Characterizing the Use of Exercise Testing in Repaired Tetralogy of Fallot Patients: A Multi-Institutional Survey.

Cardiopulmonary exercise testing (CPET) is an important tool used in the management of patients with congenital heart disease. However, there are no clear guidelines for its use in specific populations, such as repaired Tetralogy of Fallot (rTOF). We sought to characterize current practice patterns and attitudes regarding exercise testing in the rTOF population using an online survey distributed to pediatric cardiologists. Analyses were performed using qualitative statistics, Wilcoxon rank-sum, Kruskal-Wallis test, and chi-squared analysis. 103 clinicians completed the survey with 83% routinely sending symptomatic rTOF patients for exercise testing and 59% for asymptomatic patients. Respondents who routinely test asymptomatic patients reported higher levels of perceived helpfulness of exercise testing (p < 0.01) and comfort with CPET interpretation (p < 0.01). Although a large majority of respondents found exercise testing to be helpful (81% either "somewhat" or "very" helpful"), a considerably smaller portion indicated comfort with CPET interpretation (49% either "comfortable" or "very comfortable"). Nearly all respondents (92%) reported changing management primarily based on exercise testing results. However, the frequency of changes varied, with 10% "frequently", 62% "occasionally", 19% "rarely" changing management. There was a statistically significant relationship between the perceived helpfulness of exercise testing and the likelihood of management changes (p < 0.01). While exercise testing is used to make clinical decisions, our findings suggest that in some cases, management changes may be made without a similar degree of confidence in interpreting CPET findings. The variability in attitudes and practices highlights the need for evidence-based guidelines addressing exercise testing in rTOF, particularly for asymptomatic patients.

Characterizing the Use of Exercise Testing in Repaired Tetralogy of Fallot Patients: A Multi-Institutional Survey.

Long-term survival for repaired Tetralogy of Fallot (rTOF) is excellent. We achieve this by close clinical monitoring to stratify prognosis and guide clinical decision-making. Cardiopulmonary exercise stress testing (CPET) is used to help guide clinical decision making; however, there are no clear guidelines for its use in this population. We sought to describe practice variability with regards to exercise testing for rTOF patients and how exercise data is used to guide management. We distributed a survey to pediatric cardiologists via email. Analyses were performed using qualitative statistics, two-sample T-tests, and chi-squared analysis. One-hundred and three clinicians completed the survey with 83% reporting that they routinely send symptomatic rTOF patients for exercise testing and 59% for asymptomatic patients. Respondents who routinely test asymptomatic patients reported higher levels of perceived helpfulness of exercise testing (p = 0.04) and comfort with CPET interpretation (p = 0.03). Nearly all respondents (92%) reported changing management primarily based on exercise testing results, with 62% reporting "occasionally changing management" and 10% reporting "frequently changing management". Results indicated that exercise test results influenced clinical decisions, such as the timing of interventions, need for additional imaging, or the initiation of exercise interventions. There was a statistically significant relationship between the perceived helpfulness of exercise testing and the likelihood of management changes (p < 0.01). The variability in attitudes and practices highlights the need for evidence-based guidelines addressing exercise testing in rTOF, particularly for asymptomatic patients.

Colorectal Cancer Screening Decisions From Student-Led Telemedicine Initiative During COVID-19.

Background and Objectives: With the onset of the COVID-19 pandemic, there has been a significant decrease in colorectal cancer (CRC) screening leading to delayed diagnoses and increased cancer deaths. To mitigate these burgeoning gaps in care, we developed a medical student-led service learning project aimed at improving rates of colorectal cancer screening at the Farrell Health Center (FHC), a primary care practice within the Ambulatory Care Network (ACN) at New York-Presbyterian Hospital. Methods: A cohort of 973 FHC patients aged 50-75 years were identified as possibly overdue for screening. Student volunteers reviewed patient charts to confirm screening eligibility and then contacted patients to offer colonoscopy or stool DNA test. Following the patient outreach intervention, medical student volunteers completed a questionnaire to assess the educational value for the service-learning experience. Results: Fifty-three percent of identified patients were due for CRC screening; 67.8% of eligible patients were reached by volunteers. Among the patients reached, 47.0% were referred for CRC screening. No statistical significance was observed between likelihood of CRC screening acceptance and patient age or sex; 87% of medical student volunteers felt that the service-learning project was a valuable educational experience. Conclusion: The student-led patient telehealth outreach program is an effective model for identifying and referring patients overdue for CRC screening and an enriching educational experience for preclinical medical students. The structure provides a valuable framework to address gaps in health care maintenance.

