Health Equity and Policy Considerations for Pediatric and Adult Congenital Heart Disease Care among Minoritized Populations in the United States.

Achieving health equity in populations with congenital heart disease (CHD) requires recognizing existing disparities throughout the lifespan that negatively and disproportionately impact specific groups of individuals. These disparities occur at individual, institutional, or system levels and often result in increased morbidity and mortality for marginalized or racially minoritized populations (population subgroups (e.g., ethnic, racial, social, religious) with differential power compared to those deemed to hold the majority power in the population). Creating actionable strategies and solutions to address these health disparities in patients with CHD requires critically examining multilevel factors and health policies that continue to drive health inequities, including varying social determinants of health (SDOH), systemic inequities, and structural racism. In this comprehensive review article, we focus on health equity solutions and health policy considerations for minoritized and marginalized populations with CHD throughout their lifespan in the United States. We review unique challenges that these populations may face and strategies for mitigating disparities in lifelong CHD care. We assess ways to deliver culturally competent CHD care and to help lower-health-literacy populations navigate CHD care. Finally, we review system-level health policies that impact reimbursement and research funding, as well as institutional policies that impact leadership diversity and representation in the workforce.

In Utero Presentation of Left Ventricular Aneurysm.

Congenital left ventricular aneurysm, pseudoaneurysm, and diverticulum are rare entities. These diagnoses can be made pre- and/or postnatally. Although these entities overlap clinically and morphologically, important distinctions can allow for accurate diagnoses. Appropriate diagnosis can be imperative for risk stratification and guidance of prenatal and postnatal management. The case described in the present report highlights a challenging case of a fetal left ventricular aneurysm, management during the prenatal and postnatal periods, and important differentiating features from a ventricular diverticulum and pseudoaneurysm.

Cardiac Magnetic Resonance Strain in Beta Thalassemia Major Correlates with Cardiac Iron Overload.

BACKGROUND: Beta thalassemia major (Beta-TM) is an inherited condition which presents at around two years of life. Patients with Beta-;TM may develop cardiac iron toxicity secondary to transfusion dependence. Cardiovascular magnetic resonance (CMR) T2*, a technique designed to quantify myocardial iron deposition, is a driving component of disease management. A decreased T2* value represents increasing cardiac iron overload. The clinical manifestation is a decline in ejection fraction (EF). However, there may be early subclinical changes in cardiac function that are not detected by changes in EF. CMR-derived strain assesses myocardial dysfunction prior to decline in EF. Our primary aim was to assess the correlation between CMR strain and T2* in the Beta-TM population. METHODS: Circumferential and longitudinal strain was analyzed. Pearson's correlation was calculated for T2* values and strain in the Beta-TM population. RESULTS: We identified 49 patients and 18 controls. Patients with severe disease (low T2*) were found to have decreased global circumferential strain (GCS) in comparison to other T2* groups. A correlation was identified between GCS and T2* (r = 0.5; p < 0.01). CONCLUSION: CMR-derived strain can be a clinically useful tool to predict early myocardial dysfunction in Beta-TM.

A Prospective Study Evaluating the Effects of SSRI Exposure on Cardiac Size and Function in Newborns.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are antidepressants prescribed in 10% of pregnancies in the USA. We have previously shown in preclinical studies that sertraline exposure impacts cardiomyocyte development, leading to reductions in left ventricular size and cardiac function. OBJECTIVES: We hypothesized that in utero SSRI exposure will lead to reduced left ventricular dimensions and cardiac function on echocardiography immediately after birth. METHODS: Twenty term infants with and 21 term infants without in utero exposure to SSRIs underwent echocardiograms to assess cardiac size and function. The exclusion criteria for infants were prematurity, small or large for gestational age, any respiratory or cardiovascular support needed after birth, and any major congenital malformation. RESULTS: Infants exposed to in utero SSRIs had significantly reduced right ventricular dimensions in the diastole (controls 1.0 cm [0.86, 1.20], SSRI 0.89 cm [0.730, 1.05], p = 0.03), and left ventricular lengths in the diastole and systole (diastole: controls 3.4 cm [3.25, 3.65], SSRI 3.25 cm [3.10, 3.45], p = 0.03; systole: controls 2.9 cm [2.65, 3.05], SSRI 2.6 cm [2.50, 2.85], p = 0.01). No differences were observed in cardiac function. Importantly, there were no differences in maternal conditions or infant birth weight, body surface area, or gestational age. CONCLUSIONS: Our findings suggest an association between in utero exposure to SSRIs and ventricular size in infants. Given the increasing use of SSRIs during pregnancy and the importance of early life programming on future cardiovascular health, larger studies need to be completed to determine if in utero SSRI exposure impacts ventricular size.

