Socioeconomic Factors Influencing Pediatric Peak Oxygen Consumption Prediction.

OBJECTIVE: To determine if socioeconomic status (SES) has a greater effect than standard demographic values on predicted peak oxygen consumption (pVO2). STUDY DESIGN: We conducted a single-institution, retrospective analysis of maximal cardiopulmonary exercise test (CPET) data from 2010 to 2020 for healthy patients age <19 years with body mass index (BMI) percentile (BMI%) between 5-95. Data were sorted by self-identified race, BMI%, and adjusted gross income (AGI); AGI served as a surrogate for SES. Mean percent predicted pVO2 (pppVO2) was compared between groups. Linear regression was used to adjust for differences. RESULTS: A total of 541 CPETs met inclusion criteria. Mean pppVO2 was 97% ± 22.6 predicted (P < .01) with 30% below criterion standard for normal (85% predicted). After excluding unknown AGI and race, 418 CPETs remained. Mean pppVO2 was lower for Blacks (n = 36) and Latinx (n = 26) compared with Whites (n = 333, P < .01). Mean pppVO2 declined as AGI decreased (P < .01). The differences in pppVO2 between racial categories remained significant when adjusted for BMI% (Black r = -7.3, P = .035; Latinx r = -15.4, P < .01). These differences both decreased in magnitude and were no longer significant when adjusted for AGI (Black r = -6.0, P = .150; Latinx r = -9.3, P = .06). CONCLUSIONS: Lower SES correlates with lower measured cardiovascular fitness and may confound data interpretation. When using normative reference ranges in clinical decision making, providers should recognize that social determinants of health may influence predicted fitness. Social inequities should be considered when assessing pediatric cardiovascular fitness.

Impact of Partnership Between Children's HeartLink and IQIC Database With a Pediatric Cardiology and Cardiovascular Surgery Center in Brazil.

BACKGROUND: Aiming at fostering local development of cardiology and cardiovascular surgery centers in developing countries, the nonprofit organization Children's HeartLink (CHL) encourages centers to participate in the International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). The definition of parameters and data to evaluate patient treatment provides an opportunity to improve quality of care, reducing morbidity and mortality. The objective of the study was to analyze the outcomes of the partnership between CHL and IQIC database with a single pediatric cardiology and cardiovascular surgery center for seven years providing continuous follow-up to guide actions aiming at morbidity and mortality reduction in patients with pediatric and congenital heart diseases. METHODS: Data were collected from January 2011 to December 2017 independently and with external audits and included preoperative information (demographic data, nutritional status, chromosomal abnormalities), Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, and postoperative information such as infections or complications within the first 30 days or until hospital discharge and/or death. RESULTS: In the preoperative period, there was a trend toward an increase in the number of newborn patients. The postoperative period showed significant surgical procedure variations between groups for RACHS-1 risk category ( P = .003), prevalence of risk categories 2 and 3, and an increase in risk categories 4, 5, and 6, mainly in the last two years. Decreases in surgical site infection ( P = .03), bacterial sepsis, and other infections (both P < .001) were observed. At the 30-day postoperative follow-up, there was a decrease of in-hospital ( P = .16) and 30-day ( P = .14) mortality. CONCLUSION: The partnership between CHL and this seven-year analysis of IQIC database demonstrated structural and human flaws, whose resolution led to significant decrease in infection and reduction in mortality despite an increase in the complexity of our pediatric and congenital heart disease population.

Adjunct Targeted Biologic Inhibition Agents to Treat Aggressive Multivessel Intraluminal Pediatric Pulmonary Vein Stenosis.

OBJECTIVE: To evaluate the use of imatinib mesylate with or without bevacizumab targeting neoproliferative myofibroblast-like cells with tyrosine kinase receptor expression, as adjuncts to modern interventional therapies for the treatment of multivessel intraluminal pulmonary vein stenosis (PVS). We describe the 48- and 72-week outcomes among patients receiving imatinib mesylate with or without bevacizumab for multivessel intraluminal PVS. STUDY DESIGN: This single-arm, prospective, open-label US Food and Drug Administration approved trial enrolled patients with ≥2 affected pulmonary veins after surgical or catheter-based relief of obstruction between March 2009 and December 2014. Drug therapy was discontinued at 48 weeks, or after 24 weeks of stabilization, whichever occurred later. RESULTS: Among 48 enrolled patients, 5 had isolated PVS, 26 congenital heart disease, 5 lung disease, and 12 both. After the 72-week follow-up, 16 patients had stabilized, 27 had recurred locally without stabilization, and 5 had progressed. Stabilization was associated with the absence of lung disease (P = .03), a higher percentage of eligible drug doses received (P = .03), and was not associated with age, diagnosis, disease laterality, or number of veins involved. Survival to 72 weeks was 77% (37 of 48). Adverse events were common (n = 1489 total), but only 16 were definitely related to drug treatment, none of which were serious. CONCLUSION: Survival to 72 weeks was 77% in a referral population with multivessel intraluminal PVS undergoing multimodal treatment, including antiproliferative tyrosine kinase blockade. Toxicity specific to tyrosine kinase blockade was minimal.

