Preoperative Hemodynamics Impact the Benefit of Fenestration on Fontan Postoperative Length of Stay.

BACKGROUND: Utilization of Fontan fenestration varies considerably by center. OBJECTIVES: Using a multicenter Pediatric Heart Network dataset linking surgical and preoperative hemodynamic variables, the authors evaluated factors associated with use of Fontan fenestration and the impact of fenestration on post-Fontan length of stay (LOS). METHODS: Patients 2 to 6 years old at Fontan surgery from 2010 to 2020 with catheterization<1 year prior were included. Factors associated with fenestration were evaluated using multivariable logistic regression adjusting for key covariates. Restrictive cubic spline analysis was used to evaluate potential cut-points for hemodynamic variables associated with longer postoperative LOS stratified by fenestration with multivariable linear regression to evaluate the magnitude of effect. RESULTS: Fenestration was used in 465 of 702 patients (66.2%). Placement of a fenestration was associated with center (range 27%-93% use, P < 0.0001) and Fontan type (OR: 14.1 for lateral tunnel vs extracardiac conduit, P < 0.0001). No hemodynamic variable was independently associated with fenestration. In a multivariable linear model adjusting for center, a center-fenestration interaction, prematurity, preoperative mean pulmonary artery pressure (mPAP), and cardiac index, fenestration was associated with shorter hospital LOS after Fontan (P = 0.0024). The benefit was most pronounced at mPAP ≥13 mm Hg (median LOS: 9 vs 12 days, P = 0.001). CONCLUSIONS: There is wide center variability in use of Fontan fenestration that is not explained by preoperative hemodynamics. Fenestration is independently associated with shorter LOS, and those with mPAP ≥13 mm Hg at pre-Fontan catheterization benefit the most. We propose this threshold as minimal criteria for fenestration.

Update to Gabapentinoid Use in the United States, 2002-2021.

Gabapentinoids are commonly used medications for numerous off-label conditions. The 2002-2021 Medical Expenditure Panel Survey (MEPS) was used to investigate the proportion of the adult population who were gabapentinoid users, the ages of these users, medications and diagnoses associated with users, and the likelihood of starting, stopping, or continuing gabapentinoids. Gabapentinoid users continued to increase since our last publication from 4.0% in 2015 to 4.7% in 2021. Gabapentinoid use was much more likely among individuals who used other medications used in chronic pain. Between 2017-2021, numerous chronic pain conditions were associated with gabapentinoid use. New gabapentinoid users clearly outnumbered gabapentinoid stoppers between 2011-2012 and 2017-2018, but this difference decreased in the most recent cohorts.

Cardiac injury in children with COVID-19.

BACKGROUND: There is little known about the spectrum of cardiac injury in acute COVID-19 infection in children. METHODS: A single-centre, retrospective chart analysis was performed. The protocol was deemed IRB exempt. All patients under the age of 21 years admitted from 20 March, 2020 to 22 June, 2021 for acute symptomatic COVID-19 infection or clinical suspicion of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 were included. Past medical history, lab findings, echocardiogram and electrocardiogram/telemetry findings, and clinical outcomes were reviewed. RESULTS: Sixty-six patients with MIS-C and 178 with acute COVID-19 were reviewed. Patients with MIS-C had more cardiac testing than those with acute COVID-19. Inflammatory markers were more likely elevated, and function was more likely abnormal on echocardiogram in those with MIS-C with testing performed. Among patients with MIS-C, 17% had evidence of coronary dilation versus 0% in the acute COVID-19 group. One (0.6%) patient with acute COVID-19 had clinically significant electrocardiogram or telemetry findings, and this was in the setting of prior arrhythmias and CHD. Four (6%) patients with MIS-C had clinically significant findings on electrocardiogram or telemetry. Among patients with acute COVID-19, extracorporeal membrane oxygenation support was required in 0.6% of patients with acute COVID-19, and there was a 2.8% mortality. There were no deaths in the setting of MIS-C. CONCLUSIONS: Patients with acute COVID-19 and clinical suspicion of cardiac injury had a lower incidence of abnormal laboratory findings, ventricular dysfunction, or significant arrhythmia than those with MIS-C.

Quantifying side effects and caregiver burdens of pediatric pulmonary hypertension therapies.

