The Impact of Morbidities Following Pediatric Cardiac Surgery on Family Functioning and Parent Quality of Life

We previously selected and defined nine important post-operative morbidities linked to paediatric cardiac surgery, and prospectively measured their incidence following 3090 consecutive operations. Our aim was to study the impact of these morbidities on family functioning and parental quality of life over 6 months in a subset of cases. As part of a prospective case matched study in five of the ten children's cardiac centers in the UK, we compared outcomes for parents of children who had a 'single morbidity', 'multiple morbidities', 'extracorporeal life support (ECLS)' or 'no morbidity'. Outcomes were evaluated using the PedsQL Family impact module (FIM) at 6 weeks and 6 months post-surgery. Outcomes were modelled using mixed effects regression, with adjustment for case mix and clustering within centers. We recruited 340 patients with morbidity (60% of eligible patients) and 326 with no morbidity over 21 months. In comparison to the reference group of 'no morbidity', after adjustment for case mix, at 6 weeks parent health-related quality of life (HRQoL) and total FIM sores were lower (worse) only for ECLS (p < 0.005), although a higher proportion of parents in both the ECLS and multi-morbidity groups had low/very low scores (p < .05). At 6 months, parent outcomes had improved for all groups but parent HRQoL and total score for ECLS remained lower than the 'no morbidity' group (p < .05) and a higher proportion of families had low or very low scores in the ECLS (70%) group (p < .01). Post-operative morbidities impact parent HRQoL and aspects of family functioning early after surgery, with this impact lessening by 6 months. Families of children who experience post-operative morbidities should be offered timely psychological support.

The Relationship Between Postoperative Complications and Children's Quality of Life: A Mediation Analysis to Explore the Role of Family Factors

OBJECTIVES

To explore whether postoperative morbidities after pediatric cardiac surgery affected children's health-related quality of life (HRQOL) at 6 months, through potentially modifiable parental psychological factors.

DESIGN

We undertook a mediation analysis, to explore the causal pathway, based on data from a prospective, case-matched cohort study.

PATIENTS

Six hundred sixty-six children undergoing cardiac surgery.

SETTING

Five centers in the United Kingdom.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

Cases of morbidity were identified early after pediatric cardiac surgery, and matched controls with no morbidities were identified at discharge. Four mediators were assessed at 6 weeks after surgery, using the PedsQL Family Impact Module (Parent HRQOL and Family Function) and the PHQ-4 (Anxiety and Depression). The study outcome of child HRQOL was assessed at 6 months with the PedsQL. Of 666 children, 408 (65% of those surviving) contributed to the primary outcome. Children who had extracorporeal life support (ECLS) ( n = 11) ( p < 0.05) and multiple morbidities ( n = 62) ( p < 0.01) had worse 6-month HRQOL than those with a single morbidity ( n = 125) or no morbidity ( n = 209). After adjustment for case mix complexity and sociodemographic variables, there were significant indirect effects of parent HRQOL at 6 weeks, on the PedsQL Total Score (ECLS, -5.1 [-8.4 to -1.8]; p = 0.003; multiple morbidities, -2.1 [-3.7 to -0.5]; p = 0.01), PedsQL Physical Score (ECLS, -5.1 [-8.7 to -1.4]; p = 0.007; multiple morbidities, -2.1 [-3.8 to -0.4]; p = 0.016), and PedsQL Psychosocial Score (ECLS: -5.3 [-8.7 to -1.8); p = 0.003; multiple morbidities, -2.2 [-3.9 to -0.5]; p = 0.01). The proportion of the total effect of ECLS and multiple morbidity on the study outcomes mediated through parent HRQOL ranges between 18% and 61%. There was no evidence that the other three mediators had indirect effects on the study outcome.

CONCLUSIONS

Parental HRQOL at 6 weeks after surgery contributes to child HRQOL at 6 months, among those with the severest types of morbidity, and as such should be a target for future interventions.

