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Butler SC, Rofeberg V, Smith-Parrish M, LaRonde M, Vittner DJ, Goldberg S, Bailey V, Weeks MM, McCowan S, Severtson K, Glowick K, Rachwal CM. Caring for hearts and minds: a quality improvement approach to individualized developmental care in the cardiac intensive care unit. Front Pediatr 2024; 12:1384615. [PMID: 38655280 PMCID: PMC11037267 DOI: 10.3389/fped.2024.1384615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Infants with congenital heart disease (CHD) are at high risk for developmental differences which can be explained by the cumulative effect of medical complications along with sequelae related to the hospital and environmental challenges. The intervention of individualized developmental care (IDC) minimizes the mismatch between the fragile newborn brain's expectations and the experiences of stress and pain inherent in the intensive care unit (ICU) environment. Methods A multidisciplinary group of experts was assembled to implement quality improvement (QI) to increase the amount of IDC provided, using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), to newborn infants in the cardiac ICU. A Key Driver Diagram was created, PDSA cycles were implemented, baseline and ongoing measurements of IDC were collected, and interventions were provided. Results We collected 357 NIDCAP audits of bedside IDC. Improvement over time was noted in the amount of IDC including use of appropriate lighting, sound management, and developmentally supportive infant bedding and clothing, as well as in promoting self-regulation, therapeutic positioning, and caregiving facilitation. The area of family participation and holding of infants in the CICU was the hardest to support change over time, especially with the most ill infants. Infants with increased medical complexity were less likely to receive IDC. Discussion This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of IDC in the NIDCAP model improved over time using bedside auditing of IDC.
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Affiliation(s)
- Samantha C. Butler
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, United States
- Department of Psychiatry (Psychology), Harvard Medical School, Boston, MA, United States
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Melissa Smith-Parrish
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Meena LaRonde
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University, Fairfield, CT, United States
- Connecticut Children's Medical Center, NICU, Hartford, CT, United States
| | - Sarah Goldberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Valerie Bailey
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Malika M. Weeks
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Sarah McCowan
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Katrina Severtson
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Kerri Glowick
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
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Butler SC, Rofeberg V, Wypij D, Ferreira R, Singer J, Stopp C, Wood L, Ware J, Newburger JW, Sadhwani A. Inpatient Screening for Early Identification of Developmental Risk in Infants with Congenital Heart Defects. J Pediatr 2023; 263:113687. [PMID: 37611735 DOI: 10.1016/j.jpeds.2023.113687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To assess the utility of an inpatient standardized developmental screener for early identification of developmental risk in infants with a congenital heart defect (CHD). STUDY DESIGN This was a retrospective, observational study with convenience sample of postoperative infants with CHD (aged 3-12 months) who underwent neurodevelopmental screening with the Bayley Scales of Infant and Toddler Development Screening Test, Third Edition (Bayley-III Screener) just before discharge. Follow-up testing included outpatient Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) (12-42 mo). RESULTS The Bayley-III Screener was administered to 325 infants at a median of 5 months, 8 days (IQR 3 months, 28 days, to 7 months, 17 days). Infants scored below age expectations on the Gross Motor (79%), Fine Motor (63%), Receptive Communication (50%), Expressive Communication (38%), and Cognitive (38%) domains. In each domain, children with CHD had greater rates of scores below expectations than the normative sample (each P <.001). The odds of scoring in a greater risk category were increased for infants with genetic syndromes and longer length of hospital stay across all domains. The outpatient Bayley-III (n = 74, 23% follow-up) was completed at a median of 19 months, 9 days (IQR: 17 months, 3 days, to 23 months, 37 days). Individuals falling in greater-risk categories on their initial Bayley-III Screener were significantly more likely to have worse performance on their follow-up outpatient Bayley-III (each domain P < .01). CONCLUSIONS Inpatient standardized neurodevelopmental screening provides important clinical utility in identifying infants at risk for developmental concern, allows for provision of recommendations for developmental services, and potentially overcomes barriers often noted in returning for outpatient post-discharge assessments.
