Consensus-Based Development of a Pediatric Echocardiography Complexity Score: Design, Rationale, and Results of a Quality Improvement Collaborative.

BACKGROUND: The complexity of congenital heart disease has been primarily stratified on the basis of surgical technical difficulty, specific diagnoses, and associated outcomes. We report on the refinement and validation of a pediatric echocardiography complexity (PEC) score. METHODS AND RESULTS: The American College of Cardiology Quality Network assembled a panel from 12 centers to refine a previously published PEC score developed in a single institution. The panel refined complexity categories and included study modifiers to account for complexity related to performance of the echocardiogram. Each center submitted data using the PEC scoring tool on 15 consecutive inpatient and outpatient echocardiograms. Univariate and multivariate analyses were performed to assess for independent predictors of longer study duration. Among the 174 echocardiograms analyzed, 68.9% had underlying congenital heart disease; 44.8% were outpatient; 34.5% were performed in an intensive care setting; 61.5% were follow-up; 46.6% were initial or preoperative; and 9.8% were sedated. All studies had an assigned PEC score. In univariate analysis, longer study duration was associated with several patient and study variables (age <2 years, PEC 4 or 5, initial study, preoperative study, junior or trainee scanner, and need for additional imaging). In multivariable analysis, a higher PEC score of 4 or 5 was independently associated with longer study duration after controlling for study variables and center variation. CONCLUSIONS: The PEC scoring tool is feasible and applicable in a variety of clinical settings and can be used for correlation with diagnostic errors, allocation of resources, and assessment of physician and sonographer effort in performing, interpreting, and training in pediatric echocardiography.

Feasibility of Digital Stethoscopes in Telecardiology Visits for Interstage Monitoring in Infants with Palliated Congenital Heart Disease.

Infants with staged surgical palliation for congenital heart disease are at high-risk for interstage morbidity and mortality. Interstage telecardiology visits (TCV) have been effective in identifying clinical concerns and preventing unnecessary emergency department visits in this high-risk population. We aimed to assess the feasibility of implementing auscultation with digital stethoscopes (DSs) during TCV and the potential impact on interstage care in our Infant Single Ventricle Monitoring & Management Program. In addition to standard home-monitoring practice for TCV, caregivers received training on use of a DS (Eko CORE attachment assembled with Classic II Infant Littman stethoscope). Sound quality of the DS and comparability to in-person auscultation were evaluated based on two providers' subjective assessment. We also evaluated provider and caregiver acceptability of the DS. From 7/2021 to 6/2022, the DS was used during 52 TCVs in 16 patients (median TCVs/patient: 3; range: 1-8), including 7 with hypoplastic left heart syndrome. Quality of heart sounds and murmur auscultation were subjectively equivalent to in-person findings with excellent inter-rater agreement (98%). All providers and caregivers reported ease of use and confidence in evaluation with the DS. In 12% (6/52) of TCVs, the DS provided additional significant information compared to a routine TCV; this expedited life-saving care in two patients. There were no missed events or deaths. Use of a DS during TCV was feasible in this fragile cohort and effective in identifying clinical concerns with no missed events. Longer term use of this technology will further establish its role in telecardiology.

Association of Home Monitoring and Unanticipated Interstage Readmissions in Infants With Hypoplastic Left Heart Syndrome.