Manifold recovery using kernel low-rank regularization: application to dynamic imaging.

We introduce a novel kernel low-rank algorithm to recover free-breathing and ungated dynamic MRI data from highly undersampled measurements. The image frames in the free breathing and ungated dataset are assumed to be points on a bandlimited manifold. We show that the non-linear features of these images satisfy annihilation conditions, which implies that the kernel matrix derived from the dataset is low-rank. We penalize the nuclear norm of the feature matrix to recover the images from highly undersampled measurements. The regularized optimization problem is solved using an iterative reweighted least squares (IRLS) algorithm, which alternates between the update of the Laplacian matrix of the manifold and the recovery of the signals from the noisy measurements. To improve computational efficiency, we use a two step algorithm using navigator measurements. Specifically, the Laplacian matrix is estimated from the navigators using the IRLS scheme, followed by the recovery of the images using a quadratic optimization. We show the relation of this two step algorithm with our recent SToRM approach, thus reconciling SToRM and manifold regularization methods with algorithms that rely on explicit lifting of data to a high dimensional space. The IRLS based estimation of the Laplacian matrix is a systematic and noise-robust alternative to current heuristic strategies based on exponential maps. We also approximate the Laplacian matrix using a few eigen vectors, which results in a fast and memory efficient algorithm. The proposed scheme is demonstrated on several patients with different breathing patterns and cardiac rates.

A tale of two neglected tropical infections: using GIS to assess the spatial and temporal overlap of schistosomiasis and leprosy in a region of Minas Gerais, Brazil

BACKGROUND Despite public health efforts to reduce the global burden of leprosy, gaps remain in the knowledge surrounding transmission of infection. Helminth co-infections have been associated with a shift towards the lepromatous end of the disease spectrum, potentially increasing transmission in co-endemic areas. OBJECTIVES Using this biologically plausible association, we conducted a geographic information systems (GIS) study to investigate the spatial associations of schistosomiasis and leprosy in an endemic area of Minas Gerais (MG), Brazil. METHODS Data on new cases of Mycobacterium leprae and Schistosoma mansoni infections from 2007-2014 were retrieved from the Brazilian national notifiable diseases information system for seven municipalities in and surrounding Vespasiano, MG. A total of 139 cases of leprosy and 200 cases of schistosomiasis were mapped to a municipality level. For one municipality, cases were mapped to a neighborhood level and a stratified analysis was conducted to identify spatial associations. FINDINGS A relative risk of 6.80 [95% confidence interval (CI) 1.46 - 31.64] of leprosy was found in neighborhoods with schistosomiasis. Incidence rates of leprosy increased with corresponding incidence rates of schistosomiasis, and the temporal trends of both infections were similar. CONCLUSIONS The associations found in this project support the hypothesis that helminth infections may influence the transmission of leprosy in co-endemic areas.

A tale of two neglected tropical infections: using GIS to assess the spatial and temporal overlap of schistosomiasis and leprosy in a region of Minas Gerais, Brazil.

