The Effectiveness Of Government Masking Mandates On COVID-19 County-Level Case Incidence Across The United States, 2020.

2022

101377hlthaff202101072

2022 Feb 16

1544-5208

<p>Evidence for the effectiveness of masking on SARS-CoV-2 transmission at the individual level has accumulated, but the additional benefit of community-level mandates is less certain. In this observational study of matched cohorts from 394 US counties between March 21 and October 20, 2020, we estimated the association between county-level public masking mandates and daily COVID-19 case incidence. On average, the daily case incidence per 100,000 people in masked counties compared with unmasked counties declined by 23&nbsp;percent at four weeks, 33&nbsp;percent at six weeks, and 16&nbsp;percent across six weeks postintervention. The beneficial effect varied across regions of different population densities and political leanings. The most concentrated effects of masking mandates were seen in urban counties; the benefit of the mandates was potentially stronger within Republican-leaning counties. Although benefits were not equally distributed in all regions, masking mandates conferred benefit in reducing community case incidence during an early period of the COVID-19 pandemic.</p>

10.1377/hlthaff.2021.01072

Health Aff (Millwood)

35171693

Impact of Maternal-Fetal Environment on Mortality in Children With Single Ventricle Heart Disease.

2022

e020299

2022 Jan 18

2047-9980

<p>BACKGROUND Children with single ventricle heart disease have significant morbidity and mortality. The maternal-fetal environment (MFE) may adversely impact outcomes after neonatal cardiac surgery. We hypothesized that impaired MFE would be associated with an increased risk of death after stage 1 Norwood reconstruction. METHODS AND RESULTS We performed a retrospective cohort study of children with hypoplastic left heart syndrome (and anatomic variants) who underwent stage 1 Norwood reconstruction between 2008 and 2018. Impaired MFE was defined as maternal gestational hypertension, preeclampsia, gestational diabetes, and/or smoking during pregnancy. Cox proportional hazards regression models were used to investigate the association between impaired MFE and death while adjusting for confounders. Hospital length of stay was assessed with the competing risk of in-hospital death. In 273 children, the median age at stage 1 Norwood reconstruction was 4&nbsp;days (interquartile range [IQR], 3-6 days). A total of 72 children (26%) were exposed to an impaired MFE; they had more preterm births (18% versus 7%) and a greater percentage with low birth weights &lt;2.5&nbsp;kg (18% versus 4%) than those without impaired MFE. Impaired MFE was associated with a higher risk of death (hazard ratio [HR], 6.05; 95% CI, 3.59-10.21; &lt;0.001) after adjusting for age at surgery, Hispanic ethnicity, genetic syndrome, cardiac diagnosis, surgeon, and birth era. Children with impaired MFE had almost double the risk of prolonged hospital stay (HR, 1.95; 95% CI, 1.41-2.70; &lt;0.001). CONCLUSIONS Children exposed to an impaired MFE had a higher risk of death following stage 1 Norwood reconstruction. Prenatal exposures are potentially modifiable factors that can be targeted to improve outcomes after pediatric cardiac surgery.</p>

10.1161/JAHA.120.020299

J Am Heart Assoc

35014861

Impact of Transcatheter Pulmonary Artery Intervention Following Superior Cavopulmonary Connection on Pulmonary Artery Growth.

2021

635-642

2021 Sep

2150-136X

<p><strong>INTRODUCTION: </strong>Balloon and stent angioplasty of the pulmonary arteries (PAs) are frequently performed following superior cavopulmonary connection (SCPC), not only to normalize the caliber of the affected PA but also in hopes of maximizing downstream growth over time. There are limited data on the impact on subsequent PA growth prior to total cavopulmonary connection (TCPC).</p>

<p><strong>METHODS: </strong>A single-center, retrospective cohort study was performed on children who underwent transcatheter (TC) PA intervention following SCPC between January 1, 2010, and December 31, 2018. Growth of treated and contralateral PAs was measured at the lobar bifurcation (distal branch PA [DBPA]) and in the proximal lower lobe (lower lobe branch [LLB]) on serial angiograms. Growth rate was evaluated using a mixed-effect model clustered by individual patient with an interaction term for treated PA and time to evaluate for differential growth rates between treated and contralateral PAs.</p>