Development and Evaluation of a Continuing Education Program for Nursing Technicians at a Pediatric Cardiac Intensive Care Unit in a Developing Country.

BACKGROUND: The nursing profession faces continuous transformations demonstrating the importance of professional continuing education to extend knowledge following technological development without impairing quality of care. Nursing assistants and technicians account for nearly 80% of nursing professionals in Brazil and are responsible for uninterrupted patient care. Extensive knowledge improvement is needed to achieve excellence in nursing care. The objective was to develop and evaluate a continuing education program for nursing technicians at a pediatric cardiac intensive care unit (PCICU) using a virtual learning environment entitled EDUCATE. METHODS: From July to September 2015, a total of 24 nursing technicians working at the PCICU at a children's hospital located in the northwestern region of São Paulo state (Brazil) fully participated in the continuing education program developed in a virtual learning environment using Wix platform, allowing access to video classes and pre- and post-training theoretical evaluation questionnaires outside the work environment. The evaluation tools recorded participants' knowledge evolution, technological difficulties, educational, and overall rating. RESULTS: Knowledge development was descriptively presented as positive in more than 66.7%. Content and training were considered "excellent" by most participants and 90% showed an interest in the use of technological resources. Technical difficulties were found and quickly resolved by 40% of participants including Internet access, login, and lack of technical expertise. CONCLUSION: The continuing education program using a virtual learning environment positively contributed to the improvement in theoretical knowledge of nursing technicians in PCICU.

Decreased exercise performance with age in children with hypoplastic left heart syndrome.

OBJECTIVE: Children born with hypoplastic left heart syndrome (HLHS) may experience cardiac dysfunction after staged surgery or transplantation, which may worsen with age. We examined the hypothesis that exercise testing can address cardiovascular capacity and suggest interventions to improve quality of life. STUDY DESIGN: Children with HLHS > or = 8 years old performed treadmill or bicycle ergometric testing at 4 centers. Results were compared with norms for age and sex. RESULTS: Of the 42 participants, the mean age was 12.9 years (range, 8.5-17.0 years), 64% were boys, 20 had staged surgery, and 34 completed metabolic assessment. The percent of predicted maximal oxygen uptake (mVO2) was higher in younger children. Children aged 8 to 12 years achieved 70% of predicted mVO2; children aged 13 to 17 years achieved 60% of predicted mVO2 (P = .02). The percent of predicted peak heart rate trended higher in younger patients (83% versus 75%, P = .07). Electrocardiographic changes were more common in older children. In treadmill testing, patients who had a transplant had better exercise performance than patients who underwent staged surgery in percent of predicted exercise time (82% versus 54%, P < .0001) and peak rate-pressure product (241 x 10(3) versus 195 x 10(3), P = .02). The percent of predicted mVO2 did not differ between patients who had a transplant (66%) and patients who underwent staged surgery (61%, P = .25). CONCLUSION: Children with HLHS showed considerable age-related decline in exercise performance, regardless of surgical strategy.

Improvement in congenital heart surgery in a developing country: the Guatemalan experience.

BACKGROUND: In 1997, an effort was made to disseminate US pediatric cardiac surgical practices to create a new comprehensive program in Guatemala. The objective of this study was to describe the improvement of the program by exploring the reduction in risk-adjusted in-hospital mortality. METHODS AND RESULTS: A retrospective cohort study of surgical procedures performed in Guatemala from February 1997 to July 2004 was conducted. Data were divided into 3 time periods (1997 to 1999, 2000 to 2002, and 2003 to 2004) and compared with a US benchmark (2000 Kids' Inpatient Database of 27 states and 313 institutions). The risk adjustment for congenital heart surgery (RACHS-1) method was used to adjust for case mix. Mortality rates, standardized mortality ratios, and 95% confidence intervals were calculated. A total of 1215 surgical procedures were included. Median age was 3.1 years (range, 1 day to 17.9 years). The overall mortality was 10.7% (n=130). The RACHS-1 method showed better discrimination than in prior reports (area under receiver operating characteristic curve=0.854). A decreasing trend in mortality rate was observed in every RACHS-1 risk category over the 3 time periods. When compared against the US benchmark, the reduction in risk-adjusted mortality was noted by a decrease of standardized mortality ratio from 10.0 (95% confidence interval, 7.2 to 13.7) in 1997-1999, to 7.8 (95% confidence interval, 5.9 to 10.0) in 2000-2002, and to 5.7 (95% confidence interval, 3.8 to 8.3) in 2003-2004. CONCLUSIONS: In a short time period, mortality after congenital heart surgery has been reduced substantially in Guatemala. Measurement of risk-adjusted mortality is a useful method to assess pediatric cardiac program improvement in the developing world.