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Affiliation(s)
- Samantha C Butler
- Department of Psychiatry and Behavioral Services, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Raquel Ferreira
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jayne Singer
- Department of Psychiatry and Behavioral Services, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Laura Wood
- Department of Psychiatry and Behavioral Services, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Division of General Pediatrics, Intermountain Healthcare, Salt Lake City, UT
| | - Janice Ware
- Department of Psychiatry and Behavioral Services, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Anjali Sadhwani
- Department of Psychiatry and Behavioral Services, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
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Ortinau CM, Wypij D, Ilardi D, Rofeberg V, Miller TA, Donohue J, Reichle G, Seed M, Elhoff J, Alexander N, Allen K, Anton C, Bear L, Boucher G, Bragg J, Butcher J, Chen V, Glotzbach K, Hampton L, Lee CK, Ly LG, Marino BS, Martinez-Fernandez Y, Monteiro S, Ortega C, Peyvandi S, Raiees-Dana H, Rollins CK, Sadhwani A, Sananes R, Sanz JH, Schultz AH, Sood E, Tan A, Willen E, Wolfe KR, Goldberg CS. Factors Associated With Attendance for Cardiac Neurodevelopmental Evaluation. Pediatrics 2023; 152:e2022060995. [PMID: 37593818 PMCID: PMC10530086 DOI: 10.1542/peds.2022-060995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurodevelopmental evaluation of toddlers with complex congenital heart disease is recommended but reported frequency is low. Data on barriers to attending neurodevelopmental follow-up are limited. This study aims to estimate the attendance rate for a toddler neurodevelopmental evaluation in a contemporary multicenter cohort and to assess patient and center level factors associated with attending this evaluation. METHODS This is a retrospective cohort study of children born between September 2017 and September 2018 who underwent cardiopulmonary bypass in their first year of life at a center contributing data to the Cardiac Neurodevelopmental Outcome Collaborative and Pediatric Cardiac Critical Care Consortium clinical registries. The primary outcome was attendance for a neurodevelopmental evaluation between 11 and 30 months of age. Sociodemographic and medical characteristics and center factors specific to neurodevelopmental program design were considered as predictors for attendance. RESULTS Among 2385 patients eligible from 16 cardiac centers, the attendance rate was 29.0% (692 of 2385), with a range of 7.8% to 54.3% across individual centers. In multivariable logistic regression models, hospital-initiated (versus family-initiated) scheduling for neurodevelopmental evaluation had the largest odds ratio in predicting attendance (odds ratio = 4.24, 95% confidence interval, 2.74-6.55). Other predictors of attendance included antenatal diagnosis, absence of Trisomy 21, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, longer postoperative length of stay, private insurance, and residing a shorter distance from the hospital. CONCLUSIONS Attendance rates reflect some improvement but remain low. Changes to program infrastructure and design and minimizing barriers affecting access to care are essential components for improving neurodevelopmental care and outcomes for children with congenital heart disease.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States; Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia, United States
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States
| | - Thomas A. Miller
- Division of Cardiology, Maine Medical Center, Portland, Maine, United States
| | - Janet Donohue
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Garrett Reichle
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Mike Seed
- Department of Paediatrics, Division of Paediatric Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Justin Elhoff
- Department of Pediatrics, Division of Critical Care Medicine, Baylor School of Medicine, Houston, Texas, United States
| | - Nneka Alexander
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Kiona Allen
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Corinne Anton
- Department of Cardiology, Children’s Health, Dallas, Texas, United States; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gina Boucher
- Phoenix Children’s Hospital Heart Center, Phoenix, Arizona, United States
| | - Jennifer Bragg
- Department of Pediatrics, Mount Sinai Hospital, New York, New York, United States
| | - Jennifer Butcher
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Victoria Chen
- Department of Pediatrics, Division of Developmental-Behavioral Pediatrics, Cohen Children’s Medical Center, New Hyde Park, New York, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Kristi Glotzbach
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lyla Hampton
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Caroline K. Lee
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Linh G. Ly
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s, Cleveland, Ohio, United States
| | | | - Sonia Monteiro
- Department of Pediatrics, Baylor School of Medicine, Houston, Texas, United States
| | - Christina Ortega
- Department of Psychology, Joe DiMaggio Children’s Hospital, Hollywood, Florida, United States
| | - Shabnam Peyvandi
- University of California San Francisco Benioff Children’s Hospital, San Francisco, California, United States
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Neurology, Harvard Medical School, Boston, Massachusetts, United States
| | - Anjali Sadhwani
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Renee Sananes
- Department of Psychology, Division of Cardiology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital; Departments of Psychiatry and Behavioral Sciences & Pediatrics, The George Washington University School of Medicine, Washington D.C., United States
| | - Amy H. Schultz
- Division of Cardiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, United States
| | - Erica Sood
- Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware, United States; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Alexander Tan
- Department of Neuropsychology, Children’s Health Orange County, Orange, California, United States
| | - Elizabeth Willen
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Kelly R. Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Caren S. Goldberg
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
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Trowbridge SK, Condie LO, Landers JR, Bergin AM, Grant PE, Krishnamoorthy K, Rofeberg V, Wypij D, Staley KJ, Soul JS. Effect of neonatal seizure burden and etiology on the long-term outcome: data from a randomized, controlled trial. Ann Child Neurol Soc 2023; 1:53-65. [PMID: 37636014 PMCID: PMC10449023 DOI: 10.1002/cns3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/11/2022] [Indexed: 08/29/2023]
Abstract
Background Neonatal seizures are common, but the impact of neonatal seizures on long-term neurologic outcome remains unclear. We addressed this question by analyzing data from an early-phase controlled trial of bumetanide to treat neonatal seizures. Methods Neonatal seizure burden was calculated from continuous video-EEG data. Neurologic outcome was determined by standardized developmental tests and post-neonatal seizure recurrence. Results Of 111 enrolled neonates, 43 were randomized to treatment or control groups. There were no differences in neurologic outcome between treatment and control groups. A subgroup analysis was performed for 84 neonates with acute perinatal brain injury (57 HIE, 18 stroke, 9 ICH), most of whom (70%) had neonatal seizures. There was a significant negative correlation between seizure burden and developmental scores (p<0.01). Associations between seizure burden and developmental scores were stronger in HIE and stroke groups compared with ICH (p<0.05). Conclusion Bumetanide showed no long-term beneficial or adverse effects, as expected based on treatment duration versus duration of neonatal seizures. For neonates with perinatal brain injury, higher neonatal seizure burden correlated significantly with worse developmental outcome, particularly for ischemic versus hemorrhagic brain injury. These data highlight the need for further investigation of the long-term effects of both neonatal seizure severity and etiology.