BACKGROUND AND OBJECTIVES: Pulmonary hypertension (PH) is a rare, but serious disease among children. However, PH has been primarily evaluated among adults. Consequently, treatment therapies have not been fully evaluated among pediatric populations and are used in an 'off label' manner. The purpose of this study was to estimate the side effect profiles of the most commonly prescribed pediatric PH therapies and to understand the burdens placed upon families caring for children living with PH. METHODS: Participants were recruited online through the "Families of children with pulmonary hypertension" Facebook group and asked to complete a survey about PH treatments. RESULTS: A total of 139 parents of a child living with PH completed the survey. Almost all children used ≥ 1 medication to treat PH, with 52% using ≥ 3 medications. The highest average number of side effects was reported by users of Treprostinil, Selexipag and type-5 phosphodiesterase (PDE5) inhibitors. The most common side effects were skin flushing, headache, nasal congestion, joint/muscle pain, and nausea. In terms of accessing care, 81% travel ≥ 20 miles and 68% travel for ≥ 60 min to receive care. CONCLUSIONS: We found an array of treatment combinations employed to mitigate symptoms of PH in children, with a wide range of side effects. We also found a large, unseen economic, emotional, and time burden of caring for a child living with PH. Further research is warranted to understand the clinical implications of these side effects to move towards labeled usage of these therapies rather than post-hoc off-label usage.

Preventative practices and effects of the COVID-19 pandemic on caregivers of children with pediatric pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a serious and life-threatening disease characterized by elevated mean arterial pressure and pulmonary vascular resistance. COVID-19 may exacerbate PH, as evidenced by higher mortality rates among those with PH. The objective of this study was to understand the unique burdens that the COVID-19 pandemic has placed upon families of children living with PH. METHODS: Participants were recruited online through the "Families of children with pulmonary hypertension" Facebook group and asked to complete a survey about their experiences during the COVID-19 pandemic. RESULTS: A total of 139 parents/caregivers of children living with PH completed the online survey. Almost all (85.6%) of parents/caregivers had received the COVID-19 vaccine, though only 59.7% reported a willingness to vaccinate their child with PH against COVID-19. Over 75% of parents/caregivers felt that they practiced preventative measures (e.g., wearing a facemask, social distancing, and avoiding gatherings) more than those in the community where they live. They also reported several hardships related to caring for their child with PH during the pandemic such as financial duress, loss of work, and affording treatment costs. CONCLUSIONS: These findings indicate that parents/caregivers of children at higher risk for COVID-19 complications may be more willing to act on clinical recommendations themselves as proxy for protecting those at high risk. The economic, emotional and social impacts of COVID-19 are significantly greater for high-risk individuals.

Psychotherapy and Psychiatry Visits in the United States: A Study of MEPS, 2017-2019.

BACKGROUND: Rates of individuals with a psychotherapy visit has not been well studied, and recent reports lack granularity by age. METHODS: The 2017-2019 Medical Expenditure Panel Survey (MEPS) was used to investigate rates and associations of psychotherapy and psychiatry visits by age/sex and antidepressant/antipsychotic use. RESULTS: The study included all 90,853 individuals, of which 5.2% (95% CI, 4.9-5.4) reported any psychotherapy (excluding psychiatry visits) visit during a year, while 3.6% (95% CI, 3.4-3.8) reported a visit with a psychiatrist. Females were more likely to have a psychotherapy visit than males after 15 years of age. The highest rates of females with a psychotherapy visit were between 15 and 30 years of age, while rates among males were highest between 10 to 25 years of age. For psychiatry visits, males had higher rates than females during preteen years, similar rates through teen years, lower rates though adulthood, and similar rates after 60 years of age. Rates of a psychiatry visit did not vary as much by age as a psychotherapy visit. Among antidepressant or antipsychotic medication users, the rate of either a psychotherapy visit or a psychiatry visit during a year was markedly higher at younger ages and decreased as age advanced. CONCLUSION: Psychotherapy and psychiatry utilization have differences in population level patterns with use being highest among females between 15 to 30 years of age and higher among younger (compared with older) individuals who reported antidepressants or antipsychotics.

Learning to Crawl: Determining the Role of Genetic Abnormalities on Postoperative Outcomes in Congenital Heart Disease.

Background Our cardiac center established a systematic approach for inpatient cardiovascular genetics evaluations of infants with congenital heart disease, including routine chromosomal microarray (CMA) testing. This provides a new opportunity to investigate correlation between genetic abnormalities and postoperative course. Methods and Results Infants who underwent congenital heart disease surgery as neonates (aged ≤28 days) from 2015 to 2020 were identified. Cases with trisomy 21 or 18 were excluded. Diagnostic genetic results or CMA with variant of uncertain significance were considered abnormal. We compared postoperative outcomes following initial congenital heart disease surgery in patients found to have genetic abnormality to those who had negative CMA. Among 355 eligible patients, genetics consultations or CMA were completed in 88%. A genetic abnormality was identified in 73 patients (21%), whereas 221 had negative CMA results. Genetic abnormality was associated with prematurity, extracardiac anomaly, and lower weight at surgery. Operative mortality rate was 9.6% in patients with a genetic abnormality versus 4.1% in patients without an identified genetic abnormality (P=0.080). Mortality was similar when genetic evaluations were diagnostic (9.3%) or identified a variant of uncertain significance on CMA (10.0%). Among 14 patients with 22q11.2 deletion, the 2 mortality cases had additional CMA findings. In patients without extracardiac anomaly, genetic abnormality was independently associated with increased mortality (P=0.019). CMA abnormality was not associated with postoperative length of hospitalization, extracorporeal membrane oxygenation, or >7 days to initial extubation. Conclusions Routine genetic evaluations and CMA may help to stratify mortality risk in severe congenital heart disease with syndromic or nonsyndromic presentations.