Background The impact of home monitoring on unanticipated interstage readmissions in infants with hypoplastic left heart syndrome has not been previously studied. We sought to examine the association of our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP) with readmission frequency, cumulative readmission days, and readmission illness severity and to identify patient-level risk factors for readmission. Methods and Results We performed a retrospective single-center cohort study comparing infants with hypoplastic left heart syndrome enrolled in ISVMP (December 2010-December 2019) to historical controls (January 2007-November 2010). The primary outcome was number of readmissions per interstage days. Secondary outcomes were cumulative interstage readmission days and occurrence of severe readmissions. Inverse probability weighted and multivariable generalized linear models were used to examine the association between ISVMP and the outcomes. We compared 198 infants in the ISVMP to 128 historical controls. Infants in the ISVMP had more than double the risk of interstage readmission compared with controls (adjusted incidence rate ratio, 2.38 [95% CI, 1.50-3.78]; P=0.0003). There was no difference in cumulative interstage readmission days (adjusted incidence rate ratio, 1.02 [95% CI, 0.69-1.50]; P=0.90); however, infants in the ISVMP were less likely to have severe readmissions (adjusted odds ratio, 0.28 [95% CI, 0.11-0.68]; P=0.005). Other factors independently associated with number of readmissions included residing closer to our center, younger gestational age, genetic syndrome, and discharge on exclusive enteral feeds. Conclusions Infants in the ISVMP had more frequent readmissions but comparable readmission days and fewer severe unanticipated readmissions. These findings suggest that home monitoring can reduce interstage morbidity without increasing readmission days.

Appropriateness of cardiovascular computed tomography and magnetic resonance imaging in patients with conotruncal defects.

BACKGROUND: To promote the rational use of cardiovascular imaging in patients with congenital heart disease, the American College of Cardiology developed Appropriate Use Criteria (AUC), but its clinical application and pre-release benchmarks have not been evaluated. We aimed to evaluate the appropriateness of indications for cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) in patients with conotruncal defects and to identify factors associated with maybe or rarely appropriate (M/R) indications. METHODS: Twelve centers each contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. To incorporate patient characteristics and center-level effects, a hierarchical generalized linear mixed model was used. RESULTS: Of the 1753 studies (80% CMR, and 20% CCT), 16% were rated M/R. Center M/R ranged from 4 to 39%. Infants accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age <1 year (OR 1.90 [1.15-3.13]), truncus arteriosus (vs. tetralogy of Fallot, OR 2.55 [1.5-4.35]), and CCT (vs. CMR, OR 2.67 [1.87-3.83]). None of the provider- or center-level factors reached statistical significance in the multivariable model. CONCLUSIONS: Most CMRs and CCTs ordered for the follow-up care of patients with conotruncal defects were rated appropriate. However, there was significant center-level variation in appropriateness ratings. Younger age, CCT, and truncus arteriosus were independently associated with higher odds of M/R rating. These findings could inform future quality improvement initiatives and further exploration of factors resulting in center-level variation.

Initial Experience with Telemedicine for Interstage Monitoring in Infants with Palliated Congenital Heart Disease.

Infants with staged surgical palliation for congenital heart disease are at high-risk for interstage morbidity and mortality; home monitoring programs have mitigated these risks. In 2019, we instituted telemedicine (TM) in our established Infant Single Ventricle Monitoring Program. All consecutive patients discharged following neonatal operation/intervention were monitored until subsequent stage 2 surgical palliation. We offered TM (synchronous video) visits as part of regularly scheduled follow-up, replacing at least one in-person primary care visit with a TM cardiologist visit. We tracked emergency department (ED) visits, hospitalizations, how TM identified clinical concerns, and whether use of TM prevented unnecessary ED visits or expedited in-person assessment. We assessed caregiver and clinician satisfaction. Between 8/2019 and 5/2020, we conducted 60 TM visits for 29 patients. Of 31 eligible patients, 2 families (6.9%) declined. Median monitoring time was 199 days (range 75-264) and median number of TM visits/patient was 2 (range 1-5). In 6 visits (10%), significant clinical findings were identified which avoided an ED visit. Five TM visits led to expedited outpatient assessments, of which 1 patient required hospitalization. There were no missed events or deaths. Median ED visits/patient/month were significantly lower compared to the same calendar period of the prior year (0.0 (0-2.5) vs. 0.4 (0-3.7), p = 0.0004). Caregivers and clinicians expressed high levels of satisfaction with TM. TM for this high-risk population is feasible and effective in identifying clinical concerns and preventing unnecessary ED visits. TM was particularly effective during the COVID-19 pandemic, allowing for easy adaptation of care to ensure patient safety in this fragile cohort.

A comprehensive 3D CT based classification of intertrochanteric fracture.