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Affiliation(s)
- Sara K. Trowbridge
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Lois O. Condie
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jessica R. Landers
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ann M. Bergin
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Patricia E. Grant
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | | | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
| | - David Wypij
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Kevin J. Staley
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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Majeed A, Rofeberg V, Bellinger DC, Wypij D, Newburger JW. Machine Learning to Predict Executive Function in Adolescents with Repaired d-Transposition of the Great Arteries, Tetralogy of Fallot, and Fontan Palliation. J Pediatr 2022; 246:145-153. [PMID: 35314155 DOI: 10.1016/j.jpeds.2022.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To identify predictors of impaired executive function in adolescents after surgical repair of critical congenital heart disease (CHD). STUDY DESIGN We analyzed patient factors, medical and surgical history, and family social class from 3 single-center studies of adolescents with d-transposition of the great arteries (d-TGA), tetralogy of Fallot (TOF), and Fontan repair. Machine learning models were developed using recursive partitioning to predict an executive function composite score based on five subtests (population mean 10, SD 3) of the Delis-Kaplan Executive Function System. RESULTS The sample included 386 patients (139 d-TGA, 91 TOF, 156 Fontan) of age 15.1 ± 2.1 (mean ± SD) years and an executive function composite score of 8.6 ± 2.4. Family social class emerged as the most important predictive factor. The lowest (worst) mean executive function score (5.3) occurred in patients with low to medium social class (Hollingshead index <56) with one or more neurologic events and a diagnosis of TOF. The highest (best) mean score (9.7) occurred in subjects with high social class (Hollingshead index ≥56) and shorter duration of deep hypothermic circulatory arrest. Other factors predicting lower executive function scores included low birth weight and a greater number of catheterizations. CONCLUSIONS In regression tree modeling, family social class was the strongest predictor of executive function in adolescents with critical CHD, even in the presence of medical risk factors. Additional predictors included CHD diagnosis, birth weight, neurologic events, and number of procedures. These data highlight the importance of social class in mitigating risks of executive dysfunction in CHD.
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Affiliation(s)
- Amara Majeed
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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Butler SC, Sadhwani A, Rofeberg V, Cassidy AR, Singer J, Calderon J, Wypij D, Newburger JW, Rollins CK. Neurological features in infants with congenital heart disease. Dev Med Child Neurol 2022; 64:762-770. [PMID: 34921736 PMCID: PMC9086097 DOI: 10.1111/dmcn.15128] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
Abstract
AIM To report neurological examination findings at 5 to 12 months of age in infants with congenital heart disease (CHD) and to identify predictors of abnormal neurological examination. METHOD This retrospective observational study included infants who required cardiac surgery at less than 3 months of age and underwent a standard neurological examination from a neurologist in the cardiac neurodevelopmental outpatient clinic between age 5 months and 12 months. Predictors for abnormal neurological examination (concerns on structured developmental history, demographic factors, medical history, and newborn neurodevelopmental assessment) were considered for multivariate regression. RESULTS The sample included 127 infants (mean age 7mo 2wks), who underwent first cardiac surgery at 7 days (4-49 interquartile range [IQR]) of age and were seen for a neurological examination in the cardiac neurodevelopmental clinic. Neurological abnormalities were common; 88% of infants had an abnormal neurological examination in at least one domain assessed. The most common abnormalities were abnormal axial (48%) and extremity (44%) tone, mostly hypotonia. Abnormal neurological examination was associated with concerns on the concurrent structured developmental history, genetic condition, extracardiac anomaly, longer length of stay, more than one cardiac surgery, ongoing early intervention services, and abnormalities on newborn neurodevelopmental assessment. INTERPRETATION Neurological examination abnormalities are common in infants with CHD after infant heart surgery, supporting the need for early and ongoing therapeutic developmental services and adherence to American Heart Association recommendations for developmental follow-up for children with CHD. What this paper adds Neurological examination abnormalities are common in infants who undergo open-heart surgery. Medical complications in infancy increase risk for neurological abnormalities. Family-reported concerns on structured developmental history may predict abnormal neurological examination at 5 to 12 months of age. Abnormal newborn neurodevelopmental assessment may predict abnormal neurological examination at 5 to 12 months of age.
