First name
Heather
Middle name
M
Last name
Griffis

Title

Compression-Only Versus Rescue-Breathing Cardiopulmonary Resuscitation After Pediatric Out-of-Hospital Cardiac Arrest.

Year of Publication

2021

Number of Pages

1042-1052

Date Published

2021 Sep 07

ISSN Number

1558-3597

Abstract

<p><strong>BACKGROUND: </strong>There are conflicting data regarding the benefit of compression-only bystander cardiopulmonary resuscitation (CO-CPR) compared with CPR with rescue breathing (RB-CPR) after pediatric out-of-hospital cardiac arrest (OHCA).</p>

<p><strong>OBJECTIVES: </strong>This study sought to test the hypothesis that RB-CPR is associated with improved neurologically favorable survival compared with CO-CPR following pediatric OHCA, and to characterize age-stratified outcomes with CPR type compared with no bystander CPR (NO-CPR).</p>

<p><strong>METHODS: </strong>Analysis of the CARES registry (Cardiac Arrest Registry to Enhance Survival) for nontraumatic pediatric OHCAs (patients aged&nbsp;≤18 years) from 2013-2019 was performed. Age groups included infants (&lt;1 year), children (1 to 11 years), and adolescents (≥12 years). The primary outcome was neurologically favorable survival at hospital discharge.</p>

<p><strong>RESULTS: </strong>Of 13,060 pediatric OHCAs, 46.5% received bystander CPR. CO-CPR was the most common bystander CPR type. In the overall cohort, neurologically favorable survival was associated with RB-CPR (adjusted OR: 2.16; 95%&nbsp;CI: 1.78-2.62) and CO-CPR (adjusted OR: 1.61; 95%&nbsp;CI: 1.34-1.94) compared with NO-CPR. RB-CPR was associated with a higher odds of neurologically favorable survival compared with CO-CPR (adjusted OR: 1.36; 95%&nbsp;CI: 1.10-1.68). In age-stratified analysis, RB-CPR was associated with better neurologically favorable survival versus NO-CPR in all age groups. CO-CPR was associated with better neurologically favorable survival compared with NO-CPR in children and adolescents, but not in infants.</p>

<p><strong>CONCLUSIONS: </strong>CO-CPR was the most common type of bystander CPR in pediatric OHCA. RB-CPR was associated with better outcomes compared with CO-CPR. These results support present guidelines for RB-CPR as the preferred CPR modality for pediatric OHCA.</p>

DOI

10.1016/j.jacc.2021.06.042

Alternate Title

J Am Coll Cardiol

PMID

34474737

Title

The influence of mechanical Circulatory support on post-transplant outcomes in pediatric patients: A multicenter study from the International Society for Heart and Lung Transplantation (ISHLT) Registry.

Year of Publication

2021

Date Published

2021 Jun 11

ISSN Number

1557-3117

Abstract

<p><strong>BACKGROUND: </strong>Mechanical circulatory support (MCS) is increasingly being used as a bridge to transplant in pediatric patients. We compare outcomes in pediatric patients bridged to transplant with MCS from an international cohort.</p>

<p><strong>METHODS: </strong>This retrospective cohort study of heart-transplant patients reported to the International Society for Heart and Lung Transplantation (ISHLT) registry from 2005-2017 includes 5,095 patients &lt;18 years. Pretransplant MCS exposure and anatomic diagnosis were derived. Outcomes included mortality, renal failure, and stroke.</p>

<p><strong>RESULTS: </strong>26% of patients received MCS prior to transplant: 240 (4.7%) on extracorporeal membrane oxygenation (ECMO), 1,030 (20.2%) on ventricular assist device (VAD), and 54 (1%) both. 29% of patients were &lt;1 year, and 43.8% had congenital heart disease (CHD). After adjusting for clinical characteristics, compared to no-MCS and VAD, ECMO had higher mortality during their transplant hospitalization [OR 3.97 &amp; 2.55; 95% CI 2.43-6.49 &amp; 1.42-4.60] while VAD mortality was similar [OR 1.55; CI 0.99-2.45]. Outcomes of ECMO+VAD were similar to ECMO alone, including increased mortality during transplant hospitalization compared to no-MCS [OR 4.74; CI 1.81-12.36]. Patients with CHD on ECMO had increased 1 year, and 10 year mortality [HR 2.36; CI 1.65-3.39], [HR 1.82; CI 1.33-2.49]; there was no difference in survival in dilated cardiomyopathy (DCM) patients based on pretransplant MCS status.</p>

<p><strong>CONCLUSION: </strong>Survival in CHD and DCM is similar in patients with no MCS or VAD prior to transplant, while pretransplant ECMO use is strongly associated with mortality after transplant particularly in children with CHD. In children with DCM, long term survival was equivalent regardless of MCS status.</p>

DOI

10.1016/j.healun.2021.06.003

Alternate Title

J Heart Lung Transplant

PMID

34253457

Title

Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects.