Introduction: Despite advancements in surgical techniques complications like implant failure is very common after the fixation of intertrochanteric fractures. Classifying these complex fractures based on plain radiographs underestimates the complexity of these fractures which in turn leads to complications. We propose a comprehensive classification of the intertrochanteric fractures based on 3D Non Contrast Computed Tomography (3D NCCT) scan. Material and methods: A total of 102 patients (51 males and 51 females) with intertrochanteric fractures were included in this study conducted over a time period of 22 months in a Tertiary care center in North India. NCCT proximal femur of the intertrochanteric fracture patients was done to formulate a new CT classification system and classify all fractures. Intra and inter-observer reliability was tested using kappa variance. Results: New classification system was proposed which included 3 main and a total of 6 groups. All the fractures were classifiable into the new system. Kappa variance of the study showed a good intra and interobserver reliability (0.95 and 0.90) proving clinical agreement of the classification. Conclusion: This new 3D-CT based classification has the advantages of being easy, comprehensible with high intra and inter-observer reliability. This 3DCT based classification can prove to be useful to detect occult intertrochanteric fractures undetectable in plain radiographs as well as choosing the optimum treatment plan.

Sustained improvement in fellows' echocardiographic completeness through the coronavirus pandemic with a standardised imaging protocol.

First-year cardiology fellows must quickly learn basic competency in echocardiography during fellowship orientation. This educational process was disrupted in 2020 due to the coronavirus pandemic, as our hands-on echocardiography teaching transitioned from practice on paediatric volunteers to simulation-based training. We previously described an improvement in echocardiographic completeness after implementation of a standardised imaging protocol for the performance of acute assessments of ventricular function. Herein, we assessed whether this improvement could be sustained over the two subsequent years, including the fellowship year affected by the pandemic. Echocardiograms performed by first-year paediatric cardiology fellows to assess ventricular function were reviewed for completeness. The frequency with which each requested component was included was measured. A total demographic score (out of 7) and total imaging score (out of 23) were calculated. The pre-protocol years (2015-2017) were compared to the post-protocol years (2018-2020), and the pre-COVID years (2018-2019) were compared to the year affected by COVID (2020). There was a sustained improvement in completeness after protocol implementation with improvement in the demographic score (median increasing from 6 to 7, p < 0.001) and imaging score (median increasing from 13 to 16, p < 0.001). More individual components showed a statistically significant increase in frequency compared to our prior publication. The COVID pandemic resulted in very few differences in completeness. Demographic reporting improved modestly (p = 0.04); the imaging score was unchanged (p = 0.59). The only view obtained less frequently was the apical two-chamber view. A standardised imaging protocol allowed sustained improvements in echocardiographic completeness despite the disruption of fellowship orientation by COVID-19.

Left Ventricular Measurements and Strain in Pediatric Patients Evaluated for Systemic Hypertension and the Effect of Adequate Anti-hypertensive Treatment.

Pediatric hypertension (HTN) is an epidemic that is associated with HTN in adulthood and adverse cardiovascular outcomes. We hypothesized that children with HTN would have left ventricular (LV) hypertrophy and abnormal LV global longitudinal strain (GLS) on echocardiogram and that these values would differ by weight, race, and HTN treatment. Data were collected from first visits to the HTN Program from 12/2011 to 9/2018, excluding patients with cardiac disease or heart transplantation. LV measurements including LV mass index (LVMI), LV GLS, and diastolic indices were compared between groups. Multivariable logistic regression was used to identify risk factors for an abnormal LVMI. There were 212 patients with an interquartile age range of 13-18 years. On univariate analysis, LVMI was higher in hypertensive, obese, and African American patients. LV strain was less negative in obese and African American patients. Adequately treated patients with HTN had a higher LVMI and a higher E/e' ratio compared to patients with no HTN. On multivariate analysis, only obesity was associated with an LVMI ≥ 95th percentile (OR 2.9, 95% CI 1.4, 5.8). LVMI is higher in hypertensive, obese, and African American patients; however, in the multivariate analysis, obesity was the only independent risk factor for an abnormal LVMI. LVMI was still higher in those adequately treated for HTN compared to patients without HTN, possibly due to concomitant obesity. Future studies should focus on subclinical changes in LV performance seen in obese and hypertensive patients and the impact on long-term health.

