Mind the Gap! Working Toward Gender Equity in Pediatric and Congenital Heart Disease: Present and Future.

Evidence from medicine and other fields has shown that gender diversity results in better decision making and outcomes. The incoming workforce of congenital heart specialists (especially in pediatric cardiology) appears to be more gender balanced, but past studies have shown many inequities. Gender-associated differences in leadership positions, opportunities presented for academic advancement, and recognition for academic contributions to the field persist. In addition, compensation packages remain disparate if evaluated based on gender with equivalent experience and expertise. This review explores these inequities and has suggested individual and institutional changes that could be made to recruit and retain women, monitor the climate of the institution, and identify and eliminate bias in areas like salary and promotions.

Quality effects of home acquisitions in residential aged care.

OBJECTIVE: The recent consolidation of the Australian residential aged care market has raised concerns about the potential adverse effects of acquisition activity on quality of care (QoC). We examined changes in QoC outcomes within acquired homes and the influence of the acquiring providers' characteristics on these post-acquisition outcomes. METHODS: A retrospective observational study was conducted using de-identified data sets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was used to investigate post-acquisition changes in QoC outcomes for 225 Australian home acquisitions between 2015 and 2019. The outcomes were analysed for the first two full financial years before and after the acquisition. RESULTS: After controlling for other factors, we find acquired homes were associated with significantly worse QoC outcomes in the 2 years after acquisition, with higher rates of hospitalisations and reported complaints to the regulator. However, these results were driven by homes acquired by providers that were smaller in scale, for-profit or had comparatively poorer average quality across the other homes they operated. CONCLUSIONS: Our finding that homes' QoC on average declines in the first 2 years following acquisition, are consistent with studies in other countries and points to the potential risks that consolidation poses to the care delivered to older people in Australia during that period.

Association and risk factors of pediatric pulmonary hypertension with obstructive sleep apnea: A national study utilizing the Kids' Inpatient Database (KID).

STUDY OBJECTIVE: Assess the prevalence of and risk factors for pediatric pulmonary hypertension (PH) in the 2016 Kids' Inpatient Database (KID), including obstructive sleep apnea (OSA) and obesity. METHODS: Retrospective cross-sectional cohort study utilizing 6,081,132 weighted pediatric discharges from the 2016 KID. Study variables included age, length of stay, mortality, gender, hospital region, primary payer, race, median household income for patient's ZIP code, OSA, central sleep apnea (CSA), obesity, Down syndrome, sickle cell disease (SCD), thalassemia, congenital heart disease (CHD), hypertension, asthma and chronic lung disease of prematurity (CLDP). PH was the primary outcome of interest. Bivariate and multivariable logistic regression models were utilized with odds ratios and 95 % confidence intervals. RESULTS: The mean age was 3.76 years, the mean hospital length of stay was 3.85 days, 48.9 % were male, 52.6 % had government health insurance, 51.0 % were White, 16.1 % were Black, 21.1 % were Hispanic, 5.0 % were Asian or Pacific Islander, 0.80 % were Native American and 6.1 % identified as "other". The prevalence of PH was 0.21 % (12,777 patients). There were 37,631 patients with OSA and the prevalence of PH among this cohort was 3.3 %, over 10x greater than the overall prevalence of PH in the 2016 KID (0.21 %). Risk factors associated with PH included CLDP, CHD, Down syndrome, asthma, OSA, CSA, hypertension, SCD, obesity, race/ethnicity, government insurance, age, male gender (p < 0.0001), and hospital region (p = 0.0002). CONCLUSIONS: Several risk factors were independently associated with PH, such as OSA, CSA, obesity, asthma, and insurance status. Prospective multi-institutional studies are needed to assess the relationships between these risk factors, severity metrics, and causative links in the development of PH; in addition to identifying children with OSA who are most likely to benefit from cardiopulmonary screening prior to adenotonsillectomy. LEVEL OF EVIDENCE: Level III.

Applying Practice Analysis to Develop a New Test Content Outline for the Pediatric Cardiology Certification Examination.