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Affiliation(s)
- Samantha C Butler
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Anjali Sadhwani
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Adam R Cassidy
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jayne Singer
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Johanna Calderon
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
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7
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Sadhwani A, Wypij D, Rofeberg V, Gholipour A, Mittleman M, Rohde J, Velasco-Annis C, Calderon J, Friedman KG, Tworetzky W, Grant PE, Soul JS, Warfield SK, Newburger JW, Ortinau CM, Rollins CK. Fetal Brain Volume Predicts Neurodevelopment in Congenital Heart Disease. Circulation 2022; 145:1108-1119. [PMID: 35143287 PMCID: PMC9007882 DOI: 10.1161/circulationaha.121.056305] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is common in children with congenital heart disease (CHD), but postnatal variables explain only 30% of the variance in outcomes. To explore whether the antecedents for neurodevelopmental disabilities might begin in utero, we analyzed whether fetal brain volume predicted subsequent neurodevelopmental outcome in children with CHD. METHODS Fetuses with isolated CHD and sociodemographically comparable healthy control fetuses underwent fetal brain magnetic resonance imaging and 2-year neurodevelopmental evaluation with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and the Adaptive Behavior Assessment System, Third Edition (ABAS-3). Hierarchical regression evaluated potential predictors of Bayley-III and ABAS-3 outcomes in the CHD group, including fetal total brain volume adjusted for gestational age and sex, sociodemographic characteristics, birth measures, and medical history. RESULTS The CHD group (n=52) had lower Bayley-III cognitive, language, and motor scores than the control group (n=26), but fetal brain volumes were similar. Within the CHD group, larger fetal total brain volume correlated with higher Bayley-III cognitive, language, and motor scores and ABAS-3 adaptive functioning scores (r=0.32-0.47; all P<0.05), but this was not noted in the control group. Fetal brain volume predicted 10% to 21% of the variance in neurodevelopmental outcome measures in univariate analyses. Multivariable models that also included social class and postnatal factors explained 18% to 45% of the variance in outcome, depending on developmental domain. Moreover, in final multivariable models, fetal brain volume was the most consistent predictor of neurodevelopmental outcome across domains. CONCLUSIONS Small fetal brain volume is a strong independent predictor of 2-year neurodevelopmental outcomes and may be an important imaging biomarker of future neurodevelopmental risk in CHD. Future studies are needed to support this hypothesis. Our findings support inclusion of fetal brain volume in risk stratification models and as a possible outcome in fetal neuroprotective intervention studies.
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Affiliation(s)
- Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | | | - Julia Rohde
- Department of Neurology, Boston Children’s Hospital, Boston, MA
| | | | - Johanna Calderon
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - P. Ellen Grant
- Department of Radiology, Boston Children’s Hospital, Boston, MA
- Department of Radiology, Harvard Medical School, Boston, MA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| | | | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
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Soul JS, Bergin AM, Stopp C, Hayes B, Singh A, Fortuno CR, O'Reilly D, Krishnamoorthy K, Jensen FE, Rofeberg V, Dong M, Vinks AA, Wypij D, Staley KJ. A Pilot Randomized, Controlled, Double-Blind Trial of Bumetanide to Treat Neonatal Seizures. Ann Neurol 2021; 89:327-340. [PMID: 33201535 PMCID: PMC8122513 DOI: 10.1002/ana.25959] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE In the absence of controlled trials, treatment of neonatal seizures has changed minimally despite poor drug efficacy. We tested bumetanide added to phenobarbital to treat neonatal seizures in the first trial to include a standard-therapy control group. METHODS A randomized, double-blind, dose-escalation design was employed. Neonates with postmenstrual age 33 to 44 weeks at risk of or with seizures were eligible. Subjects with electroencephalography (EEG)-confirmed seizures after ≥20 and <40mg/kg phenobarbital were randomized to receive additional phenobarbital with either placebo (control) or 0.1, 0.2, or 0.3mg/kg bumetanide (treatment). Continuous EEG monitoring data from ≥2 hours before to ≥48 hours after study drug administration (SDA) were analyzed for seizures. RESULTS Subjects were randomized to treatment (n = 27) and control (n = 16) groups. Pharmacokinetics were highly variable among subjects and altered by hypothermia. The only statistically significant adverse event was diuresis in treated subjects (48% vs 13%, p = 0.02). One treated (4%) and 3 control subjects died (19%, p = 0.14). Among survivors, 2 of 26 treated subjects (8%) and 0 of 13 control subjects had hearing impairment, as did 1 nonrandomized subject. Total seizure burden varied widely, with much higher seizure burden in treatment versus control groups (median = 3.1 vs 1.2 min/h, p = 0.006). There was significantly greater reduction in seizure burden 0 to 4 hours and 2 to 4 hours post-SDA (both p < 0.01) compared with 2-hour baseline in treatment versus control groups with adjustment for seizure burden. INTERPRETATION Although definitive proof of efficacy awaits an appropriately powered phase 3 trial, this randomized, controlled, multicenter trial demonstrated an additional reduction in seizure burden attributable to bumetanide over phenobarbital without increased serious adverse effects. Future trials of bumetanide and other drugs should include a control group and balance seizure severity. ANN NEUROL 2021;89:327-340.