Quantification of Volume Mismatch of Acetabulum and Femoral Head in Developmental Dysplasia of Hip.

Objectives: The sustained subluxation or dislocation of the femoral head over time does not permit normal development of acetabulum and results in predictable pattern of acetabular growth disturbance that is termed hip dysplasia. The primary aim of this study is to analyze and quantify the volume mismatch between acetabulum and femoral head of affected side as compared to normal hip. Methods: A prospective observational study was conducted by including isolated untreated unilateral idiopathic developmental dysplasia of hip (DDH). After routine clinical and radiographic examination, computed tomography (CT) of both hips was done with pre-determined radiation dosage within safe limits for the pediatric age group in 18 patients of median age 2 years (range 1-5 years). Results: A significant difference was noted between acetabular index (p<0.001), acetabular volume (p<0.001), femoral head volume (p<0.001), and acetabular anterior sectoral angle (p=0.002) of the affected and the normal hips. As compared to the normal side, the acetabulum is 2.6 times smaller than the normal side and femoral epiphysis volume by 3.8 times. A significant negative correlation (r=-0.66, p=0.04) was noted between posterior acetabular sectoral angle and acetabular volume of affected hip. Conclusion: CT is an important investigation in evaluation of late-presenting DDH. The absence of femoral head in its orthotopic location affects the volume of acetabulum as well as that of femoral head. The abnormality of the volume of acetabulum which is seen as related to the dysplasia should be studied and assessed in detail in a child of late-presenting DDH. This would guide us toward the coverage defect and type of osteotomy to be performed.

Infection and utilization rates of bone allografts in a hospital-based musculoskeletal tissue bank in north India.

BACKGROUND: The bone bank unit of interest in this article was established in January 2018, in a tertiary care teaching institute of north India. Aim of this article is to describe the sources of allografts obtained, discard rates of allografts and infection rates in the recipients after use. MATERIAL AND METHODS: All the relevant details of donors and recipients were maintained, and donors were screened for standard inclusion and exclusion criteria before obtaining the grafts. Aerobic culture was performed before storage and just prior to use. Samples with incomplete documentation, incomplete donor screening or positive cultures were discarded. Data on surgical site infection in recipients was collected from hospital records retrospectively. Initially ELISA based serological tests were used for screening. Donor has to undergo these tests again after 6 months to account for the window period of proliferation of viruses. Nucleic acid amplification tests (NAAT) for these viral agents were introduced in the hospital in May 2018. RESULTS: Allografts from a total of 196 donors were obtained in the bone bank over 2 years. Major source of bone was femoral heads harvested during total hip arthroplasty or hemi-arthroplasty. 44(22.4%) grafts had to be discarded. 95 allografts were used in 88 patients during this time. Most common indication for use was surgery for bone tumors (40%), followed by complex primary or revision arthroplasty (30.5%). Three (3.4%) recipients developed deep infection postoperatively. CONCLUSION: Frozen allograft bone from hospital based bone banks is a reliable source of allografts. When meticulous precautions for sterility are followed, risk of infection is low. Monitoring of such bone banks should fall within a framework of the local legislature. Incomplete documentation is the major reason for wastage of the samples obtained. NAAT may be useful in screening of donors, as it reduces the wastage and the holding time of the allografts.

Prevalence of Patent Foramen Ovale in a Cohort of Children With Cryptogenic Ischemic Stroke.