Developmental Exposure to Low Concentrations of Organophosphate Flame Retardants Causes Life-Long Behavioral Alterations in Zebrafish.

As the older class of brominated flame retardants (BFRs) are phased out of commercial use because of findings of neurotoxicity with developmental exposure, a newer class of flame retardants have been introduced, the organophosphate flame retardants (OPFRs). Presently, little is known about the potential for developmental neurotoxicity or the behavioral consequences of OPFR exposure. Our aim was to characterize the life-long neurobehavioral effects of 4 widely used OPFRs using the zebrafish model. Zebrafish embryos were exposed to 0.1% DMSO (vehicle control); or one of the following treatments; isopropylated phenyl phosphate (IPP) (0.01, 0.03, 0.1, 0.3 µM); butylphenyl diphenyl phosphate (BPDP) (0.003, 0.03, 0.3, 3 µM); 2-ethylhexyl diphenyl phosphate (EHDP) (0.03, 0.3, 1 µM); isodecyl diphenyl phosphate (IDDP) (0.1, 0.3, 1, 10 µM) from 0- to 5-days postfertilization. On Day 6, the larvae were tested for motility under alternating dark and light conditions. Finally, at 5-7 months of age the exposed fish and controls were tested on a battery of behavioral tests to assess emotional function, sensorimotor response, social interaction and predator evasion. These tests showed chemical-specific short-term effects of altered motility in larvae in all of the tested compounds, and long-term impairment of anxiety-related behavior in adults following IPP, BPDP, or EHDP exposures. Our results show that OPFRs may not be a safe alternative to the phased-out BFRs and may cause behavioral impacts throughout the lifespan. Further research should evaluate the risk to mammalian experimental models and humans.

Developmental exposure to low concentrations of two brominated flame retardants, BDE-47 and BDE-99, causes life-long behavioral alterations in zebrafish.

BACKGROUND: Polybrominated diphenyl ethers (PBDEs) were widely used as flame retardants until the early 2000s, mainly in home furnishings and electronics. The persistence of PBDEs in the environment leads to continued ubiquitous exposure to low levels, with infants and children experiencing higher exposures than adults. Accumulating evidence suggest that low-level exposures during early life stages can affect brain development and lead to long-term behavioral impairments. We investigated the effects of zebrafish exposure to low doses of the two prominent PBDEs; 2,2',4,4',5,-Pentabromodiphenyl ether (BDE-99) and 2,2',4,4',-Tetrabromodiphenyl ether (BDE-47), during embryo-development on short- and long-term behavioral endpoints. We included the organophosphate pesticide chlorpyrifos (CPF) due to its well documented neurotoxicity across species from zebrafish to humans. METHODS: Zebrafish embryos were exposed to the following individual treatments; 0.1% DMSO (vehicle control); 0.3µM CPF; 0.01, 0.03, 0.1, 0.3µM BDE-47; 0.003, 0.03, 0.3, 1, 3, 10, 20µM BDE-99 from 5 until 120h post fertilization (hpf). Low exposure levels were determined as those not causing immediate overt toxicity, and behavior assays were conducted in the low-level range. At 144 hpf the larvae were tested for locomotor activity. At approximately 6 months of age adult zebrafish were tested in a behavioral battery including assays for anxiety-related behavior, sensorimotor response and habituation, social interaction, and predator avoidance. RESULTS: In the short-term, larval locomotor activity was reduced in larvae treated with 0.3µM CPF and 0.1µM BDE-47. BDE-99 treatment caused non-monotonic dose effects, with 0.3µM causing hyperactivity and 1µM or higher causing hypoactivity. In the long-term, adult anxiety-related behavior was reduced in all treatments as measured in both the novel tank dive test and tap test. DISCUSSION: We show that exposure of zebrafish embryos to low concentrations of the brominated flame retardants BDE-47 and BDE-99, and the organophosphate pesticide CPF, caused both short- and long-term behavioral impairments. Interestingly, we also found that at very low exposure concentrations, where there were no visible effects on larval activity, adult behavior was still strongly affected.