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Affiliation(s)
- Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ann M Bergin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Breda Hayes
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Avantika Singh
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carmen R Fortuno
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deirdre O'Reilly
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kalpathy Krishnamoorthy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Frances E Jensen
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin J Staley
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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9
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Calderon J, Wypij D, Rofeberg V, Stopp C, Roseman A, Albers D, Newburger JW, Bellinger DC. Randomized Controlled Trial of Working Memory Intervention in Congenital Heart Disease. J Pediatr 2020; 227:191-198.e3. [PMID: 32827526 DOI: 10.1016/j.jpeds.2020.08.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the efficacy of Cogmed Working Memory Training compared with the standard of care to improve executive function and social outcomes in adolescents with congenital heart disease (CHD) who underwent open-heart surgery in infancy and to identify factors associated with changes in outcomes following the intervention. STUDY DESIGN In a single-center, randomized controlled trial, adolescents (13-16 years) with CHD were randomly assigned to either Cogmed (home-based 45-minutes sessions for 5-8 weeks) or to a control group. The primary outcome was working memory. Secondary outcomes included inhibitory control and cognitive flexibility as well as parent-reported executive function, symptoms of attention deficit hyperactivity disorder, and social outcomes. All measures were assessed at baseline, post-treatment (1-3 weeks post-training) and at 3-month follow-up. Data were analyzed using an intention-to-treat approach. RESULTS Sixty adolescents with CHD participated (28 assigned to Cogmed). No improvement at the post-treatment or 3-month follow-up assessments was found for the primary outcome measure of working memory. Compared with the control group, participants assigned to the intervention demonstrated benefits in inhibitory control and attention at the 3-month follow-up (P = .02) and in parent-reported cognitive regulatory skills at post-treatment and 3-month follow-up (P = .02 and P = .04, respectively). Preterm birth, biventricular CHD, and history of attention deficit hyperactivity disorder diagnosis were associated with improved response to the intervention. CONCLUSIONS Cogmed intervention produced improvements in the self-regulatory control abilities of adolescents with CHD. The training did not enhance other areas of executive function or behavioral outcomes. Further studies are needed to evaluate the longer-term potential benefits to other domains. TRIAL REGISTRATION Clinicaltrials.gov: NCT02759263.
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Affiliation(s)
- Johanna Calderon
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | - Daniel Albers
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David C Bellinger
- Department of Psychiatry, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Harvard Medical School, Boston, MA
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10
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Rollins CK, Ortinau CM, Stopp C, Friedman KG, Tworetzky W, Gagoski B, Velasco-Annis C, Afacan O, Vasung L, Beaute JI, Rofeberg V, Estroff JA, Grant PE, Soul JS, Yang E, Wypij D, Gholipour A, Warfield SK, Newburger JW. Regional Brain Growth Trajectories in Fetuses with Congenital Heart Disease. Ann Neurol 2020; 89:143-157. [PMID: 33084086 DOI: 10.1002/ana.25940] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Congenital heart disease (CHD) is associated with abnormal brain development in utero. We applied innovative fetal magnetic resonance imaging (MRI) techniques to determine whether reduced fetal cerebral substrate delivery impacts the brain globally, or in a region-specific pattern. Our novel design included two control groups, one with and the other without a family history of CHD, to explore the contribution of shared genes and/or fetal environment to brain development. METHODS From 2014 to 2018, we enrolled 179 pregnant women into 4 groups: "HLHS/TGA" fetuses with hypoplastic left heart syndrome (HLHS) or transposition of the great arteries (TGA), diagnoses with lowest fetal cerebral substrate delivery; "CHD-other," with other CHD diagnoses; "CHD-related," healthy with a CHD family history; and "optimal control," healthy without a family history. Two MRIs were obtained between 18 and 40 weeks gestation. Random effect regression models assessed group differences in brain volumes and relationships to hemodynamic variables. RESULTS HLHS/TGA (n = 24), CHD-other (50), and CHD-related (34) groups each had generally smaller brain volumes than the optimal controls (71). Compared with CHD-related, the HLHS/TGA group had smaller subplate (-13.3% [standard error = 4.3%], p < 0.01) and intermediate (-13.7% [4.3%], p < 0.01) zones, with a similar trend in ventricular zone (-7.1% [1.9%], p = 0.07). These volumetric reductions were associated with lower cerebral substrate delivery. INTERPRETATION Fetuses with CHD, especially those with lowest cerebral substrate delivery, show a region-specific pattern of small brain volumes and impaired brain growth before 32 weeks gestation. The brains of fetuses with CHD were more similar to those of CHD-related than optimal controls, suggesting genetic or environmental factors also contribute. ANN NEUROL 2021;89:143-157.