BACKGROUND AND OBJECTIVES: To determine the significance of patent foramen ovale (PFO) in childhood stroke, we compared PFO prevalence, PFO features, and stroke recurrence risk in 25 children with cryptogenic arterial ischemic stroke (AIS), 54 children with AIS from a known etiology, and 209 healthy controls. METHODS: We performed a case-control analysis of a 14-year prospectively enrolled single-center cohort of children with AIS who underwent transthoracic echocardiogram (TTE) and compared them to TTEs of otherwise healthy children evaluated for benign cardiac concerns. Stroke patients 29 days to 18 years of age at stroke ictus with confirmed acute AIS on imaging, availability of complete diagnostic studies of stroke risk factors, including TTE images available for central review, and at least 1 follow-up evaluation after index stroke were included. Presence of PFO and high-risk PFO features were assessed by 2 independent, blinded reviewers and compared between groups with the Fisher exact test. Stroke/TIA recurrence risk was determined from Cox proportional hazards models. RESULTS: Of 154 children with first-ever AIS, 79 were eligible; 25 had cryptogenic AIS, and 54 had a known cause. PFO prevalence was higher in the cryptogenic group (7, 28%) compared to both the known stroke etiology group (3, 5.6%, p = 0.009) and controls without stroke (24, 11.5%, p = 0.03). There were no significant differences in presence of right-to-left shunt and atrial septal aneurysm. Median follow-up time for entire stroke cohort was 20.9 months. Stroke-free recurrence at 2-years did not differ between children with and without PFO (HR 2.0, 95% CI 0.4-9.3, p = 0.39). DISCUSSION: PFO prevalence was higher in children with cryptogenic stroke compared to patients with AIS with known etiology and healthy controls. PFO was not associated with increased recurrence risk. Optimal secondary preventive treatment in children with cryptogenic stroke and PFO remains uncertain and requires further study. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that children with cryptogenic ischemic stroke have an increased frequency of PFO compared to children with ischemic stroke of known etiology and healthy controls.

Symptom Interval in Cases of Benign Cystic Lesions of Bone and its correlation with Surgical Intervention.

INTRODUCTION: Benign lesions in bone are less studied in terms of progression and prognosis. There is presently no literature studying symptom interval (SI) in neoplastic bone lesions or determinants of delay in Indian setting. The literature is also sparse on SI in benign lesions of bone, since benign bone lesions have seemingly less menacing symptoms and slow progression as compared to their malignant counterparts. Social and cultural issues peculiar to the region of study have an impact on the symptom interval of benign bony lesions. METHOD: A prospective, observational study was conducted at a tertiary level University teaching hospital from December 2017 to August 2019. The study included 55 patients presenting with benign cystic lesions of bone. Appropriate radiological investigations along with tissue biopsy were done. All the patients were enquired as per a preformed questionnaire to determine the delay and its determinants. RESULT: Out of the 55 patients included in the study, wide variety of cystic lesions was observed with varied presentation and delay. Median SI of 175 days (range 27-3705 days) was observed in the present study. However, it was found that longer SI did not have a statistically significant effect on the type of procedure done (p = 0.206) though diagnostic delay was significantly related to the intervention required (p = 0.004). It was observed that tumor behavior at the time of presentation such as histopathological diagnosis (p = 0.000), presence of cortical breach (p = 0.001), stage of tumor (0.001), and articular involvement (p = 0.000) remained as some of the most important factors in determining the prognosis and outcome in case of benign cystic lesions of bone.

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.

Delivery room care and neonatal resuscitation while on intact placental circulation: an open-label, single-arm study.

OBJECTIVE: To assess feasibility, safety, usability and learnability of delivery room care and resuscitation with intact placental circulation (RIPC) at mother's bedside. MATERIALS AND METHODS: We included neonates ≥24 weeks GA after parental consent. Both in vigorous and babies requiring resuscitation, appropriate steps of resuscitation were provided with intact cord till 3 min using RIPC warmer. Outcomes were assessed by set criteria and standard system usability scale. RESULTS: Of 380 enrolled, intervention was feasible in 376 babies (98.9%). Safety criteria were met in all 376 babies received onto the trolley (100%). Median GA was 38 (37-39) weeks and median BW 2740 (2330-3120) g. Of 376, 92 required resuscitation; 90 (97.8%) PPV, 49 (53.2%) intubations and 13 (14.1%) chest compressions. System Usability Score rated >68 (good) in 90% and 52-68 (fair) in 10%. Temperature at 5 min was 36.5 ± 0.1. CONCLUSIONS: Delivery room care and neonatal RIPC is feasible and safe across gestations.