Psychiatric Medication Users by Age and Sex in the United States, 1999-2018.

PURPOSE: This study aimed to determine the rates of psychiatric medication users in the United States between 1999 to 2018 for different medication categories by age and sex. METHODS: The 1999 to 2002, 2006 to 2009, and 2015 to 2018 Medical Expenditure Panel Surveys (MEPS) were used for the analysis. All individuals with a valid age were included. Any antidepressant, benzodiazepine, attention deficit hyperactivity disease (ADHD) medication, antipsychotics, and mood stabilizer report use was defined as a medication user. Separate multivariable logistic regression predicted medication users by age with restricted cubic splines by sex, medication category, and year category (1999 to 2002, 2006 to 2009, and 2015 to 2018). In addition, the rate of prescribing to males and females at different ages was determined for medication categories. RESULTS: Rates of any psychiatric medication users increased during the study period. Females had higher rates of medication users around 20 years of age. Rates of antidepressant users increased over time and were higher for females after earlier adolescence. Rates of benzodiazepine users were higher for females, increased after 1999 to 2002, and had consistent patterns of use over time. Antipsychotic and mood stabilizer user rates were lower than other categories. Adolescent antipsychotic users markedly decreased between 2006 to 2009 and 2015 to 2018. Rates of ADHD medication users increased over time, particularly among younger adults between 25 and 50 years of age. CONCLUSION: The rates of individuals reporting the use of any psychiatric medications increased over the last few decades. Rates and patterns of medication users have large variations by medication category, age, and sex, but these patterns of use were stable for most medication categories.

Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017.

We sought to describe the proportion of patients in contact with a primary care physician, as well as the total number of primary care contacts over a 2-year period, using the 2002-2017 Medical Expenditure Panel Survey. The rate of any contact with a primary care physician for patients in the population decreased by 2.5% over the study period (adjusted odds ratio [aOR] = 0.99 per panel, 95% CI, 0.98-0.99; P <.001). The number of contacts with a primary care physician decreased among individuals with any contact by 0.5 contacts over 2 years (aOR = -0.04 per panel, 95% CI, -0.04 to -0.03, P <.001). The decreases were observed across all age groups at varying rates. The results of this study suggest that the driver for the previously reported decreases in primary care visits is secondary to fewer contacts per patient.

The Ecology of Antihypertensives in the United States, 1997-2017.

OBJECTIVE: Antihypertensives are the most used medication type in the USA, yet there remains uncertainty about the use of different antihypertensives. We sought to characterize use of antihypertensives by and within medication class(es) between 1997 and 2017. PATIENTS AND METHODS: A repeated cross-sectional study of 493,596 adult individuals using the 1997-2017 Medical Expenditure Panel Survey (MEPS). The Orange Book was used for adjunctive information. The primary outcome was the estimated use by and within antihypertensive medication class(es). RESULTS: The proportion of individuals taking any antihypertensive during a year increased from 1997 to the early 2010s and then remained stable. The proportion of adults using angiotensin II receptor blockers (ARBs) and dihydropyridine calcium channel blockers (CCBs) increased during the study period, while angiotensin-converting enzyme inhibitors (ACE-Is) increased until 2010 after which rates remained stable. Beta-blocker use was similar to that of ACE-Is with an earlier decline starting in 2012. Thiazide diuretic use increased from 1997 to 2007, leveled off until 2014, and declined from 2015 to 2017. Non-dihydropyridine CCB use declined throughout the study. ACE-Is, ARBs, CCBs, thiazide diuretics, and loop diuretics all had one dominant in-class medication. There was a clear increase in the use of losartan within ARBs, lisinopril within ACE-Is, and amlodipine within CCBs following generic conversion. Furosemide and hydrochlorothiazide started with and maintained a dominant position in their classes. Metoprolol use increased throughout the study and became the dominant beta-blocker. CONCLUSIONS: Antihypertensive classes appear to have a propensity to equilibrate to an individual medication, despite a lack of outcomes-based research to compare medications within a class.