<p><strong>RESULTS: </strong>Thirty-five patients underwent TC PA intervention following SCPC, at a median of 70 days (interquartile range: 19-297 days) postoperatively. Significant growth was seen at both DBPA and LLB for raw (0.8 mm/year, 95% CI: 0.6-1.0, &lt; .001 for both) and body surface area (BSA) adjusted measures (8.4mm/m/year, 95% CI: 5.6-11.2, &lt; .001; 7.9 mm/m/year, 95% CI: 5.5-10.2, &lt; .001). The growth rate of the treated vessel was not significantly different from that of the contralateral vessel at the DBPA or LLB positions for raw ( = .71, .70) or BSA-adjusted measurements ( = .86, .64).</p>

<p><strong>CONCLUSION: </strong>Transcatheter PA intervention was associated with normal distal PA growth rate relative to the untreated side.</p>

10.1177/21501351211033238

World J Pediatr Congenit Heart Surg

34597205

Prevalent Pharmacotherapy of United States Fontan Survivors: A study utilizing data from the MarketScan Commercial and Medicaid Claims Databases.

2021

2021 Sep 25

1097-6744

<p><strong>BACKGROUND: </strong>Survivors of Fontan palliation are at life-long risk of thrombosis, arrhythmia, and circulatory failure. To our knowledge, no studies have evaluated current United States pharmaceutical prescription practice in this population.</p>

<p><strong>METHODS: </strong>A retrospective observational study evaluating the prevalent use of prescription medications in children and adolescents with hypoplastic left heart syndrome or tricuspid atresia after Fontan completion (identified using ICD9/10 codes) was performed using data contained in the MarketScan® Commercial and Medicaid databases for the years 2013 through 2018. Cardiac pharmaceuticals were divided by class. Anticoagulant agents other than platelet inhibitors, which are not uniformly a prescription medication, were also studied. Associations between increasing age and the likelihood of a filled prescription for each class of drug were evaluated. Annualized retail costs of pharmaceutical regimens were calculated.</p>

<p><strong>RESULTS: </strong>A cohort of 4056 subjects [median age 12 years (IQR: 8-16), 61% male, 60% commercial insurance] was identified. Of the cohort, 50% received no prescription medications. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (38%), diuretics (15%), and mineralocorticoid receptor antagonists (8%) were prescribed with the highest frequency. Pulmonary vasodilators were received by 6% of subjects. Older age was associated with increased likelihood of filled prescriptions for anticoagulants (p=0.008), antiarrhythmic agents, digoxin, ACEi/ARB, and beta blockers (each p&lt;0.0001), but also lower likelihood of filled prescriptions for pulmonary vasodilators, conventional diuretics (both p&lt;0.0001), and mineralocorticoid receptor antagonists (p=0.02).</p>

<p><strong>CONCLUSION: </strong>Pharmaceuticals typically used to treat heart failure and pulmonary hypertension are the most commonly prescribed medications following Fontan palliation. While the likelihood of treatment with a particular class of medication is associated with the age of the patient, determining the optimal regimen for individual patients and the population at large is an important knowledge gap for future research.</p>

10.1016/j.ahj.2021.09.012

Am Heart J

34582777

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach.

2021

685855

2021

2297-055X

<p>Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. We conducted a single-center prospective cohort study of children &lt;2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment ( = 22, 13.6%), cardiac catheterization ( = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) ( = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.</p>

10.3389/fcvm.2021.685855

Front Cardiovasc Med

34368247

Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Case-Control Study.