Year of Publication

2020

Date Published

2020 Jul 16

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center.</p>

<p><strong>DESIGN: </strong>Quality improvement project.</p>

<p><strong>SETTING: </strong>High volume cardiac center, tertiary care children's hospital.</p>

<p><strong>PATIENTS: </strong>Neonates undergoing Norwood operation.</p>

<p><strong>INTERVENTIONS: </strong>The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02).</p>

<p><strong>CONCLUSIONS: </strong>This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.</p>

DOI

10.1097/PCC.0000000000002478

Alternate Title

Pediatr Crit Care Med

PMID

32701749

Title

Prevalence and Cause of Early Fontan Complications: Does the Lymphatic Circulation Play a Role?

Year of Publication

2020

Number of Pages

e015318

Date Published

2020 Apr 07

ISSN Number

2047-9980

Abstract

<p><strong>Background</strong> Recent studies suggest that lymphatic congestion plays a role in development of late Fontan complications, such as protein-losing enteropathy. However, the role of the lymphatic circulation in early post-Fontan outcomes is not well defined.</p>

<p><strong>Methods and Results</strong> This was a retrospective, single-center study of patients undergoing first-time Fontan completion from 2012 to 2017. The primary outcome was ≤6&nbsp;months after surgery, a composite of death, Fontan takedown, extracorporeal membrane oxygenation, chest tube drainage &gt;14&nbsp;days, cardiac catheterization, readmission, or transplant. Complication causes were assigned to 1 of 4 groups: (1) Fontan circuit obstruction, (2) ventricular dysfunction or atrioventricular valve regurgitation, (3) persistent pleural effusions Fontan obstruction or ventricular dysfunction, and (4) chylothorax or plastic bronchitis. T2-weighted magnetic resonance imaging sequences were used to assess for lymphatic perfusion abnormality. The cohort consisted of 238 patients. Fifty-eight (24%) developed early complications: 20 of 58 (34.5%) in group 1, 8 of 58 (14%) in group 2, 18 of 58 (31%) in group 3, and 12 of 58 (20%) in group 4. Preoperative T2 imaging was available for 126 (53%) patients. Patients with high-grade lymphatic abnormalities had 6 times greater odds of developing early complications (=0.001).</p>

<p><strong>Conclusions </strong>There is substantial morbidity in the early post-Fontan period. Half of those who developed early complications had lymphatic failure or persistent effusions unrelated to structural or functional abnormalities. Preoperative T2 imaging demonstrated that patients with higher-grade lymphatic perfusion abnormalities were significantly more likely to develop early complications. This has implications for risk stratification and optimization of patients before Fontan palliation.</p>

DOI

10.1161/JAHA.119.015318

Alternate Title

J Am Heart Assoc

PMID

32223393

Title

Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES.

Year of Publication

2019

Number of Pages

e012637

Date Published

2019 Jul 16

ISSN Number

2047-9980

Abstract

<p>Background Whether racial and neighborhood characteristics are associated with bystander cardiopulmonary resuscitation ( BCPR ) in pediatric out-of-hospital cardiac arrest ( OHCA ) is unknown. Methods and Results An analysis was conducted of CARES (Cardiac Arrest Registry to Enhance Survival) for pediatric nontraumatic OHCA s from 2013 to 2017. An index (range, 0-4) was created for each arrest based on neighborhood characteristics associated with low BCPR (&gt;80% black; &gt;10% unemployment; &lt;80% high school; median income, &lt;$50&nbsp;000). The primary outcome was BCPR . BCPR occurred in 3399 of 7086 OHCA s (48%). Compared with white children, BCPR was less likely in other races/ethnicities (black: adjusted odds ratio [ aOR ], 0.59; 95% CI , 0.52-0.68; Hispanic: aOR , 0.78; 95% CI , 0.66-0.94; and other: aOR , 0.54; 95% CI , 0.40-0.72). Compared with arrests in neighborhoods with an index score of 0, BCPR occurred less commonly for arrests with an index score of 1 ( aOR , 0.80; 95% CI , 0.70-0.91), 2 ( aOR , 0.75; 95% CI , 0.65-0.86), 3 ( aOR , 0.52; 95% CI , 0.45-0.61), and 4 ( aOR , 0.46; 95% CI , 0.36-0.59). Black children had an incrementally lower likelihood of BCPR with increasing index score while white children had an overall similar likelihood at most scores. Black children with an index of 4 were approximately half as likely to receive BCPR compared with white children with a score of 0. Conclusions Racial and neighborhood characteristics are associated with BCPR in pediatric OHCA . Targeted CPR training for nonwhite, low-education, and low-income neighborhoods may increase BCPR and improve pediatric OHCA outcomes.</p>