The evolving breadth and complexity of the contemporary pediatric cardiology specialty requires regular, systematic analysis of the practice to ensure that training and certification requirements address the demands of real-world clinical experience. We report the process of the American Board of Pediatrics (ABP) for conducting such a practice analysis and revising the test content outline (TCO) for the pediatric cardiology subspecialty certification exam. A panel of 15 pediatric cardiologists conducted seven 2-h virtual meetings, during which they identified 37 unique tasks that represent the work a pediatric cardiologist may reasonably expect to perform within the first 5 years after training. These tasks were grouped into nine performance domains, similar to the entrustable professional activities (EPA), previously endorsed by the ABP in collaboration with the pediatric cardiology education community, and which represent the critical activities of the profession. The panel then enumerated the knowledge, skills, and abilities necessary to perform each task. These deliberations resulted in two work products: a practice analysis document (PAD) and subspecialty board TCO based on testable knowledge, skills, and abilities. Survey assessments of the panel's work were then distributed to pediatric cardiology fellowship program directors and to practicing pediatric cardiologists for their input, which largely aligned with the panel's recommendations. Survey responses were considered in the final revisions of the PAD and TCO. This approach to practice analysis proved to be an efficient process for describing the work performed by today's pediatric cardiologists and the knowledge, skills, and abilities needed to competently perform that work.

The quality effects of agency staffing in residential aged care.

OBJECTIVES: In Australia, temporary agency workers are a relatively small but enduring component of the residential aged care workforce. However, evidence from other countries suggests reliance on agency workers has a detrimental effect on the quality of care (QoC). We examined whether QoC outcomes differ for Australian residential aged care facilities (RACFs) based on their reliance on agency care staff. METHODS: A retrospective observational study was conducted using de-identified datasets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was conducted using data comprising 6221 RACF-year observations, across 5 years (2015-2019), from 1709 unique RACFs in Australia. RESULTS: After controlling for other determinants of QoC, RACFs with a greater reliance on agency care staff have poorer QoC outcomes, with significantly higher rates of complaints, missing persons, reportable assaults, hospitalisations, and accreditation flags. CONCLUSIONS: Consistent with international evidence, we found that the QoC of Australian RACFs is sensitive to the reliance on agency staff in delivering direct care to residents. These findings illustrate the importance of workers' employment conditions, alongside other workforce characteristics, in driving the quality of residential aged care.

Aortic migration of Amplatzer Piccolo™ ductal Occluder.

We present the case of a 4-month-old, former 23-week premature baby who underwent patent ductus arteriosus device closure in the cardiac catheterisation lab with an Amplatzer Piccolo™ device at 12 weeks of life. This was complicated by late migration of the device into the aorta resulting in severe obstruction and requiring surgical intervention.

Considering the new minimum staffing standards for Australian residential aged care.

Objective To compare the historical staffing patterns and organisational characteristics of Australian residential aged care facilities (RACFs) against the new minimum staffing standards recommended by the Royal Commission into Aged Care Quality and Safety (RCACQS). Method Retrospective data analysis was used to compare the staffing levels and characteristics of 1705 RACFs (for 4 years, 2016-19) with the three new mandatory staffing requirements. De-identified datasets were provided by the RCACQS, obtained under its legal authority. Results Only 3.8% of RACFs have staffing levels at or above all three requirements. Although many (79.7%) already meet the requirement to have a registered nurse (RN) on-site for morning and afternoon shifts, few have staffing levels above requirements for total direct care per resident per day (10.4%) or care provided by an RN per resident per day (11.1%). Historical levels of on-site RNs, total direct care, and RN care vary significantly across facilities of different size, location and provider scale. Conclusion The new staffing standards, to be mandatory by 2023, prescribe minimum requirements significantly higher than existing levels, particularly in care per resident per day. Each of the three requirements will likely have a differential effect for different types of RACFs. What is known about the topic? International evidence suggests that introducing mandatory minimum staffing standards tends to increase the amount of care provided by staff in residential aged care facilities (RACFs). However, the impact of staffing standards is influenced by the stringency of the minimum threshold relative to existing staffing levels, the capacity of organisations to increase their staffing levels, and the specific way the regulation is formulated. What does this paper add? This paper explores the potential implications of the three national minimum staffing standards, to be in force by October 2023, specifying total direct care, care received by a registered nurse (RN), and an RN on-site. By examining the existing staffing levels of Australian RACFs, it identifies the extent to which facilities already meet the new standards and the characteristics of facilities with staffing levels above and below the three requirements (individually and in combination). What are the implications for practitioners? The study informs both policy and practice in relation to the likely effects of implementing the national minimum staffing standards for residential aged care in Australia. It demonstrates that the new minimum thresholds are likely to require substantial increases in staffing across the sector, both in terms of all direct care workers and RNs. It also shows that the three requirements are likely to have a differential effect for RACFs of different size, location and chain affiliation, thereby guiding policy about the future needs for Australia's aged care workforce.

Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening.

STUDY OBJECTIVES: Our objective was to determine the prevalence of elevated right ventricular pressure (RVP) as a surrogate marker for pulmonary hypertension in children with obstructive sleep apnea syndrome (OSAS) undergoing echocardiography. METHODS: This was a retrospective chart review of children ages 2-21 years diagnosed with OSAS by an overnight polysomnogram who underwent cardiac echocardiogram to screen for pulmonary hypertension within 6 months of polysomnogram in a tertiary inner-city pediatric hospital. The primary outcome was elevated RVP defined by estimated RVP ≥ 25 mm Hg above right atrial pressure or ventricular septal configuration consistent with elevated RVP. RESULTS: A total of 174 children were included. The median (interquartile range) age was 8.9 (5.5-13.1) years with 59.2% male, 41.4% Hispanic, and 25.9% non-Hispanic Black patients. The prevalence of obesity was 72.0% and severe or very severe OSAS was present in 93.1%. The median (interquartile range) apnea-hypopnea index was 28.3 events/h (18.8-52.7 events/h). Seven children (4.0%) had elevated RVP. There was no association between elevated RVP and age, sex, race, body mass index percentile, apnea-hypopnea index, oxygen nadir, or severe OSAS (apnea-hypopnea index ≥ 10 events/h). CONCLUSIONS: Elevated RVP was rare and was not associated with OSAS severity. The prevalence in this cohort is higher than the prevalence of pulmonary hypertension noted in similar studies (0%-1.8%), which may be related to differences in methodology or unassessed cohort characteristics. Further effort to determine the optimal role for pulmonary hypertension screening in pediatric OSAS is needed. CITATION: Bitners AC, Arens R, Mahgerefteh J, et al. Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening. J Clin Sleep Med. 2021;17(11):2225-2232.

Outflow graft obstruction in patients with the HM 3 LVAD: A percutaneous approach.

BACKGROUND: The use of the HeartMate 3 (HM3) left ventricular assist device (LVAD) is expanding. Despite being associated with lower rates of adverse events and increased survival, outflow graft obstruction (OGO) has been reported in patients with HM3. The incidence and best management of this serious complication remain unclear. METHODS: We describe six cases of HM3 OGO occurring in five patients in our institutional HM3 cohort. Four cases underwent computed tomography angiography and in two percutaneous angiography was directly performed to confirm the diagnosis. In four cases, percutaneous repair of the OG was performed using common interventional cardiology (IC) techniques. RESULTS: Our institutional incidence of OGO was 7% (event rate of 0.05 per patient year); much higher than the previously reported incidence of 1.6%. All cases occurred in the bend relief covered segment. Only two patients had apparent OG twisting, and in two, OGO occurred despite placement of an anti-twist clip at the time of implant. External compression seems to play a role in most cases. Balloon "graftoplasty" and stent deployment via the femoral artery alleviated the obstruction and normalized LVAD flow in all patients who underwent percutaneous repair. The use of self-expanding stents allowed for downsizing of the procedural access site to 10 Fr. No serious procedure-related complications occurred. CONCLUSION: OGO is common in HM3 patients, external compression due to biomaterial accumulated surrounding the OG is a common etiology. Percutaneous repair using standard IC techniques is safe and feasible in cases of compression with or without partial twisting.