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Affiliation(s)
- Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Departments of Neurology, Harvard Medical School, Boston, MA, USA
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Borjan Gagoski
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | | | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Lana Vasung
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jeanette I Beaute
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Judy A Estroff
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - P Ellen Grant
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Departments of Neurology, Harvard Medical School, Boston, MA, USA.,Maternal Fetal Care Center, Boston Children's Hospital, Boston, MA, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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11
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Jaimes C, Rofeberg V, Stopp C, Ortinau CM, Gholipour A, Friedman KG, Tworetzky W, Estroff J, Newburger JW, Wypij D, Warfield SK, Yang E, Rollins CK. Association of Isolated Congenital Heart Disease with Fetal Brain Maturation. AJNR Am J Neuroradiol 2020; 41:1525-1531. [PMID: 32646947 DOI: 10.3174/ajnr.a6635] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Brain MRI of newborns with congenital heart disease show signs of immaturity relative to healthy controls. Our aim was to determine whether the semiquantitative fetal total maturation score can detect abnormalities in brain maturation in fetuses with congenital heart disease in the second and third trimesters. MATERIALS AND METHODS We analyzed data from a prospective study of fetuses with and without congenital heart disease who underwent fetal MR imaging at 25-35 weeks' gestation. Two independent neuroradiologists blinded to the clinical data reviewed and scored all images using the fetal total maturation score. Interrater reliability was evaluated by the intraclass correlation coefficient using the individual reader scores, which were also used to calculate an average score for each subject. Comparisons of the average and individual reader scores between affected and control fetuses and relationships with clinical variables were evaluated using multivariable linear regression. RESULTS Data from 69 subjects (48 cardiac, 21 controls) were included. High concordance was observed between readers with an intraclass correlation coefficient of 0.98 (95% CI, 0.97-0.99). The affected group had significantly lower fetal total maturation scores than the control group (β-estimate, -0.9 [95% CI, -1.5 to -0.4], P = .002), adjusting for gestational age and sex. Averaged fetal total maturation, germinal matrix, myelination, and superior temporal sulcus scores were significantly delayed in fetuses with congenital heart disease versus controls (P < .05 for each). The fetal total maturation score was not significantly associated with any cardiac, anatomic, or physiologic variables. CONCLUSIONS The fetal total maturation score is sensitive to differences in brain maturation between fetuses with isolated congenital heart disease and healthy controls.