2021

2021 Feb 16

1536-4801

<p><strong>OBJECTIVES: </strong>Inflammatory bowel disease (IBD) is associated with increased risk of venous thromboembolism (VTE). Despite this recognized risk, there are limited data and no anticoagulation guidelines for hospitalized pediatric IBD patients. The objectives of this study were to characterize pediatric IBD patients with VTE and determine risk factors.</p>

<p><strong>METHODS: </strong>This was a nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center. Standard descriptive statistics were used to describe the VTE group. Multivariable conditional logistic regression was used to assess risk factors.</p>

<p><strong>RESULTS: </strong>Twenty-three cases were identified. Central venous catheter (CVC) presence (OR 77.9 (95% CI: 6.9, 880.6; p &lt; 0.001)) and steroid use (OR 12.7 (95% CI: 1.3, 126.4; p = 0.012)) were independent risk factors. Median age at VTE was 17 years (IQR 13.5, 18.2), and in 48% VTE was the indication for admission. Median duration of anticoagulation was 3.8 months (IQR 2.3, 7.6), and there were no major bleeding events for patients on anticoagulation. There were no patients with known sequelae from VTE, though 22% had severe VTE that required interventions.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric patients with IBD are at risk for VTE, although the absolute risk remains relatively low. The safety and efficacy of pharmacologic thromboprophylaxis needs to be further evaluated in this population with attention to risk factors, such as steroid use and presence of CVC.</p>

<p>An infographic is available for this article at:http://links.lww.com/MPG/C232.</p&gt;

10.1097/MPG.0000000000003078

J Pediatr Gastroenterol Nutr

33605670

Pediatric/Congenital Cardiac Catheterization Quality: An Analysis of Existing Metrics.

2020

2853-2864

2020 Dec 28

1876-7605

<p><strong>OBJECTIVES: </strong>The aim of this study was to enumerate and categorize quality metrics relevant to the pediatric/congenital cardiac catheterization laboratory (PCCL).</p>

<p><strong>BACKGROUND: </strong>Diagnostic and interventional catheterization procedures are an increasingly important part of the care of young patients with cardiac disease. Measurement of the performance of PCCL programs in a stringent and consistent fashion is a crucial step toward improving outcomes. To the best of our knowledge, a systematic evaluation of current quality metrics in PCCL has not been performed previously.</p>

<p><strong>METHODS: </strong>Potential metrics were evaluated by: 1) a systematic review of peer-reviewed research; 2) a review of metrics from organizations interested in quality improvement, patient safety, and/or PCCL programs; and 3) a survey of U.S. PCCL cardiologists. Collected metrics were grouped on 2 dimensions: 1) Institute of Medicine domains; and 2) the Donabedian structure/process/outcome framework. Survey responses were dichotomized between favorable and unfavorable responses and then compared within and between categories.</p>

<p><strong>RESULTS: </strong>In the systematic review, 6 metrics were identified (from 9 publications), all focused on safety either as an outcome (adverse events [AEs], mortality, and failure to rescue along with radiation exposure) or as a structure (procedure volume or operator experience). Four organizations measure quality metrics of PCCL programs, of which only 1 publicly reports data. For the survey, 229 cardiologists from 118 hospital programs responded (66% of individuals and 72% of hospital programs). The highest favorable ratings were for safety metrics (p&nbsp;&lt;&nbsp;0.001), of which major AEs, failure to rescue, and procedure-specific AEs had the highest ratings. Of respondents, 67% stated that current risk adjustment were not effective. Favorability ratings for hospital characteristics, PCCL characteristics, and quality improvement processes were significantly lower than for safety and less consistent within categories.</p>

<p><strong>CONCLUSIONS: </strong>There is a limited number of PCCL quality metrics, primarily focused on safety. Confidence in current risk adjustment methodology is low. The knowledge gaps identified should guide future research in the development of new quality metrics.</p>

10.1016/j.jcin.2020.09.002

JACC Cardiovasc Interv

33357522

Dynamic Annular Modeling of the Unrepaired Complete Atrioventricular Canal Annulus.