BACKGROUND: Despite public health efforts to reduce the global burden of leprosy, gaps remain in the knowledge surrounding transmission of infection. Helminth co-infections have been associated with a shift towards the lepromatous end of the disease spectrum, potentially increasing transmission in co-endemic areas. OBJECTIVES: Using this biologically plausible association, we conducted a geographic information systems (GIS) study to investigate the spatial associations of schistosomiasis and leprosy in an endemic area of Minas Gerais (MG), Brazil. METHODS: Data on new cases of Mycobacterium leprae and Schistosoma mansoni infections from 2007-2014 were retrieved from the Brazilian national notifiable diseases information system for seven municipalities in and surrounding Vespasiano, MG. A total of 139 cases of leprosy and 200 cases of schistosomiasis were mapped to a municipality level. For one municipality, cases were mapped to a neighborhood level and a stratified analysis was conducted to identify spatial associations. FINDINGS: A relative risk of 6.80 [95% confidence interval (CI) 1.46 - 31.64] of leprosy was found in neighborhoods with schistosomiasis. Incidence rates of leprosy increased with corresponding incidence rates of schistosomiasis, and the temporal trends of both infections were similar. CONCLUSIONS: The associations found in this project support the hypothesis that helminth infections may influence the transmission of leprosy in co-endemic areas.

Tissue Plasminogen Activator Use in Children: Bleeding Complications and Thrombus Resolution.

OBJECTIVE: To review our institutional experience with tissue plasminogen activator (tPA) to determine outcomes related to bleeding complications and thrombus resolution. STUDY DESIGN: We performed a retrospective review of all patients who received systemic tPA for thrombolysis. Data points included location of thrombus, initial and maximum tPA dose, and duration of tPA. The primary endpoint was bleeding complication. RESULTS: Between 2005 and 2014, 46 patients received systemic tPA for thrombolysis: 17 (37%) were patients with a primary cardiac diagnosis, there were 17 (37%) hematology/oncology patients, and 12 (26%) patients with noncardiac, nonhematology/oncology diagnoses. The indication for tPA was central venous thrombus (n = 23), pulmonary artery thrombus (n = 9), and cardiac or aortic thrombus (n = 14). Bleeding complications occurred in 15 patients (33%). Median initial tPA dose in the bleeding complication group was 0.10 mg/kg/h vs 0.03 mg/kg/h in the group without bleeding complication group (P = .01). Cardiac patients experienced more bleeding complications (P = .01). Multivariate analysis indicated that dose of tPA (P = .01) and diagnostic category (P < .01) were associated with bleeding complication. Complete thrombus resolution occurred in 21 patients, partial in 10 patients, and no resolution in 15 patients. Complete resolution of thrombus was not associated with diagnosis, thrombus location, tPA dose, or duration. CONCLUSIONS: Cardiac patients appear to be at highest risk of bleeding complication; bleeding complications were associated with higher doses of tPA, and cardiac patients were the cohort who received the highest doses of tPA. Higher tPA doses are associated with increased risk of bleeding complication but are not associated with successful thrombus resolution.

Memory deficit associated with worse functional trajectories in older adults in low-vision rehabilitation for macular disease.

OBJECTIVES: To examine whether performance on a brief memory test is related to functional outcomes in older individuals undergoing low-vision rehabilitation (LVR) for macular disease. DESIGN: Observational cohort study of individuals receiving outpatient LVR. SETTING: Academic center. PARTICIPANTS: Ninety-one individuals (average age 80.1) with macular disease. MEASUREMENTS: Memory was assessed at baseline using a 10-word list; memory deficit was defined as immediate recall of two or fewer words. Vision-related function was measured using the 25-item Visual Function Questionnaire (VFQ-25) administered at baseline and during subsequent interviews (mean follow-up, 115 days). Linear mixed models were constructed to compare average trajectories of four VFQ-25 subscales: near activities, distance activities, dependency, and role difficulty. RESULTS: The 29.7% of participants with memory deficits tended to decline in ability to accomplish activities that involved near vision. Controlling for age, sex, and education, the functional trajectory of participants with memory deficit differed significantly from that of those with better memory (P = .002), who tended to report improvements in ability to accomplish near activities. CONCLUSION: Of older adults receiving LVR for macular disease, those with memory deficits experienced worse functional trajectories in their ability to perform specific visually mediated tasks. A brief memory screen may help explain variability in rehabilitation outcomes and identify individuals who might require special accommodations.

