Racial, ethnic, and socio-economic disparities in neonatal ICU admissions among neonates born with cyanotic CHD in the United States, 2009-2018.

INTRODUCTION: Disparities in CHD outcomes exist across the lifespan. However, less is known about disparities for patients with CHD admitted to neonatal ICU. We sought to identify sociodemographic disparities in neonatal ICU admissions among neonates born with cyanotic CHD. MATERIALS & METHODS: Annual natality files from the US National Center for Health Statistics for years 2009-2018 were obtained. For each neonate, we identified sex, birthweight, pre-term birth, presence of cyanotic CHD, and neonatal ICU admission at time of birth, as well as maternal age, race, ethnicity, comorbidities/risk factors, trimester at start of prenatal care, educational attainment, and two measures of socio-economic status (Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] status and insurance type). Multivariable logistic regression models were fit to determine the association of maternal socio-economic status with neonatal ICU admission. A covariate for race/ethnicity was then added to each model to determine if race/ethnicity attenuate the relationship between socio-economic status and neonatal ICU admission. RESULTS: Of 22,373 neonates born with cyanotic CHD, 77.2% had a neonatal ICU admission. Receipt of WIC benefits was associated with higher odds of neonatal ICU admission (adjusted odds ratio [aOR] 1.20, 95% CI 1.1-1.29, p < 0.01). Neonates born to non-Hispanic Black mothers had increased odds of neonatal ICU admission (aOR 1.20, 95% CI 1.07-1.35, p < 0.01), whereas neonates born to Hispanic mothers were at lower odds of neonatal ICU admission (aOR 0.84, 95% CI 0.76-0.93, p < 0.01). CONCLUSION: Maternal Black race and low socio-economic status are associated with increased risk of neonatal ICU admission for neonates born with cyanotic CHD. Further work is needed to identify the underlying causes of these disparities.

"But for the blind spot": Accuracy and diagnostic performance of smart watch cardiac features in pediatric patients.

BACKGROUND: The Apple Watch™ (AW) offers heart rate (HR) tracking by photoplethysmography (PPG) and single-lead electrocardiographic (ECG) recordings. The accuracy of AW-HR and diagnostic performance of AW-ECGs among children during both sinus rhythm and arrhythmias have not been explored. OBJECTIVE: The purposes of this study were to assess the accuracy of AW-HR measurements compared to gold standard modalities in children during sinus rhythm and arrhythmias and to identify non-sinus rhythms using AW-ECGs. METHODS: Subjects ≤18 years wore an AW during (1) telemetry admission, (2) electrophysiological study (EPS), or (3) exercise stress test (EST). AW-HRs were compared to gold standard modality values. Recorded AW-ECGs were reviewed by 3 blinded pediatric electrophysiologists. RESULTS: Eighty subjects (median age 13 years; interquartile range 1.0-16.0 years; 50% female) wore AW (telemetry 41% [n = 33]; EPS 34% [n = 27]; EST 25% [n = 20]). A total of 1090 AW-HR measurements were compared to time-synchronized gold standard modality HR values. Intraclass correlation coefficient (ICC) was high 0.99 (0.98-0.99) for AW-HR during sinus rhythm compared to gold standard modalities. ICC was poor comparing AW-HR to gold standard modality HR in tachyarrhythmias (ICC 0.24-0.27) due to systematic undercounting of AW-HR values. A total of 126 AW-ECGs were reviewed. Identification of non-sinus rhythm by AW-ECG showed sensitivity of 89%-96% and specificity of 78%-87%. CONCLUSIONS: We found high levels of agreement for AW-HR values with gold standard modalities during sinus rhythm and poor agreement during tachyarrhythmias, likely due to hemodynamic effects of tachyarrhythmias on PPG-based measurements. AW-ECGs had good sensitivity and moderate specificity in identification of non-sinus rhythm in children.

Cardiac magnetic resonance predictors for successful primary biventricular repair of unbalanced complete common atrioventricular canal.