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Affiliation(s)
- C Jaimes
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - V Rofeberg
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts
| | - C Stopp
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts
| | - C M Ortinau
- Pediatrics (C.M.O.), Washington University in St. Louis, St. Louis, Missouri
| | - A Gholipour
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - K G Friedman
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - W Tworetzky
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - J Estroff
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - J W Newburger
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - D Wypij
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts.,Biostatistics (D.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - S K Warfield
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - E Yang
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts.,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
| | - C K Rollins
- From the Departments of Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Cardiology (V.R., C.S., K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Fetal-Neonatal Neuroimaging and Developmental Science Center (C.J.), Boston Children's Hospital, Boston, Massachusetts .,Radiology (C.J., A.G., J.E., S.K.W., E.Y.), Pediatrics (K.G.F., W.T., J.W.N., D.W.), Neurology (C.K.R.), Harvard Medical School, Boston, Massachusetts
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Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Balk EM, Gordon CE, Earley A, Rofeberg V, Knoll GA. Summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2020; 104:708-714. [PMID: 32224812 PMCID: PMC7147399 DOI: 10.1097/tp.0000000000003137] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 11/25/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence. The strengths of recommendations are provided in the full report. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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Affiliation(s)
- Steven J Chadban
- Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Curie Ahn
- Seoul National University, Seoul, South Korea
| | | | - Bethany J Foster
- The Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | | | - Vijah Kher
- Medanta Kidney and Urology Institute, Haryana, India
| | - Deepali Kumar
- University Health Network, University of Toronto, Toronto, Canada
| | | | | | | | | | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Ethan M Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | | | | | - Valerie Rofeberg
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Gregory A Knoll
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada
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13
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Lima FV, Kolte D, Rofeberg V, Molino J, Zhang Z, Elmariah S, Aronow HD, Abbott JD, Ben Assa E, Khera S, Gordon PC, Inglessis I, Palacios IF. Thirty-day readmissions after transcatheter versus surgical mitral valve repair in high-risk patients with mitral regurgitation: Analysis of the 2014-2015 Nationwide readmissions databases. Catheter Cardiovasc Interv 2019; 96:664-674. [PMID: 31868999 DOI: 10.1002/ccd.28647] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/25/2019] [Accepted: 12/07/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Determine the rates, reasons, predictors, and costs of 30-day readmissions following transcatheter mitral valve repair (TMVR) versus surgical mitral valve repair (SMVR) in the United States. BACKGROUND Data on 30-day readmissions after TMVR are limited. METHODS High-risk patients with mitral regurgitation (MR) undergoing TMVR or SMVR were identified from the 2014-2015 Nationwide Readmissions Databases. Multivariable stepwise regression models were used to identify independent predictors of 30-day readmission. Risk of 30-day readmission was compared between the two groups using univariate and propensity score adjusted regression models. RESULTS Among 8,912 patients undergoing mitral valve repair during 2014-2015 (national estimate 17,809), we identified 7,510 (84.7%) that underwent SMVR and 1,402 (15.3%) that underwent TMVR. Thirty-day readmission rates after SMVR and TMVR were 10.7% and 11.7%, respectively (unadjusted OR 1.11, 95% CI 0.89-1.39, p = .35). After propensity score adjustment, TMVR was associated with a lower risk of 30-day readmissions compared with SMVR (adjusted OR 0.70, 95% CI 0.51-0.95, p = .02). Heart failure and arrhythmias were the leading cardiac reasons for readmission. Anemia and fluid and electrolyte disorder were independent predictors of 30-day readmission after TMVR. Demographics, comorbidities, and length of stay were independent predictors of 30-day readmission after SMVR. CONCLUSIONS One in 10 patients are readmitted within 30 days following TMVR or SMVR. Approximately half of the readmissions are for cardiac reasons. The predictors of 30-day readmission are different among patients undergoing TMVR and SMVR, but can be easily screened for to identify patients at highest risk for readmission.
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Affiliation(s)
- Fabio V Lima
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dhaval Kolte
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Valerie Rofeberg
- Center for Evidence Synthesis in Health, School of Public Health of Brown University, Providence, Rhode Island
| | - Janine Molino
- Lifespan Biostatistics Core, Rhode Island Hospital, Providence, Rhode Island
| | - Zheng Zhang
- Department of Biostatistics, School of Public Health of Brown University, Providence, Rhode Island
| | - Sammy Elmariah
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Herbert D Aronow
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eyal Ben Assa
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahil Khera
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul C Gordon
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ignacio Inglessis
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Igor F Palacios
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Springs S, Rofeberg V, Brown S, Boudreau S, Hey SP, Baruch J. Community-engaged Evidence Synthesis to Inform Public Health Policy and Clinical Practice: A Case Study. Med Care 2019; 57 Suppl 10 Suppl 3:S253-S258. [PMID: 31517796 PMCID: PMC6749975 DOI: 10.1097/mlr.0000000000001180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND This case study documents the work of the Rhode Island Arts and Health Advisory Group, which convened in 2016 to develop a set of policy, clinical practice, and research recommendations for implementation by the Rhode Island Department of Health, The Rhode Island State Council on the Arts, and partners. Comprised of artists, clinicians, community members, and patients, the group partnered with researchers to complete an evidence synthesis project of arts-based health care interventions. METHODS The group took a community-engaged approach to evidence synthesis, featuring the use of online, and in-person training materials to facilitate the codesign and coexecution of the evidence synthesis protocol. The final evidence map was translated into an online evidence map to facilitate analysis and discussion on arts-based interventions in health care. RESULTS The evidence map informed the development of recommendations for advancing the integration of arts and health in the state. The project evaluation indicated that our community-engaged approach to evidence synthesis promoted engagement as defined by the PCORI Engagement Strategy Rubric (ie, reciprocal relationships, partnership, colearning, transparency, honesty, and trust). Participation also improved community research partners confidence in engaging with the health care system, developed greater empathy and understanding of others in the community, and increased interest in using science or research in advocacy efforts. CONCLUSIONS Engaging community partners in evidence synthesis promotes community dialogue and engagement in research, specifically towards: (1) elucidating outcomes of import to patients and communities that are not represented in the medical literature; and (2) identifying comparisons among interventions that resonate with patients and communities.