The cardiovascular outcomes, heart failure and kidney disease trials tell that the time to use Sodium Glucose Cotransporter 2 inhibitors is now.

Sodium glucose contrasporter 2 inhibitors (SGLT2i) were initially introduced as a novel class of modestly effective antiglycemics. Over the last 5 years, multiple members of this class have been examined for their cardiovascular safety, effects on heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD) in diverse populations with or without diabetes type 2. The plethora of studies and outcomes examined make it difficult for the practitioner to track the entirety of the evidence. SGLT2i improve cardiorenal outcomes and have a beneficial risk benefit ratio across populations with cardiovascular disease, HFrEF and kidney disease. In this quantitative review, we synthesize the data from the large outcomes trials about the benefits and risks of SGLT2i. SGLT2i reduce all cause, cardiovascular mortality, heart failure hospitalizations, need for dialysis and acute kidney injury as a class effect across a broad range of populations with diabetes Type 2 at risk for cardiovascular disease, patients with HFrEF or CKD with or without diabetes. While certain adverse events for example, diabetic ketoacidosis and genital mycotic infections are reproducibly increased by SGLT2i, the absolute increase in the risk of these complications is smaller than the absolute risk reductions conferred by SGLT2i. Other complications such as amputations, fractures and urinary tract infections are increased to a lesser degree, or not at all (e.g., hypoglycemia). Overall, SGLT2is appear to have a favorable safety profile and thus should be used by cardiologists, nephrologists, endocrinologists, primary care physicians when managing the cardiorenal risk of their patients.

Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017.

PURPOSE: Total and out-of-pocket visit expenditures for primary care physician visits may affect how primary care is delivered. We determined trends in these expenditures for visits to US primary care physicians. METHODS: Using the 2002-2017 Medical Expenditure Panel Survey, we ascertained changes in total and out-of-pocket visit expenditures for primary care visits for Medicare, Medicaid, and private insurance. We calculated mean values for each insurer using a generalized linear model and a 2-part model, respectively. RESULTS: Analyses were based on 750,837 primary care visits during 2002-2017. Over time, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- or Medicaid-associated visits increased. The proportion of visits with $0 out-of-pocket expenditure increased, primarily from an increase in $0 private insurance visits. Total expenditure per visit increased for private insurance and Medicare visits, but did not notably change for Medicaid visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher expenditures of this type. Medicare and Medicaid had minimal change in out-of-pocket expenditure per visit. CONCLUSIONS: Between 2002 and 2017, mean total expenditures and out-of-pocket expenditures increased for primary care visits, but at notably lower rates than those previously documented for emergency department visits. A rise in total expenditure per visit was identified for private insurance and Medicare, but not for Medicaid. Out-of-pocket expenditures increased marginally related to changes in out-of-pocket expenditures for private insurance visits. We would expect increasing difficulty with primary care physician access, particularly for Medicaid patients, if the current trends continue.

Thyroid Hormone Use in the United States, 1997-2016.

BACKGROUND: Thyroid disorders are among the most commonly treated conditions by the United States health care system. The number of patients reporting thyroid hormone use has increased in recent years, but it is unknown if there have been differential increases in the number of treated individuals within different demographic groups. Previous research has also not evaluated how expenditures for different thyroid hormone medications have changed in recent years. METHODS: Using data from the 1997 through 2016 Medical Expenditure Panel Survey, we calculated the proportion of adults reporting thyroid hormone prescriptions by 3 demographic variables (age, sex, and race) and determined expenditures from thyroid hormone prescriptions by medication type (overall, generic, Synthroid or Cytomel, and other brand). RESULTS: Between 1997 and 2016, the proportion of adults who reported thyroid hormone use increased from 4.1% (95% CI, 3.7-4.4) to 8.0% (95% CI, 7.5-8.5). Most of the growth in thyroid hormone use occurred among adults aged >65, and use was also more common among females and non-Hispanic whites. Expenditures from thyroid hormones increased from $1.1 billion (95% CI, 0.9-1.3) in 1997 to $3.2 billion dollars (95% CI, 2.9-3.6) in 2016. Generic thyroid hormone prescriptions comprised 18.1% of all thyroid hormone prescriptions in 2004 (95% CI, 15.8-20.4) and 80.8% of all thyroid hormone prescriptions (95% CI, 78.4-83.2) in 2016. CONCLUSIONS: Thyroid hormone use nearly doubled over the last 20 years, and increased use was associated with being older, female, and non-Hispanic white. During the same time period, thyroid hormone expenditures almost tripled.