A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy.

We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.

A Randomized Control Trial of 3 IU IV Oxytocin Bolus with 7 IU Oxytocin Infusion versus 10 IU Oxytocin Infusion During Cesarean Section for Prevention of Postpartum Hemorrhage.

PURPOSE: Oxytocin is the preferred choice for prophylaxis and treatment of postpartum hemorrhage. Intravenous infusion has been a widely accepted route for Oxytocin administration. However, intravenous bolus route is not a readily preferred route due to apprehensions regarding hypotension that it may cause. This trial compares low dose 3 IU intravenous (IV) bolus Oxytocin along with 7 IU Oxytocin in intravenous infusion to 10IU Oxytocin intravenous infusion during cesarean section. PATIENTS AND METHODS: A total of 250 term pregnant women were randomized to either 3 IU intravenous bolus with 7 IU intravenous infusion of Oxytocin or 10IU of intravenous Oxytocin infusion. The difference in pre- and post-operative hemoglobin levels, tone of the uterus, hemodynamic changes, adverse effects of the drug, need for additional uterotonics and need for blood transfusions were assessed. RESULTS: There was 6.7% less blood loss in the 3 IU IV bolus Oxytocin with 7 IU Oxytocin infusion group in comparison to the Oxytocin infusion group. The tone of the uterus was firmer in IV bolus Oxytocin with Oxytocin infusion group at 5 minutes (p<0.001) than the Oxytocin infusion group. There was no significant difference in the hemodynamic changes, adverse effects or need for blood transfusions. CONCLUSION: Intravenous bolus of 3 IU Oxytocin along with 7 IU infusion of Oxytocin is as safe and more effective than intravenous infusion of 10 IU of Oxytocin during cesarean section in the prevention of postpartum hemorrhage.

Echocardiographic strain analysis reflects impaired ventricular function in youth with pediatric-onset systemic lupus erythematosus.

BACKGROUND: Strain analysis with speckle-tracking echocardiography shows promise as a screening tool for silent myocardial dysfunction in pediatric-onset systemic lupus erythematosus (pSLE). We compared left ventricular (LV) systolic deformation (measured by strain) in children and adolescents with pSLE to controls, and assessed the relationship between strain, disease activity, and other noninvasive measures of cardiovascular health. METHODS: Twenty pSLE subjects ages 9-21 underwent comprehensive cardiovascular testing, including 2D speckle-tracking echocardiography, ambulatory blood pressure monitoring (ABPM), peripheral endothelial function testing, pulse wave velocity and analysis, and carotid ultrasound. Longitudinal apical-4 chamber (LSA4C ) and midpoint circumferential strain (CSmid ) were compared to that of 70 healthy controls using multivariable linear regression. Among pSLE subjects, Pearson correlation coefficients were calculated to evaluate relationships between global longitudinal or circumferential strain and other measures of cardiovascular health. RESULTS: Average SLE disease duration was 3.2 years (standard deviation [SD] 2.1). 2/20 pSLE subjects had persistent disease activity, and only one met criteria for hypertension by ABPM. LSA4C was significantly reduced in pSLE subjects compared to controls (mean -18.3 [SD 3.2] vs -21.8% [SD 2.2], P-value <.001). There was no significant difference in CSmid (-24.8 [SD 3.7] vs -25.7% [SD 3.4], P = .29). Among pSLE subjects, decreased nocturnal blood pressure dipping on ABPM was associated with reduced global circumferential strain (r -0.59, P = .01). CONCLUSIONS: Longitudinal myocardial deformation is impaired in pSLE patients despite clinical remission and may represent early myocardial damage. Strain analysis should be considered in addition to standard echocardiographic assessment during follow-up of patients with pSLE.