BACKGROUND: Patients with unbalanced common atrioventricular canal can be difficult to manage. Surgical planning often depends on pre-operative echocardiographic measurements. We aimed to determine the added utility of cardiac MRI in predicting successful biventricular repair in common atrioventricular canal. METHODS: We conducted a retrospective cohort study of children with common atrioventricular canal who underwent MRI prior to repair. Associations between MRI and echocardiographic measures and surgical outcome were tested using logistic regression, and models were compared using area under the receiver operator characteristic curve. RESULTS: We included 28 patients (median age at MRI: 5.2 months). The optimal MRI model included the novel end-diastolic volume index (using the ratio of left ventricular end-diastolic volume to total end-diastolic volume) and the left ventricle-right ventricle angle in diastole (area under the curve 0.83, p = 0.041). End-diastolic volume index ≤ 0.18 and left ventricle-right ventricle angle in diastole ≤ 72° yield a sensitivity of 83% and specificity of 81% for successful biventricular repair. The optimal multimodality model included the end-diastolic volume index and the echocardiographic atrioventricular valve index with an area under the curve of 0.87 (p = 0.026). CONCLUSIONS: Cardiac MRI can successfully predict successful biventricular repair in patients with unbalanced common atrioventricular canal utilising the end-diastolic volume index alone or in combination with the MRI left ventricle-right ventricle angle in diastole or the echocardiographic atrioventricular valve index. A prospective cardiac MRI study is warranted to better define the multimodality characteristic predictive of successful biventricular surgery.

Improvement in Palivizumab Administration Prior to Discharge for Hospitalized Infants with Hemodynamically Significant Congenital Heart Disease: A Quality Improvement Initiative.

In this quality improvement initiative, we aimed to increase provider adherence with palivizumab administration guidelines for hospitalized infants with hemodynamically significant congenital heart disease. We included 470 infants over four respiratory syncytial virus (RSV) seasons from 11/2017 to 03/2021 (baseline season: 11/2017-03/2018). Interventions included the following: education, including palivizumab in the sign-out template, identifying a pharmacy expert, and a text alert (seasons 1 and 2: 11/2018-03/2020) that was replaced by an electronic health record (EHR) best practice alert (BPA) in season 3 (11/2020-03/2021). The text alert and BPA prompted providers to add "Need for RSV immunoprophylaxis" to the EHR problem list. The outcome metric was the percentage of eligible patients administered palivizumab prior to discharge. The process metric was the percentage of eligible patients with "Need for RSV immunoprophylaxis" on the EHR problem list. The balancing metric was the percentage of palivizumab doses administered to ineligible patients. A statistical process control P-chart was used to analyze the outcome metric. The mean percentage of eligible patients who received palivizumab prior to hospital discharge increased significantly from 70.1% (82/117) to 90.0% (86/96) in season 1 and to 97.9% (140/143) in season 3. Palivizumab guideline adherence was as high or higher for those with "Need for RSV immunoprophylaxis" on the problem list than for those without it in most time periods. The percentage of inappropriate palivizumab doses decreased from 5.7% (n = 5) at baseline to 4.4% (n = 4) in season 1 and 0.0% (n = 0) in season 3. Through this initiative, we improved adherence with palivizumab administration guidelines for eligible infants prior to hospital discharge.

Biomarkers, Socioeconomic Factors, and Right Ventricular Function After Surgical Repair for Tetralogy of Fallot.

Right ventricular (RV) dysfunction early after tetralogy of Fallot (TOF) increases post-operative morbidity. We investigated associations of circulating biomarkers and socioeconomic factors with early post-operative RV systolic function. Single-center prospective cohort study of infants undergoing TOF repair. Six serologic biomarkers of myocardial fibrosis and wall stress collected at the time of surgery were measured with immunoassay. Geocoding was performed for socioeconomic factors. Multivariate adaptive regression splines (MARS) models identified factors associated with RV function parameters: fractional area change (FAC), global longitudinal strain and strain rate, and free wall strain and strain rate. Seventy-one patients aged 3.5 months (IQR 2.4, 5.2) were included. Galectin-3 was the highest ranked predictor for FAC, global longitudinal strain, and free wall strain, and procollagen type-I carboxy-terminal propeptide (PICP) was the highest ranked predictor for global longitudinal strain rate and free wall strain rate. Several neighborhood characteristics were also highly ranked. Models adjusted R2 ranged from 0.71 to 0.85 (FAC, global longitudinal strain/strain rate), and 0.55-0.57 (RV free wall strain/strain rate). A combination of serologic biomarkers, socioeconomic, and clinical variables explain a significant proportion of the variability in RV function after TOF repair. These factors may inform pre-operative risk-stratification for these patients.

