULTS: 3,011 patients were included with 387 (13%) receiving continuous ASA, 676 (22%) receiving intermittent ASA, and 1,948 (65%) receiving no ASA. ASA use was highly variable across centers (0%-100%). At baseline patients receiving continuous ASA therapy demonstrated inferior graft survival (p < 0.001) and worse freedom from CAV (p = 0.002), but with lower CAV grades (p = 0.05). In multiphase parametric hazard modeling continuous ASA use was not independently associated with CAV, but remained associated with inferior graft survival. Propensity-matched sub-analysis between continuous and no ASA groups demonstrated no difference in freedom from CAV or overall graft loss. CONCLUSIONS: ASA use varies widely across pediatric HTx centers. Early ASA use did not reduce the risk of CAV or graft loss in pediatric heart transplant recipients.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care.

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.

A case report of myocarditis masquerading as hypertrophic cardiomyopathy.

We report the case of a 16-year-old girl diagnosed with myocarditis, although initial echocardiographic imaging was consistent with hypertrophic cardiomyopathy (HCM). The diagnosis of myocarditis was made with the findings of troponin elevation, presence of influenza A, and a more characteristic electrocardiogram. She eventually made a full recovery. Clinicians must be vigilant for such rare presentations of myocarditis masquerading as HCM.

Pediatric donor heart allocation in the United States, 2006-2017: Current patterns and potential for improvement.

OBJECTIVE: To understand current donor heart allocation practices for pediatric transplantation. BACKGROUND: Despite high waitlist mortality rates among pediatric patients awaiting transplant, a substantial proportion of donor hearts go unused. Analysis of UNOS match run data may identify opportunities to optimize organ utilization. METHODS: Using UNOS/OPTN data, we evaluated all match runs for pediatric (<18 years) donor hearts from 1/1/2006 to 3/31/2017. We assessed final disposition of donor hearts, reasons for donor refusal, and other match run characteristics. Variation in total offers made per organ, and refusal rates by OPOs were also evaluated. RESULTS: Of 7585 pediatric potential donor hearts, 2226 (29.3%) were refused. Hearts accepted underwent a median of 2 offers (IQR: 1-5), compared to 11 (IQR: 5-24) for refused donor hearts. Organ refusal rates decreased from 36.9% in 2006-2009 to 22.3% in 2014-2017 (P < .001). Reasons for refusal included quality (80.9%), size mismatch (57.5%), and known/suspected crossmatch positivity (39.1%). Among 1800 hearts deemed "poor quality" by ≥1 transplant program, less than half (46.6%) were coded "poor quality" by multiple refusing programs. Organ refusal rates ranged from 13.5% to 83.3% across OPOs, and there was no correlation between refusal rates and median number of offers made by the OPO. CONCLUSION: Although more organs are being used over time, 1 in 5 available pediatric donor hearts are still discarded. The lack of donor evaluation consensus and wide variability in donor refusal rates indicates a need for standardization of donor assessment and match run processes across OPOs.

Decellularized Bovine Pericardial Mitral Valve in a Neonatal Marfan Patient.

Mitral valve construction using decellularized bovine pericardium is a new procedure. A 10-month-old infant with neonatal Marfan syndrome underwent mitral valve replacement due to severe mitral regurgitation with a cylinder valve constructed from decellularized bovine pericardium. Nineteen months postoperatively the patient is clinically well with trivial mitral regurgitation, mild stenosis, and without need for anticoagulation.

Pediatric marginal donor hearts: Trends in US national use, 2005-2014.

Pediatric patients awaiting heart transplant face high mortality rates due to donor organ shortages, including non-use of marginal donor hearts. We examined national trends in pediatric marginal donor heart use over time. UNOS data were queried for heart donors <18 years from 2005 to 2014. The proportion of donor hearts considered marginal was determined using previously cited marginal characteristics: left ventricular ejection fraction (LVEF) <50%, use of ≥2 inotropes, cerebrovascular death, CDC high-risk status, and eGFR < 30 mL/min/1.73 m2 . Disposition of donor hearts was determined and stratified by marginal donor status. Of 6778 pediatric hearts offered from 2005 to 2014, 2373 (35.0%) were considered marginal. Non-use of marginal donor hearts was significantly higher than that of donor hearts without any marginal characteristics (59.5% vs 20.3%, P < .001). In particular, LVEF < 50% and donor inotropes were associated with high rates of organ non-use among pediatric donors. Yet, non-use of marginal donor organs decreased from 67% to 48% from 2005 to 2014 (P < .001). Although the proportion of pediatric donor hearts used for pediatric patients has increased, more than half of donor hearts are declined for use in pediatric recipients due, in part, to perceived marginal status.

Paediatric abstract publication rates for the American Society of Echocardiography Meeting.