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Affiliation(s)
- Stacey Springs
- Center for Evidence Synthesis in Health, Brown University School of Public Health
- Swearer Center for Public Service, Brown University
| | - Valerie Rofeberg
- Center for Evidence Synthesis in Health, Brown University School of Public Health
| | | | | | - Spencer Phillips Hey
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women’s Hospital
- Center for Bioethics, Harvard Medical School, Boston, MA
| | - Jay Baruch
- Alpert Medical School of Brown University, Providence, RI
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Drucker AM, Adam GP, Rofeberg V, Gazula A, Smith B, Moustafa F, Weinstock MA, Trikalinos TA. Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Network Meta-analysis. Ann Intern Med 2018; 169:456-466. [PMID: 30242379 DOI: 10.7326/m18-0678] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most interventions for basal cell carcinoma (BCC) have not been compared in head-to-head randomized trials. PURPOSE To evaluate the comparative effectiveness and safety of treatments of primary BCC in adults. DATA SOURCES English-language searches of MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase from inception to May 2018; reference lists of guidelines and systematic reviews; and a search of ClinicalTrials.gov in August 2016. STUDY SELECTION Comparative studies of treatments currently used in adults with primary BCC. DATA EXTRACTION One investigator extracted data on recurrence, histologic clearance, clinical clearance, cosmetic outcomes, quality of life, and mortality, and a second reviewer verified extractions. Several investigators evaluated risk of bias for each study. DATA SYNTHESIS Forty randomized trials and 5 nonrandomized studies compared 18 interventions in 9 categories. Relative intervention effects and mean outcome frequencies were estimated using frequentist network meta-analyses. Estimated recurrence rates were similar for excision (3.8% [95% CI, 1.5% to 9.5%]), Mohs surgery (3.8% [CI, 0.7% to 18.2%]), curettage and diathermy (6.9% [CI, 0.9% to 36.6%]), and external-beam radiation (3.5% [CI, 0.7% to 16.8%]). Recurrence rates were higher for cryotherapy (22.3% [CI, 10.2% to 42.0%]), curettage and cryotherapy (19.9% [CI, 4.6% to 56.1%]), 5-fluorouracil (18.8% [CI, 10.1% to 32.5%]), imiquimod (14.1% [CI, 5.4% to 32.4%]), and photodynamic therapy using methyl-aminolevulinic acid (18.8% [CI, 10.1% to 32.5%]) or aminolevulinic acid (16.6% [CI, 7.5% to 32.8%]). The proportion of patients reporting good or better cosmetic outcomes was better for photodynamic therapy using methyl-aminolevulinic acid (93.8% [CI, 79.2% to 98.3%]) or aminolevulinic acid (95.8% [CI, 84.2% to 99.0%]) than for excision (77.8% [CI, 44.8% to 93.8%]) or cryotherapy (51.1% [CI, 15.8% to 85.4%]). Data on quality of life and mortality were too sparse for quantitative synthesis. LIMITATION Data are sparse, and effect estimates are imprecise and informed by indirect comparisons. CONCLUSION Surgical treatments and external-beam radiation have low recurrence rates for the treatment of low-risk BCC, but substantial uncertainty exists about their comparative effectiveness versus other treatments. Gaps remain regarding high-risk BCC subtypes and important outcomes, including costs. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42016043353).
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Affiliation(s)
- Aaron M Drucker
- Alpert Medical School of Brown University, Providence, Rhode Island, and University of Toronto and Women's College Hospital, Toronto, Ontario, Canada (A.M.D.)
| | - Gaelen P Adam
- Brown University School of Public Health, Providence, Rhode Island (G.P.A., V.R., A.G., B.S., T.A.T.)
| | - Valerie Rofeberg
- Brown University School of Public Health, Providence, Rhode Island (G.P.A., V.R., A.G., B.S., T.A.T.)
| | - Abhilash Gazula
- Brown University School of Public Health, Providence, Rhode Island (G.P.A., V.R., A.G., B.S., T.A.T.)
| | - Bryant Smith
- Brown University School of Public Health, Providence, Rhode Island (G.P.A., V.R., A.G., B.S., T.A.T.)
| | - Farah Moustafa
- Alpert Medical School of Brown University, Providence, Rhode Island (F.M., M.A.W.)
| | - Martin A Weinstock
- Alpert Medical School of Brown University, Providence, Rhode Island (F.M., M.A.W.)
| | - Thomas A Trikalinos
- Brown University School of Public Health, Providence, Rhode Island (G.P.A., V.R., A.G., B.S., T.A.T.)
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