Association of race and ethnicity with resource utilisation among children with CHD: an evaluation of the National Health Interview Survey, 2010-2018.

INTRODUCTION: Racial and ethnic disparities in resource use among children with CHD remain understudied. We sought to evaluate associations between race, ethnicity, and resource utilisation in children with CHD. MATERIALS AND METHODS: Annual data from the National Health Interview Survey were collected for years 2010-2018. Children with self-reported CHD and Non-Hispanic White race, Non-Hispanic Black race, or Hispanic ethnicity were identified. Resource use in the preceding year was identified with four measures: primary place of care visited when sick, receiving well-child checkups, number of emergency department visits, and number of office visits. Cohort characteristics were compared across racial and ethnic groups using Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to determine the association of race and ethnicity with likelihood of having an emergency department visit. RESULTS: We identified 209 children for the primary analysis. Non-Hispanic Black children had significantly more emergency department visits in the prior year, with 11.1% having ≥6 emergency department visits compared to 0.7% and 5.6% of Non-Hispanic White and Hispanic children. Further, 35.2% of Hispanic children primarily received care at clinics/health centres, compared to 17% of Non-Hispanic White children and 11.1% of Non-Hispanic Black children (p = 0.03). On multivariable analysis, Black race was associated with higher odds of emergency department visit compared to White race (odds ratio = 4.19, 95% confidence interval = 1.35 to 13.04, p = 0.01). CONCLUSION: In a nationally comprehensive, contemporary cohort of children with CHD, there were some significant racial and ethnic disparities in resource utilisation. Further work is needed to consider the role of socio-economics and insurance status in perpetuating these disparities.

Palliative Care Conversations for Heart Failure Nurses: A Pilot Education Intervention.

INTRODUCTION: Heart failure is a progressive condition affecting 6.2 million Americans. The use of palliative and supportive care for symptom management and improved quality of life is recommended for persons with heart failure. However, 91% of nurses believe they need further training to have palliative care conversations. The purpose of this pilot education intervention was to determine if providing nurses with education on the timing and content of palliative care conversations would improve their perceived skill and knowledge. METHODS: This was a pilot study of an online educational intervention. Data were electronically collected from 13 participants using validated questionnaires delivered via Qualtrics. Participants completed a demographic survey and End-of-Life Professional Caregiver Survey (EPCS) before and after completing an online, asynchronous education module. RESULTS: Mean scores were higher on all posttest measures. Independent samples t-tests revealed statistically significant differences on the Effective Care Delivery (ECD) scale (t[32] = -2, p = .05) and total EPCS scale scores (t[32] = -2.2, p = .03) from pre- to posttest. CONCLUSION: Scores increased on all dimensions pretest to posttest with statistically significant differences in ECD and total scores. Providing asynchronous online education on timing and content of palliative care conversations to nurses caring for people with heart failure is a feasible and effective way to improve perceived knowledge and skill of palliative care conversations.

Older Adult Suicides: What You Should Know and What You Can Do.

Suicide among most age groups has been on the rise in the United States for the past 20 years. Suicide is currently the 10th leading cause of death in the United States, but suicide completion and suicide attempts may be underreported. Suicide is a very personal act often predicated on a sense of hopelessness and despair, but often prompted by very addressable factors such as pain and social isolation. This article will use a case narrative to illustrate life circumstances that may influence suicidal thinking. In addition, risk factors are addressed. Lastly, the article addresses some useful assessment tools to gauge suicide risk among older adult clients and provides resources for home care clinicians.

Red Flags and Off Ramps: Providing Community Education About Driving and Dementia.

Driving safety for older adults with dementia presents a continuing complex challenge in the community. More than 5 million people in the United States suffer from dementia, and their numbers are expected to grow. Evidence-based resources to identify and manage driving risks in older adults with dementia do exist, but the challenges of limited time in primary care and outpatient settings can make application difficult. This innovative project, funded by a Hartford Foundation Change Agents Action grant award, focused on interprofessional work to address the educational need for primary care professionals and family caregivers to manage driving safety for their loved ones with dementia. An interactive theater performance with development of an educational DVD was tested in a sample of professional and family caregivers. This project also forged new sustainable interprofessional community partnerships among educators/researchers and healthcare providers caring for this vulnerable community population.

A Framework Illustrating Care-Seeking Among Older Adults in a Hospital Emergency Department.