DOI

10.1161/JAHA.119.012637

Alternate Title

J Am Heart Assoc

PMID

31288613

Title

Preoperative Clinical and Echocardiographic Factors Associated with Surgical Timing and Outcomes in Primary Repair of Common Atrioventricular Canal Defect.

Year of Publication

2019

Date Published

2019 May 07

ISSN Number

1432-1971

Abstract

<p>In complete atrioventricular canal defect (CAVC), there are limited data on preoperative clinical and echocardiographic predictors of operative timing and postoperative outcomes. A retrospective, single-center analysis of all patients who underwent primary biventricular repair of CAVC between 2006 and 2015 was performed. Associated cardiac anomalies (tetralogy of Fallot, double outlet right ventricle) and arch operation were excluded. Echocardiographic findings on first postnatal echocardiogram were correlated with surgical timing and postoperative outcomes using bivariate descriptive statistics and multivariable logistic regression. 153 subjects (40% male, 84% Down syndrome) underwent primary CAVC repair at a median age of 3.3 (IQR 2.5-4.2) months. Median postoperative length of stay (LOS) was 7 (IQR 5-15) days. Eight patients (5%) died postoperatively and 24 (16%) required reoperation within 1&nbsp;year. On multivariable analysis, small aortic isthmus (z score &lt; -&nbsp;2) was associated with early primary repair at &lt; 3&nbsp;months (OR 2.75, 95% CI 1.283-5.91) and need for early reoperation (OR 3.79, 95% CI 1.27-11.34). Preoperative ventricular dysfunction was associated with higher postoperative mortality (OR 7.71, 95% CI 1.76-33.69). Other factors associated with mortality and longer postoperative LOS were prematurity (OR 5.30, 95% CI 1.24-22.47 and OR 5.50, 95% CI 2.07-14.59, respectively) and lower weight at surgery (OR 0.17, 95% CI 0.04-0.75 and OR 0.55, 95% CI 0.35-0.85, respectively). Notably, preoperative atrioventricular valve regurgitation and Down syndrome were not associated with surgical timing, postoperative outcomes or reoperation, and there were no echocardiographic characteristics associated with late reoperation beyond 1 year after repair. Key preoperative echocardiographic parameters helped predict operative timing and postoperative outcomes in infants undergoing primary CAVC repair. Aortic isthmus z score &lt; -&nbsp;2&nbsp; was associated with early surgical repair and need for reoperation, while preoperative ventricular dysfunction was associated with increased mortality. These echocardiographic findings may help risk-stratified patients undergoing CAVC repair and improve preoperative counseling and surgical planning.</p>

DOI

10.1007/s00246-019-02116-0

Alternate Title

Pediatr Cardiol

PMID

31065759

Title

Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow.

Year of Publication

2019

Number of Pages

e007232

Date Published

2019 Apr

ISSN Number

1941-7632

Abstract

<p><strong>BACKGROUND: </strong>In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown.</p>

<p><strong>METHODS AND RESULTS: </strong>Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all).</p>

<p><strong>CONCLUSIONS: </strong>In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.</p>

DOI

10.1161/CIRCINTERVENTIONS.118.007232

Alternate Title

Circ Cardiovasc Interv

PMID

30998390

Title

Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries.

Year of Publication

2018

Number of Pages

2119-2129

Date Published

2018 Nov 06

ISSN Number

1524-4539

Abstract

<p><strong>BACKGROUND: </strong>The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied.</p>

<p><strong>METHODS: </strong>A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models.</p>

<p><strong>RESULTS: </strong>Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age &gt;6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P&lt;0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P&lt;0.004), and higher cost ( P&lt;0.001). Other hospital factors were not independently associated with the outcomes of interest.</p>

<p><strong>CONCLUSIONS: </strong>There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.</p>

DOI

10.1161/CIRCULATIONAHA.118.036145

Alternate Title

Circulation

PMID

30474422

Title

A Mixed Methods Evaluation of Early Childhood Abuse Prevention Within Evidence-Based Home Visiting Programs.