Categorizing the effect of comorbidity: a qualitative study of individuals' experiences in a low-vision rehabilitation program.

OBJECTIVES: To identify generalizable ways that comorbidity affects older adults' experiences in a health service program directed toward an index condition and to develop a framework to assist clinicians in approaching comorbidity in the design, delivery, and evaluation of such interventions. DESIGN: A qualitative data content analysis of interview transcripts to identify themes related to comorbidity. SETTING: An outpatient low-vision rehabilitation program for macular disease. PARTICIPANTS: In 2007/08, 98 individuals undergoing low-vision rehabilitation and their companions provided 624 semistructured interviews that elicited perceptions about barriers and facilitators of successful program participation. RESULTS: The interviews revealed five broad themes about comorbidity: (i) "good days, bad days," reflecting participants' fluctuating health status during the program because of concurrent medical problems; (ii) "communication barriers." which were sometimes due to participant impairments and sometimes situational; (iii) "overwhelmed," which encompassed pragmatic and emotional concerns of participants and caregivers; (iv) "delays," which referred to the tendency of comorbidities to delay progress in the program and to confer added inconvenience during lengthy appointments; and (v) value of companion involvement in overcoming some barriers imposed by comorbid conditions. CONCLUSION: This study provides a taxonomy and conceptual framework for understanding consequences of comorbidity in the experience of individuals receiving a health service. If confirmed in individuals receiving interventions for other index diseases, the framework suggests actionable items to improve care and facilitate research involving older adults.

Comorbid cognitive impairment and functional trajectories in low vision rehabilitation for macular disease.

BACKGROUND AND AIMS: Comorbid cognitive impairment is common among visually impaired older adults. This study investigated whether baseline cognitive status predicts functional trajectories among older adults in low vision rehabilitation (LVR) for macular disease. METHODS: The Telephone Interview for Cognitive Status - modified (TICS-m) was administered to macular disease patients aged ≥ 65 years receiving outpatient LVR. Mixed models assessed the rate of change in instrumental activities of daily living and visual function measures over a mean follow-up of 115 days. RESULTS: Of 91 participants, 17 (18.7%) had cognitive impairment (TICS-m score ≤ 27) and 23 (25.3%) had marginal impairment (TICS-m scores 28 to 30). Controlling for age and gender, baseline cognitive status did not predict most functional outcomes. However, participants with marginal cognitive impairment experienced worse functional trajectories in ability to prepare meals (p=0.03) and activities that require distance vision (p=0.05). CONCLUSION: Patients with mild to moderate cognitive impairment should not be excluded from LVR, but programs should be prepared to detect and accommodate a range of cognitive ability.

Prevalence and patterns of comorbid cognitive impairment in low vision rehabilitation for macular disease.

The prevalence of comorbid cognitive impairment among older adults referred to low vision rehabilitation (LVR) for macular disease is unknown. We performed cognitive testing on 101 adults aged 65 years or older with macular disease who were referred to The Duke LVR Clinic between September 2007 and March 2008. Scores on the telephone interview for cognitive status-modified (TICS-m) ranged from 7 to 44, with 18.8% of scores below an established cutoff for cognitive impairment (< or = 27) and an additional 27.7% of scores considered marginal (28-30). On letter fluency, 46% of participants scored at least 1 x standard deviation (SD) below the mean for their age, gender, race, and education level, and 18% of participants scored at least 2 x below their demographic mean. On logical memory, 26% of participants scored at least 1x below the mean for their age group and race and 6% scored at least 2 x below their demographic mean. High prevalence of cognitive impairment, with particular difficulty in verbal fluency and verbal memory, may compromise the success of LVR interventions among macular disease patients. Additional work is needed to develop strategies to maximize function in older adults with this common comorbidity.