AB0501 COMPREHENSIVE ASSESSMENT OF PATIENTS WITH SUSPECTED SJÖGREN’S SYNDROME: 5-YEAR RESULTS OF A MULTIDISCIPLINARY SJÖGREN’S SYNDROME CLINIC

Background

Primary Sjögren’s syndrome (pSS) is a systemic rheumatic disease that affects several organ systems, most frequently the ocular, oral and musculoskeletal domains. Multidisciplinary care is thus crucial in the optimal management of SS patients.

Objectives

To report the clinical impact of a Multidisciplinary SS Clinic (MSSC) over a 5-year period.

Methods

We prospectively included patients assessed in the MSSC from September 2015 to October 2020. All patients had a full clinical evaluation, including disease-related questionnaires, specialized oral/ocular assessment, salivary gland biopsy (SGB) and ultrasound (SGUS), tear and salivary flow and ocular staining scores. We compared the results of patient-reported outcomes, comprehensive clinical assessments and specialized complementary exams in patients with pSS and other diagnoses.

Results

445 patients (96% women, mean age 57±14 years) with sicca symptoms underwent complete multidisciplinary evaluation. Patients were most frequently referred from Rheumatology (91%), but also from Stomatology (5%), Ophthalmology (2%), Internal Medicine (1%) and other medical specialties (1%). Most patients were diagnosed with pSS (n=221; 50%), followed by non-Sjögren sicca syndrome (nSSS, n=134; 30%), secondary SS (sSS, n=60; 13%) and undifferentiated connective tissue disease (n=30; 7%). Positive sicca tests were present in 217/385 patients (56%): unstimulated whole salivary flow (UWSF) ≤0.1ml/min in 84/317 (27%); Schirmer’s test ≤5mm/5min in 163/354 (46%); van Bijsterveld score ≥4 in 42/349 (12%); Ocular Staining Score (OSS) ≥5 in 36/343 (11%). Subjective complaints assessed by the EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI), the EULAR Sicca Score (ESS), the Profile of Fatigue and Discomfort - Sicca Symptoms Inventory (PROFAD-SSI), the Xerostomia Inventory (XI), and the Ocular Surface Disease Index (OSDI) did not differ between patients with pSS and other diagnoses. However, objective dryness measures such as UWSF (31vs20%, p=0.028), Schirmer’s test (51vs40%, p=0.040) and OSS (14vs7%, p=0.048) were significantly associated with pSS. A positive SGB (focus score≥1) was seen in 48% of patients with a clinical diagnosis of pSS (p<0.001 vs. other diagnoses), with a mean focus score of 1.1±1.6. Instead, 94% of patients with nSSS had grade 0-1 biopsies. Mean SGUS scores (p=0.006) and the frequency of moderate/severe changes (p<0.001) were higher in pSS patients.

Conclusion

Multidisciplinary evaluation was crucial in the assessment of patients with similar sicca complaints and in the management of ocular/oral/systemic involvement. Objective measurements and specialized complementary exams greatly contribute to establishing or confirming the diagnosis of pSS.

Disclosure of Interests

None declared

Factors associated with unplanned reinterventions and their relation to early mortality after pediatric cardiac surgery

OBJECTIVE

Unplanned reintervention (uRE) is used as an indicator of patient morbidity and quality of care in pediatric cardiac surgery. We investigated associated factors and early mortality after uREs.

METHODS

Morbidity data were prospectively collected in 5 UK centers between 2015 and 2017; uRE included surgical cardiac, interventional transcatheter cardiac, permanent pacemaker, and diaphragm plication procedures. Mortality (30-day and 6-month) in uRE/no-uRE patients was reported before and after matching. Predicted 30-day mortality was calculated using the Partial Risk Adjustment in Surgery score.