BACKGROUND: Abstract presentations of scientific information at meetings are important for broadcasting new information. Publication of these studies should be the final goal, but minimal data exist documenting publication rates, especially for paediatric sub-speciality meetings. The goal of this study was to document the manuscript publication rate for paediatric cardiac echocardiography abstracts and to determine whether there were differences between abstracts that were published versus not published. METHODS: Paediatric cardiac echocardiography abstracts presented from 2007 to 2011 at the American Society of Echocardiography Meetings were reviewed. Characteristics of the abstracts were noted. A Medline/Pubmed search was performed using keywords, first author, and senior author criteria to determine publication. Fisher's exact tests or χ2 tests were used for analysis. RESULTS: A total of 194 abstracts were reviewed. In all, 27 abstracts were oral presentations and 167 were poster presentations. A total of 124 abstracts were prospective studies and 70 were retrospective studies; 11 abstracts were basic science studies and 183 were clinical studies. Altogether, 25 abstracts dealt with three-dimensional echocardiography, 15 with fetal echocardiography, 56 with deformation analysis, 79 with standard transthoracic echocardiography, and 19 were in the other category. A total of 73 abstracts were subsequently published - with a 37.6% publication rate - 2.1±1.7 years after initial presentation. There were no significant differences in publication rates based on the above-noted variables. CONCLUSION: A paediatric cardiac echocardiography abstract publication rate of 37.6% is comparable to previous published publication rates for other meetings. No differences in variables analysed were noted between published versus unpublished abstracts.

Clinical Tests of Standing Balance in the Knee Osteoarthritis Population: Systematic Review and Meta-analysis.

BACKGROUND: People with knee osteoarthritis (OA) have a high prevalence of falls. Poor standing balance is one risk factor, but the extent of standing balance deficits in people with knee OA is unknown. PURPOSE: The primary purpose of this study was to summarize available data on standing balance in people with knee OA compared with people without knee OA. A secondary purpose was to establish the extent of balance impairment across disease severity. DATA SOURCES: A literature search of the MEDLINE, EMBASE, CINAHL, and Web of Science databases through November 19, 2014, was conducted. STUDY SELECTION: Studies on individuals with knee OA containing clinical, quantifiable measures of standing balance were included. Methodological quality was assessed by 2 reviewers using a 16-item quality index developed for nonrandomized studies. Studies scoring >50% on the index were included. DATA EXTRACTION: Participant characteristics (age, sex, body mass index, OA severity, compartment involvement, unilateral versus bilateral disease) and balance outcomes were extracted by 2 reviewers. Standardized mean differences were pooled using a random-effects model. DATA SYNTHESIS: The search yielded 2,716 articles; 8 met selection and quality assessment criteria. The median score on the quality index was 13/17. People with knee OA consistently performed worse than healthy controls on the Step Test, Single-Leg Stance Test, Functional Reach Test, Tandem Stance Test, and Community Balance and Mobility Scale. The pooled standardized mean difference was -1.64 (95% confidence interval=-2.58, -0.69). No differences were observed between varying degrees of malalignment, or between unilateral versus bilateral disease. LIMITATIONS: No studies compared between-knee OA severities. Thus, expected changes in balance as the disease progresses remain unknown. CONCLUSIONS: Few studies compared people with knee OA and healthy controls, but those that did showed that people with knee OA performed significantly worse. More research is needed to understand the extent of balance impairments in people with knee OA using easy-to-administer, clinically available tests.

Laboratory-based measurement of standing balance in individuals with knee osteoarthritis: a systematic review.

BACKGROUND: Laboratory-based measurement of standing balance is used to assess postural control in people with and without pathology, including knee osteoarthritis. However, no summary of available data has been reported in this patient population. This study aimed to summarize available data and testing methods for individuals with knee osteoarthritis. METHODS: Medline (OvidSP and PubMed), Embase, CINAHL, and Web of Science were searched from 1994 to October 25, 2014 to identify studies containing a quantifiable measure of standing balance. Methodological quality was assessed using a modified 17-item Downs & Black quality index. Studies scoring <50% were eliminated. FINDINGS: The search strategy initially yielded 1523 unique papers; 21 met all inclusion and quality assessment criteria. The variables measured in three or more of the 21 papers were anteroposterior centre of pressure (COP) velocity, mediolateral COP velocity, mean COP velocity, anteroposterior range of COP, mediolateral range of COP, anteroposterior COP standard deviation, mediolateral COP standard deviation, COP path length, COP area, Biodex anteroposterior score, Biodex mediolateral score, and overall Biodex score. In general, people with knee osteoarthritis exhibited worse standing balance compared to healthy controls. However, there remained much discrepancy in testing procedures across studies. INTERPRETATION: These findings indicate that people with knee osteoarthritis exhibit altered postural control. However, no conclusions could be made on the differences between radiographic severities. That said, these findings provide an opportunity for future researchers and clinicians to compare their findings with the currently published data.

Measuring the grafting density of nanoparticles in solution by analytical ultracentrifugation and total organic carbon analysis.

Many of the solution phase properties of nanoparticles, such as their colloidal stability and hydrodynamic diameter, are governed by the number of stabilizing groups bound to the particle surface (i.e., grafting density). Here, we show how two techniques, analytical ultracentrifugation (AUC) and total organic carbon analysis (TOC), can be applied separately to the measurement of this parameter. AUC directly measures the density of nanoparticle-polymer conjugates while TOC provides the total carbon content of its aqueous dispersions. When these techniques are applied to model gold nanoparticles capped with thiolated poly(ethylene glycol), the measured grafting densities across a range of polymer chain lengths, polymer concentrations, and nanoparticle diameters agree to within 20%. Moreover, the measured grafting densities correlate well with the polymer content determined by thermogravimetric analysis of solid conjugate samples. Using these tools, we examine the particle core diameter, polymer chain length, and polymer solution concentration dependence of nanoparticle grafting densities in a gold nanoparticle-poly(ethylene glycol) conjugate system.