The relationship of hypertension with obesity and obstructive sleep apnea in adolescents.

OBJECTIVES: To assess the independent relationships of obesity and obstructive sleep apnea (OSA) with hypertension/elevated blood pressure (EBP) in adolescent patients. STUDY DESIGN: A retrospective cohort analysis was performed on 501 patients (age 13-21 years) with three separate blood pressure measurements within 6 months of polysomnography. EBP was defined as average systolic blood pressure (SBP) ≤120 mm Hg; obesity as body mass index Z-score ≤1.65; and OSA as obstructive apnea-hypopnea index <1. Pearson correlations and multivariable analyses were performed to assess the independent effects of the apnea-hypopnea index and body mass index Z-score on SBP. RESULTS: Of 501 patients (mean age 16 ± 2 years), 246 (49%) were male. OSA was present in 329 (66%) patients, obesity in 337 (67%), and EBP in 262 (52%). EBP was present in 70% of obese adolescents and 60% of adolescents with OSA. Univariable correlation showed a significant relationship between SBP, body mass index Z-score, and apnea-hypopnea index. Multivariable linear regression analysis showed blood pressure was significantly associated with body mass index Z-score (ß = .46; P < .01), age (ß = .25; P < .01), and height Z-score (ß = .14; P < .01), but not apnea-hypopnea index (ß = .01; P = .72). CONCLUSIONS: The relationship between OSA and EBP in adolescents is most closely associated with the degree of obesity. Further studies are needed to assess the effect of the treatment of obesity and OSA on blood pressure in adolescents.

Development and Utility of Quality Metrics for Ambulatory Pediatric Cardiology in Kawasaki Disease.

The Adult Congenital and Pediatric Cardiology (ACPC) Section of the American College of Cardiology sought to develop quality indicators/metrics for ambulatory pediatric cardiology practice. The objective of this study was to report the creation of metrics for patients with Kawasaki disease. Over a period of 5 months, 12 pediatric cardiologists developed 24 quality metrics based on the most relevant statements, guidelines, and research studies pertaining to Kawasaki disease. Of the 24 metrics, the 8 metrics deemed the most important, feasible, and valid were sent on to the ACPC for consideration. Seven of the 8 metrics were approved using the RAND method by an expert panel. All 7 metrics approved by the ACPC council were accepted by ACPC membership after an "open comments" process. They have been disseminated to the pediatric cardiology community for implementation by the ACPC Quality Network.

Aluminum phosphide poisoning: Successful recovery of multiorgan failure in a pediatric patient.

Aluminum phosphide (AlP) is an insecticide and rodenticide that produces phosphine gas when exposed to moisture. Exposure to AIP has been described as through inhalation and ingestion routes and is typically either accidental or a suicidal attempt. The result is potential multiorgan toxicity involving the heart, kidneys, lungs, and liver, with an overall mortality related to exposure reported from 30% to 77%. The initial symptoms are nonspecific and can include epigastric pain, vomiting, diarrhea, dizziness, and dyspnea. Patients rapidly experience multisystem organ failure, cardiovascular collapse, and, finally, death. We report the case of a 3 year old girl with AlP poisoning who developed cardiogenic shock, ventricular arrhythmias, respiratory failure, liver injury, and significant acute kidney injury (AKI). She was successfully supported with veno-arterial extracorporeal membrane oxygenation (ECMO) for 16 days, treated with lidocaine and magnesium sulfate for ventricular arrhythmias, and received continuous renal replacement therapy (CRRT) and hemodialysis for 24 days for metabolic acidosis secondary to AKI. Despite her severe clinical presentation, she had complete normalization of her end-organ dysfunction with no neurological sequelae. This case demonstrates the high index of suspicion required for AlP poisoning given the potential for rapid progression and severe multiorgan toxicity. The authors recommend prompt referral to a tertiary care center with ECMO and CRRT capability in cases of suspected or documented AlP poisoning.