RESULTS

A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 146 uREs, resulting in an uRE rate of 4.7%. Partial Risk Adjustment in Surgery score, 30-day mortality and 6-month mortality in uRE and no-uRE groups were 2.4% versus 1.3%, 8.9% versus 1%, and 17.1% versus 2.4%, respectively. After matching, mortality at 6 months remained higher in uRE compared with no-uRE (12.2% vs 1.4%; P = .02; 74 pairs). In the uRE group, 21 out of 25 deaths at 6 months occurred when at least 1 additional postoperative complication was present. In multivariable analysis, neonatal age (P = .002), low weight (P = .009), univentricular heart (P < .001), and arterial shunt (P < .001) were associated with increased risk of uRE, but Partial Risk Adjustment in Surgery score was not (only in univariable analysis).

CONCLUSIONS

uREs are a relatively frequent complication after pediatric cardiac surgery and are associated with some patient characteristics, but not the Partial Risk Adjustment in Surgery risk score. Early mortality was higher after uRE, independent of preoperative factors, but linked to other postoperative complications.

Costs of postoperative morbidity following paediatric cardiac surgery: observational study

OBJECTIVE

Early mortality rates for paediatric cardiac surgery have fallen due to advancements in care. Alternative indicators of care quality are needed. Postoperative morbidities are of particular interest. However, while health impacts have been reported, associated costs are unknown. Our objective was to calculate the costs of postoperative morbidities following paediatric cardiac surgery.

DESIGN

Two methods of data collection were integrated into the main study: (1) case-matched cohort study of children with and without predetermined morbidities; (2) incidence rates of morbidity, measured prospectively.

SETTING

Five specialist paediatric cardiac surgery centres, accounting for half of UK patients.

PATIENTS

Cohort study included 666 children (340 with morbidities). Incidence rates were measured in 3090 consecutive procedures.

METHODS

Risk-adjusted regression modelling to determine marginal effects of morbidities on per-patient costs. Calculation of costs for hospital providers according to incidence rates. Extrapolation using mandatory audit data to report annual financial burden for the health service.

OUTCOME MEASURES

Impact of postoperative morbidities on per-patient costs, hospital costs and UK health service costs.

RESULTS

Seven of the 10 morbidity categories resulted in significant costs, with mean (95% CI) additional costs ranging from £7483 (£3-£17 289) to £66 784 (£40 609-£103 539) per patient. On average all morbidities combined increased hospital costs by 22.3%. Total burden to the UK health service exceeded £21 million each year.

CONCLUSION

Postoperative morbidities are associated with a significant financial burden. Our findings could aid clinical teams and hospital providers to account for costs and contextualise quality improvement initiatives.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

Background

Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.

Objectives

We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.

Design and setting

Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.

Participants

The participants were children aged < 17 years.

Methods

We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.

Results

Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).

Limitations

Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.

Conclusions

Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.

Future work

National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

What are the important morbidities associated with paediatric cardiac surgery? A mixed methods study

OBJECTIVES

Given the current excellent early mortality rates for paediatric cardiac surgery, stakeholders believe that this important safety outcome should be supplemented by a wider range of measures. Our objectives were to prospectively measure the incidence of morbidities following paediatric cardiac surgery and to evaluate their clinical and health-economic impact over 6 months.

DESIGN

The design was a prospective, multicentre, multidisciplinary mixed methods study.

SETTING

The setting was 5 of the 10 paediatric cardiac surgery centres in the UK with 21 months recruitment.

PARTICIPANTS

Included were 3090 paediatric cardiac surgeries, of which 666 patients were recruited to an impact substudy.

RESULTS

Families and clinicians prioritised:Acute neurological event, unplanned re-intervention, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, postsurgical infection and prolonged pleural effusion or chylothorax.Among 3090 consecutive surgeries, there were 675 (21.8%) with at least one of these morbidities. Independent risk factors for morbidity included neonatal age, complex heart disease and prolonged cardiopulmonary bypass (p<0.001). Among patients with morbidity, 6-month survival was 88.2% (95% CI 85.4 to 90.6) compared with 99.3% (95% CI 98.9 to 99.6) with none of the morbidities (p<0.001). The impact substudy in 340 children with morbidity and 326 control children with no morbidity indicated that morbidity-related impairment in quality of life improved between 6 weeks and 6 months. When compared with children with no morbidities, those with morbidity experienced a median of 13 (95% CI 10.2 to 15.8, p<0.001) fewer days at home by 6 months, and an adjusted incremental cost of £21 292 (95% CI £17 694 to £32 423, p<0.001).