Year of Publication

2018

Date Published

2018 May 31

ISSN Number

1573-6628

Abstract

<p>Objectives In this large scale, mixed methods evaluation, we determined the impact and context of early childhood home visiting on rates of child abuse-related injury. Methods Entropy-balanced and propensity score matched retrospective cohort analysis comparing children of Pennsylvania Nurse-Family Partnership (NFP), Parents As Teachers (PAT), and Early Head Start (EHS) enrollees and children of Pennsylvania Medicaid eligible women from 2008 to 2014. Abuse-related injury episodes were identified in medical assistance claims with ICD-9 codes. Weighted frequencies and logistic regression odds of injury within 24 months are presented. In-depth interviews with staff and clients (n = 150) from 11 programs were analyzed using a modified grounded theory approach. Results The odds of a healthcare encounter for early childhood abuse among clients were significantly greater than comparison children (NFP: 1.32, 95% CI [1.08, 1.62]; PAT: 4.11, 95% CI [1.60, 10.55]; EHS: 3.15, 95% CI [1.41, 7.06]). Qualitative data illustrated the circumstances of and program response to client issues related to child maltreatment, highlighting the role of non-client caregivers. All stakeholders described curricular content aimed at prevention (e.g. positive parenting) with little time dedicated to addressing current or past abuse. Clients who reported a lack of abuse-related content supposed their home visitor's assumption of an absence of risk in their home, but were supportive of the introduction of abuse-related content. Approach, acceptance, and available resources were mediators of successfully addressing abuse. Conclusions for Practice Home visiting aims to prevent child abuse among high-risk families. Adequate home visitor capacity to proactively assess abuse risk, deliver effective preventive curriculum with fidelity to caregivers, and access appropriate resources is necessary.</p>

DOI

10.1007/s10995-018-2530-1

Alternate Title

Matern Child Health J

PMID

29855837

Title

Family Characteristics Associated With Child Maltreatment Across the Deployment Cycle of U.S. Army Soldiers.

Year of Publication

2017

Number of Pages

e1879-e1887

Date Published

2017 Sep

ISSN Number

1930-613X

Abstract

<p><strong>OBJECTIVE: </strong>Soldier deployment can create a stressful environment for U.S. Army families with young children. Prior research has identified elevated rates of child maltreatment in the 6 months immediately following a soldier's return home from deployment. In this study, we longitudinally examine how other child- and family-level characteristics influence the relationship of deployment to risk for maltreatment of dependent children of U.S. Army soldiers.</p>

<p><strong>METHODS: </strong>We conducted a person-time analysis of substantiated reports and medical diagnoses of maltreatment among the 73,404 children of 56,087 U.S. Army soldiers with a single deployment between 2001 and 2007. Cox proportional hazard models estimated hazard rates of maltreatment across deployment periods and simultaneously considered main effects for other child- and family-level characteristics across periods.</p>

<p><strong>RESULTS: </strong>In adjusted models, maltreatment hazard was highest in the 6 months following deployment (hazard ratio [HR] = 1.63, p &lt; 0.001). Children born prematurely or with early special needs independently had an increased risk for maltreatment across all periods (HR = 2.02, p &lt; 0.001), as well as those children whose soldier-parent had been previously diagnosed with a mental illness (HR = 1.68, p &lt; 0.001). In models testing for effect modification, during the 6 months before deployment, children of female soldiers (HR = 2.22, p = 0.006) as well as children of soldiers with a mental health diagnosis (HR = 2.78, p = 0.001) were more likely to experience maltreatment, exceeding the risk at all other periods.</p>

<p><strong>CONCLUSIONS: </strong>Infants and children are at increased risk for maltreatment in the 6 months following a parent's deployment, even after accounting for other known family- and child-level risk factors. However, the risk does not appear to be the same for all soldiers and their families in relation to deployment, particularly for female soldiers and those who had previously diagnosed mental health issues, for whom the risk appears most elevated before deployment. Accounting for the unique needs of high-risk families at different stages of a soldier's deployment cycle may allow the U.S. Army to better direct resources that prevent and address child maltreatment.</p>

DOI

10.7205/MILMED-D-17-00031

Alternate Title

Mil Med

PMID

28885950

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