Initial experience with the 3.3 Fr Mongoose® pigtail catheter for aortic angiography during patent ductus arteriosus closure in small patients.

BACKGROUND: Smaller femoral arterial sheaths may be associated with fewer vascular complications. The 3.3 Fr Mongoose® Pediavascular pigtail catheter is a catheter that allows higher flow rates, potentially resulting in improved angiographic quality. We reviewed our experience with this small catheter during patent ductus arteriosus (PDA) closure. MATERIALS AND METHODS: Review of patients ≤20 kg in whom the Mongoose® catheter was used during PDA closure from 12/13 to 4/15. Angiographic efficacy and procedural details were compared to ten 4 Fr catheter cases. Comparisons were performed using Mann-Whitney U-test; P < 0.05 was statistically significant. RESULTS: Twelve (9 female) patients were catheterized with a 3.3 Fr Mongoose®. Median weight 10.5 kg (range 6.4-18.2), height 81 cm (range 37-111), and body surface area (BSA) 0.47 m2 (range 0.33-0.75) were similar to ten patients (3 females) in the 4 Fr control group (P = NS); median weight 9.9 kg (range 6-16.8), height 80 cm (range 64-102), and BSA 0.46 m2 (range 0.31-0.74). Angiographic quality was subjectively adequate with both with no difference in the median pixel density between the two techniques (3.3 Fr: 76.7 [range 33.5-90] and 4 Fr: [70; 38-102]; P = NS). Contrast used was similar between the groups (3.3 Fr: median 4.2 ml/kg and 4 Fr: 4.9 ml/kg; P = NS). Median radiation dose was similar in the two groups (3.3 Fr: 28.1 mGy [range 17.2-38] and 4 Fr: 38 mGy [range 20.4-58.5]; P = NS). All ducts were closed at latest follow-up (P = NS). No complications were encountered. CONCLUSIONS: The 3.3 Fr Mongoose® allowed similar angiography to the 4 Fr pigtail catheter, allowing safe and effective transcatheter PDA closure in small children.

Radiation dosage during pediatric diagnostic or interventional cardiac catheterizations using the "air gap technique" and an aggressive "as low as reasonably achievable" radiation reduction protocol in patients weighing <20 kg.

BACKGROUND: Cardiac catheterizations expose both the patient and staff to the risks of ionizing radiation. Studies using the "air gap" technique (AGT) in various radiological procedures indicate that its use leads to reduction in radiation exposure but there are no data on its use for pediatric cardiac catheterization. The aim of this study was to retrospectively review the radiation exposure data for children weighing <20 kg during cardiac catheterizations using AGT and an "as low as reasonably achievable (ALARA)" radiation reduction protocol. PATIENTS AND METHODS: All patients weighing <20 kg who underwent cardiac catheterization at the Children's Hospital at Montefiore (CHAM), New York, the United States from 05/2011 to 10/2013 were included. Transplant patients who underwent routine endomyocardial biopsy and those who had surgical procedures at the time of the catheterizations were excluded. The ALARA protocol was used in concert with AGT with the flat panel detector positioned 110 cm from the patient. Demographics, procedural data, and patient radiation exposure levels were collected and analyzed. RESULTS: One-hundred and twenty-seven patients underwent 151 procedures within the study period. The median age was 1.2 years (range: 1 day to 7.9 years) and median weight was 8.8 kg (range: 1.9-19.7). Eighty-nine (59%) of the procedures were interventional. The median total fluoro time was 13 min [interquartile range (IQR) 7.3-21.8]. The median total air Kerma (K) product was 55.6 mGy (IQR 17.6-94.2) and dose area product (DAP) was 189 Gym2 (IQR 62.6-425.5). CONCLUSION: Use of a novel ALARA and AGT protocol for cardiac catheterizations in children markedly reduced radiation exposure to levels far below recently reported values. ABBREVIATIONS: AGT: Air gap technique, ALARA: As low as reasonably achievable.