Background and Objectives: Older adults seeking emergency department (ED) care often have multiple, complex chronic conditions. We sought to understand factors that influence ED care-seeking by older adults and present a theoretical framework illustrating this process. Research Design and Methods: In this grounded theory study, we interviewed 40 older adults with chronic illness within 90 days of an ED visit to explore their decision-making about seeking ED care. We also interviewed 10 primary care and ED physicians to explore conditions that influence ED referrals. Interview transcripts were analyzed using constant comparison and dimensional analysis. Results: ED care-seeking among older adults is complex and influenced by multiple internal and external conditions including symptom type, severity, and onset; previous experience with and meaning of similar symptoms; limited access to prompt primary care; social and financial concerns; and deciding if symptoms warranted immediate attention. When contacting their primary care providers (PCPs), patients were often referred to the ED. Discussion and Implications: Older adults seeking ED care make rational and appropriate choices which are often predicated by referrals from their PCPs. Expecting patients to have the requisite knowledge to determine if symptoms require emergency care is unrealistic. ED visits are often the best strategy for patients to receive appropriate care. A healthcare system that provides better continuity between PCPs and the ED, better access to PCPs for urgent care, and timely follow-up care that takes into account the multiple and complex medical and social needs of older community-living adults is needed.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation.

INTRODUCTION: Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients' care-seeking decisions. METHODS: We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients' reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. RESULTS: PAM scores fell in both groups after the ED visit but fell significantly more in "usual care" (average decline -4.64) than "intervention" participants (average decline -2.77) (ß=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. CONCLUSION: The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.

Complicated Dementia: Teaching Caregivers to Recognize Signs and Take the Next Steps.

Older adults who exhibit extreme behaviors present a complex diagnostic and management picture for home healthcare clinicians and family caregivers. This case study describes the situation of Mrs. M, whose aggressive, combative behavior was so difficult for her children to comprehend and manage, she was secluded in a locked basement of her home. This article details assessment techniques, symptom presentation and possible diagnostic implications, as well as resources for caregivers.

The evolution of brachiation in ateline primates, ancestral character states and history.

This study examines how brachiation locomotion evolved in ateline primates using recently-developed molecular phylogenies and character reconstruction algorithms, and a newly-collected dataset including the fossils Protopithecus, Caipora, and Cebupithecia. Fossils are added to two platyrrhine molecular phylogenies to create several phylogenetic scenarios. A generalized least squares algorithm reconstructs ateline and atelin ancestral character states for 17 characters that differentiate between ateline brachiators and nonbrachiators. Histories of these characters are mapped out on these phylogenies, producing two scenarios of ateline brachiation evolution that have four commonalities: First, many characters change towards the Ateles condition on the ateline stem lineage before Alouatta splits off from the atelins, suggesting that an ateline energy-maximizing strategy began before the atelines diversified. Second, the ateline last common ancestor is always reconstructed as an agile quadruped, usually with suspensory abilities. It is never exactly like Alouatta and many characters reverse and change towards the Alouatta condition after Alouatta separates from the atelins. Third, most characters undergo homoplastic change in all ateline lineages, especially on the Ateles and Brachyteles terminal branches. Fourth, ateline character evolution probably went through a hindlimb suspension with tail-bracing phase. The atelines most likely diversified via a quick adaptive radiation, with bursts of punctuated change occurring in their postcranial skeletons, due to changing climatic conditions, which may have caused competition among the atelines and between atelines and pitheciines.

Hallucial convergence in early hominids.

There is a richly documented fossil record of the evolutionary transition from ape-sized brains that are less that one-third the size of modern humans through a series of intermediate-sized brains up to the modern range. The first report on the discovery of the foot of the Stw 573 skeleton emphasized the apparent transitional nature of its great toe [Clarke, R.J., Tobias, P.V., 1995. Sterkfontein Member 2 foot bones of the oldest South African hominid. Science 269, pp. 521-524]. The hallux appeared to be intermediate in its divergence between human-like adduction and ape-like abduction. A major part of this evidence is the medial encroachment of the metatarsal I facet on the medial cuneiform. This study quantifies the variability of this feature in extant hominoids and fossil hominids. The results are consistent with the view that all currently known hominids were specialized for bipedality and lacked the ape-like ability to oppose the great toe.