Pyogenic Vertebral Body Osteomyelitis in a Child: A Case Report.

INTRODUCTION: Pyogenic vertebral body osteomyelitis is rarer in children in comparison to adults. A rare case of pyogenic vertebral body osteomyelitis in a 10-year-old male is presented which was managed conservatively with antibiotics on the basis of antibiogram of blood culture. With 6 weeks of antibiotic therapy and at 12-month follow-up, the patient has no symptoms with no affection of any activity. This should be considered as a differential diagnosis in pediatric patients presenting with atypical symptoms related to spine and hip. CASE REPORT: A 10-year-old child presented with a 7-day history of progressively increasing insidious onset pain in the lower back radiating to the right hip, with an associated limp and restriction of floor level activities and activities of daily living. On examination, the child had tenderness at L3, L4, and L5 vertebral level and normal neurology in both lower limbs. A pseudoflexion deformity 20° was also noted in the right hip with normal range of motion in other planes. Keeping a differential of infective etiology of either hip or spine, routine blood investigations, blood culture, and radiological evaluation were done which included X-rays of lumbosacral spine and hip, ultrasound of bilateral hips and abdomen, and magnetic resonance imaging (MRI) of lumbosacral spine. The blood investigations showed an increase in white blood cell count, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein, with the isolation of methicillin-sensitive Staphylococcus aureus in blood culture. Ultrasonography of hip showed mild effusion in the right hip and collections in the psoas; MRI confirmed the findings with an enhancement of L4 vertebral body. CONCLUSION: Pyogenic vertebral body osteomyelitis is a rare diagnosis in children that should be considered in patients with atypical symptoms. MRI is the investigation of choice with prompt antibiotic therapy instituted on time which leads to healing without any sequelae.

Decreasing Interstage Mortality After the Norwood Procedure: A 30-Year Experience.

Background The superior cavo-pulmonary connection was introduced at our institution in 1988 for infants undergoing surgery for hypoplastic left heart syndrome. Patients with hypoplastic left heart syndrome remain at high risk for mortality in the time period between the Norwood procedure and the superior cavo-pulmonary connection. The primary objectives of this study were to compare interstage mortality across 4 eras and analyze factors that may impact interstage mortality. Methods and Results Patients with hypoplastic left heart syndrome who underwent the Norwood procedure, were discharged from the hospital, and were eligible for superior cavo-pulmonary connection between January 1, 1988, and December 31, 2017, were included. The study period was divided into 4 eras based on changes in operative or medical management. Mortality rates were estimated with 95% CIs. Adjusted and unadjusted logistic regression models were used to identify risk factors for mortality. There were 1111 patients who met the inclusion criteria. Overall, interstage mortality was 120/1111 (10.8%). Interstage mortality was significantly lower in era 4 relative to era 1 (4.6% versus 13.4%; P=0.02) during the time that age at the superior cavo-pulmonary connection was the lowest (135 days; P<0.01) and the interstage monitoring program was introduced. In addition, use of the right ventricle to pulmonary artery shunt was associated with decreased interstage mortality (P=0.02) and was more routinely practiced in era 4. Conclusions During this 30-year experience, the risk of interstage mortality decreased significantly in the most recent era. Factors that coincide with this finding include younger age at superior cavo-pulmonary connection, introduction of an interstage monitoring program, and increased use of the right ventricle to pulmonary artery shunt.

Association of neighborhood-level social determinants and food environments with pediatric hypertension care.

Despite the apparent relationship between neighborhood characteristics and health, few studies of child health address neighborhood-level barriers, which may contribute to clinic no-show rates and difficulties following treatment plans in children and youth. We used longitudinal data from an outpatient hypertension clinic to examine neighborhood social disorganization, built environments, and their associations with patients' clinic attendance and the risk of obesity/hypertension using mixed-effects regression models. Patients from disorganized neighborhoods were less likely to attend a baseline visit, and more likely to develop overweight/obesity and hypertension during follow-up. High-level fast-food expenditures in the neighborhood were associated with higher BMI percentiles and SBP during follow-up.