CRIB scores as a tool for assessing risk for the development of pulmonary hypertension in extremely preterm infants with bronchopulmonary dysplasia.

OBJECTIVE: Bronchopulmonary dysplasia (BPD) increases the risk for developing pulmonary hypertension (PH). However, the risk factors associated with BPD-associated PH remain unclear. Our primary aim was to determine perinatal risk factors associated with the development of PH in infants with BPD. STUDY DESIGN: We retrospectively reviewed medical records of 303 infants born at ≤ 28 weeks' gestation. Infants were categorized as having no, mild, moderate, or severe BPD. PH was diagnosed by echocardiogram. Data were analyzed using Fisher exact test, two-sample t-test, and multivariable logistic regression. RESULTS: The incidence of PH in our cohort was 12%. Infants with PH had lower birth weights and gestational ages (p < 0.001). After controlling for confounding variables, severe BPD (p < 0.001), and higher Clinical Risk Index for Babies (CRIB) scores (p = 0.04) were associated with the development of PH. CONCLUSION: Severe BPD increases the risk for developing PH. Higher CRIB scores correlate with PH development in infants with BPD. We speculate that CRIB scores may allow for early categorization of preterm infants with a higher likelihood of developing PH.

Intervening for RPA stenosis following Waterston shunt: Importance of anatomical definition of the coronary arteries.

Right pulmonary artery (RPA) stenosis following Waterston shunt is common. We report a case of RPA stenosis many years following tetralogy of Fallot repair with take-down of a Waterston shunt and demonstrate an unusual and important anatomic variant of proximity of the left coronary artery to the mid-portion of the RPA.

Pediatric patient radiation dosage during endomyocardial biopsies and right heart catheterization using a standard "ALARA" radiation reduction protocol in the modern fluoroscopic era.

BACKGROUND: Surveillance endomyocardial biopsy (EMB) with right heart catheterization (RHC) is the standard of care for the assessment of post cardiac transplantation rejection. This procedure has traditionally relied upon fluoroscopy, which exposes both patient and staff to the risks of ionizing radiation. These risks may be of particular concern in the transplant patient who must undergo many such procedures lifelong. We present data on a new "ALARA - As Low As Reasonably Achievable" protocol to reduce radiation exposure during the performance of RHC with EMB. METHODS: All cardiac transplantation patients < 21 years of age who underwent RHC with EMB at The Children's Hospital at Montefiore from 6/11-12/11 were included. EMB was performed after all right heart pressures including wedge pressure and thermodilution cardiac output were measured. A novel ALARA protocol consisting of multiple features including ultra-low frame rates (2-3 fps), low fluoro dose/frame (10-18 nGy/frame), use of the "air-gap" technique for patients < 20 kg, and multiple other techniques aimed at minimizing use of fluoroscopy were employed in all cases. Demographics, procedural data and patient radiation exposure levels were collected and analyzed. RESULTS: 18 patients underwent 45 surveillance RHC with EMB in the study period and were the subject of this analysis. The mean age was 5.9 ± 6.1 years, weight was 20.4 kg ± 16.6 kg, and BSA was 0.75 ± 45 m(2) . PA fluoroscopy was used exclusively in 45/45. Vascular access was RFV (21/45; 47%), RIJV (17/45; 38%), LFV (4/45; 9%) and LIJV (3/45; 7%). The median number of EMB specimens obtained was 5 (range, 4-7). The median fluoroscopy time was 3.7 min (range, 1.2-9). The median air Kerma product (K) was 1.4 mGy (range, 0.4-14), and dose area product (DAP) was 15.8 uGym(2) (range, 3.5-144.5). The K and DAP are substantially lower than any prior published data for RHC/EMB in this patient group. There were no procedural complications. CONCLUSIONS: The use of a novel ALARA protocol for RHC and EMB in pediatric cardiac transplantation patients markedly reduced radiation exposure to levels far below any previously reported values without negatively affecting the safety or efficacy of these procedures.