CONCLUSIONS

Evaluation of postoperative morbidity is more complicated than measuring early mortality. However, tracking morbidity after paediatric cardiac surgery over 6 months offers stakeholders important data that are of value to parents and will be useful in driving future quality improvement.

Development of a homogeneous immunoassay for the detection of zolpidem in urine

Sleep disorders are common conditions that affect about 40 million people in the U.S every year, the most common of which is insomnia, which is characterized by difficulty falling or staying asleep. Zolpidem (Ambien) is a non-benzodiazepine prescription drug that is used to treat insomnia and is often preferred over the commonly used benzodiazepines due to a lesser side effect profile. This is because the non-benzodiazepine binding is more selective to GABA-A receptors versus the non-selective binding of benzodiazepines. With the increasing popularity of non-benzodiazepines, drug abuse and driving-while-impaired cases involving sleep-inducing drugs have risen. Therefore, a highly sensitive and rapid homogeneous immunoassay (EMIT-type assay) has been developed for the detection of zolpidem in urine. The zolpidem antibody is highly specific and does not cross-react with other newer sleep aids such as zopiclone and zaleplon. This assay has a detection limit of 5 ng/mL for zolpidem in urine. Further evaluation of this assay using liquid chromatography-tandem mass spectrometry (LC-MS-MS) analysis of authentic urine samples demonstrated that the accuracy of the assay is greater than 90%. Because this assay is designed to measure the non-conjugated drug in urine, it resulted in simplification for gas chromatography-MS or LC-MS-MS confirmation methods that do not require urine hydrolysis before solid-phase extraction or liquid-liquid extraction.

Development and GC-MS Validation of a Highly Sensitive Recombinant G6PDH-Based Homogeneous Immunoassay for the Detection of Buprenorphine and Norbuprenorphine in Urine

Buprenorphine is now increasingly prescribed as an alternative to methadone for the treatment of heroin addiction. Because of its potency (dosage usages from 0.2 mg to 8 mg), the drug concentrations in body fluids are normally very low. Here, we report the first recombinant glucose-6-phosphate dehydrogenase (G6PDH)-based homogeneous immunoassay (EMIT-type assay) for free buprenorphine and free norbuprenorphine in urine. The antibody used in this assay cross-reacts nearly identically with buprenorphine and norbuprenorphine and, at the same time, has less than 1% cross-reactivity with a wide range of commonly prescribed opiates, particularly those structurally related compounds such as morphine, codeine, and dihydrocodeine. More importantly, this assay has a low detection limit of 1 ng/mL for buprenorphine or norbuprenorphine. Further evaluation of this technique using gas chromatography-mass spectrometry (GC-MS) of authentic urine samples demonstrated that the accuracy of the assay is greater than 95%. Because this assay is designed to measure the free drugs in urine, it resulted in simplification for GC-MS or liquid chromatography-MS confirmation methods that did not require urine hydrolysis before solid-phase or liquid-liquid extraction.

Erectile dysfunction and HTLV-I infection: a silent problem

The human T-lymphotropic virus type I (HTLV-I) is a retrovirus associated with a chronic myelopathy known as HTLV-I-Associated Myelopathy or Tropical Spastic Paraparesis (HAM/TSP). The main objective was to assess the frequency of erectile dysfunction (ED) in HTLV-I-infected individuals from Salvador and other cities from Bahia, Brazil, as well as to verify if sexual dysfunction correlates with urinary symptoms and overall neurological impairment. From January 2001 to April 2004, 218 HTLV-I carriers (111 male and 107 female subjects) had complete clinical, neurological, and urological evaluation. They were assessed using standardized questionnaires to determine urinary complaints (Urinary Distress Inventory) and ED (Brief Male Sexual Function Inventory). Neurological impairment was established by Expanded Disability Status Scale (EDSS) from 0 to 10. HAM/TSP was considered as EDSS> or =2. A total of 17 males had clinically defined HAM/TSP (group 1). From the 94 HTLV-I-infected males, 62 were selected (group 2) and paired by age with patients in group 1. A total of 79 individuals were selected for this study. The age ranged from 35 to 81 y (mean=47.9+/-9.65). The percentage of ED in the studied population was 40.5%. In the HAM/TSP group, ED frequency was 88.2%. The associations among sexual dissatisfaction, erectile dysfunction, urinary symptoms (frequency, nocturia, and urgency) and EDSS> or =2 were statistically significant. In HAM/TSP, there is a slow and progressive degeneration of the lateral funiculus of the spinal cord. HTLV-I-infected individuals present a high frequency of ED and it is closely associated to urinary symptoms and the overall neurological picture. The HTLV-I carriers already had prominent compromise of the sexual activity.

X-ray imaging and microspectroscopy of plants and fungi

X-ray fluorescence microscopy and microspectroscopy with micrometre spatial resolution and unprecedented capabilities for the study of biological and environmental samples are reported. These new capabilities are a result of both the combination of high-brilliance synchrotron radiation and high-performance X-ray microfocusing optics and the intrinsic advantages of X-rays for elemental mapping and chemical-state imaging. In this paper, these capabilities are illustrated by experimental results on hard X-ray phase-contrast imaging, X-ray fluorescence (XRF) imaging and microspectroscopy of mycorrhizal plant roots and fungi in their natural hydrated state. The XRF microprobe is demonstrated by the simultaneous mapping of the elemental distributions of P, S, K, Ca, Mn, Fe, Ni, Cu and Zn with a spatial resolution of approximately 1 x 3 micron and with an elemental sensitivity of approximately 500 p.p.b. Microspectroscopy with the same spatial resolution is demonstrated by recording near-edge X-ray absorption (XANES) spectra of Mn at a concentration of approximately 3 p.p.m.

Cesarean delivery in northeast region of Brazil, 1978-80

This study presents information on cesarean section rates for the last baby born to 1,746 women in Northeast Brazil between January 1978 and the date of a 1980 household survey. For hospital deliveries, the c-section rate is 19 per cent. Rates were highest in the major urban areas and lowest in rural areas. Within residence categories, the section rate was related directly to education, early prenatal care, and delivery in private hospitals.

Sterilization in the northeast of Brazil

Results of household surveys carried out in four states in the Northeast of Brazil showed that female sterilization is the most prevalent method among women who want no more children. Many women who indicated an interest in tubal ligation, however, had not been sterilized. Access to sterilization depends on the type of hospital in which the child was delivered and the type of delivery the woman had. Over 60% of the sterilized women reported that they had a tubal ligation at the time they were hospitalized for a cesarean delivery. Compared with unsterilized women, the sterilized women are characterized by relatively higher education levels and a greater likelihood of urban residence and were far more likely to have had cesarean deliveries and, therefore, to have qualified for postpartum sterilization on medical grounds.

Breastfeeding and use of the health care system in Bahia State, Brazil: three multivariate analyses

Three multivariate methods--deviation from total proportion breastfeeding, polynomial regression, and proportional hazards--are used on current status breastfeeding data to explain an inverse relationship between use of the health care system and breastfeeding in Bahia State, Brazil. Among the intervening variables analyzed--urban/rural residence, educational attainment, age of woman, and place of last live birth--education and place of last live birth are found to have a net effect on breastfeeding by all three methods of analysis. The advantages and disadvantages of each method are described.