2020

2020 Dec 23

1552-6259

<p><strong>BACKGROUND: </strong>Repair of complete atrioventricular canal (CAVC) is often complicated by atrioventricular valve regurgitation, particularly of the left-sided valve. Understanding the three-dimensional (3D) structure of the atrioventricular canal annulus prior to repair may help to inform optimized repair. However, the 3D shape and movement of the CAVC annulus has yet to be quantified nor has it been rigorously compared to a normal mitral valve annulus.</p>

<p><strong>METHODS: </strong>The complete annuli of 43 patients with CAVC were modeled in 4 cardiac phases using transthoracic 3D echocardiograms and custom code. The annular structure was compared to the annuli of 20 normal pediatric mitral valves using 3D metrics and statistical shape analysis (Procrustes analysis).</p>

<p><strong>RESULTS: </strong>The unrepaired CAVC annulus varied in shape significantly throughout the cardiac cycle. Procrustes analysis visually demonstrated that the average normalized CAVC annular shape is more planar than the normal mitral annulus. Quantitatively, the annular height to valve width ratio of the native left CAVC atrioventricular valve was significantly lower than that of a normal mitral valve in all systolic phases(p&lt;0.001).</p>

<p><strong>CONCLUSIONS: </strong>The left half of the CAVC annulus is more planar than that of a normal mitral valve with an annular height to valve width ratio similar to dysfunctional mitral valves. Given the known importance of annular shape to mitral valve function, further exploration of the association of 3D structure to valve function in CAVC is warranted.</p>

10.1016/j.athoracsur.2020.12.013

Ann Thorac Surg

33359720

Daily text message assessments of 6-mercaptopurine adherence and its proximal contexts in adolescents and young adults with leukemia: A pilot study.

2020

e28767

2020 Oct 18

1545-5017

<p><strong>BACKGROUND: </strong>This pilot study explored the feasibility and acceptability of implementing text-based assessments of oral chemotherapy adherence in adolescents and young adults (AYA) with leukemia.</p>

<p><strong>METHODS: </strong>AYA prescribed maintenance 6-mercaptopurine (6MP) received daily text message surveys and utilized an electronic pill bottle for 28&nbsp;days. Text surveys assessed 6MP adherence and contextual associates (eg, mood). Feasibility was defined by recruitment/retention rates, survey completion rates, cost, and technical issues. After the 28-day period, AYA completed an acceptability survey. Secondary analyses compared text survey and electronic pill bottle adherence rates, and explored the daily associations between contextual factors and 6MP nonadherence.</p>

<p><strong>RESULTS: </strong>Eighteen AYA enrolled (M age&nbsp;=&nbsp;18, range 15-22) and completed study procedures (100% recruitment and retention rates). Adherence survey completion rates were high (M&nbsp;=&nbsp;88.9%), the technology cost was $204.00, and there were few technical issues. AYA reported high satisfaction with the surveys and perceived them as a helpful medication reminder. While not significantly correlated, survey and electronic pill bottle adherence data converged on the majority of days (&gt;90%). Exploratory analyses showed that AYA were more likely to miss a dose of 6MP on weekends (OR&nbsp;=&nbsp;2.33, P&nbsp;=&nbsp;.048) and on days when their adherence motivation (OR&nbsp;=&nbsp;0.28, P&nbsp;=&nbsp;.047) and negative effect (OR&nbsp;=&nbsp;3.92, P&nbsp;=&nbsp;.02) worsened from their own typical functioning.</p>

<p><strong>CONCLUSIONS: </strong>For AYA with leukemia, daily text-based surveys are a feasible and acceptable method for delivering medication adherence assessments, and may operate as a short-term intervention. To develop personalized mobile health interventions, findings also highlighted the need to study time-varying predictors of 6MP nonadherence.</p>

10.1002/pbc.28767

Pediatr Blood Cancer

33073479

Association of Social Distancing, Population Density, and Temperature With the Instantaneous Reproduction Number of SARS-CoV-2 in Counties Across the United States.

2020

e2016099

2020 Jul 01

2574-3805

<p><strong>Importance: </strong>Local variation in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the United States has not been well studied.</p>

<p><strong>Objective: </strong>To examine the association of county-level factors with variation in the SARS-CoV-2 reproduction number over time.</p>

<p><strong>Design, Setting, and Participants: </strong>This cohort study included 211 counties, representing state capitals and cities with at least 100 000 residents and including 178 892 208 US residents, in 46 states and the District of Columbia between February 25, 2020, and April 23, 2020.</p>

<p><strong>Exposures: </strong>Social distancing, measured by percentage change in visits to nonessential businesses; population density; and daily wet-bulb temperatures.</p>

<p><strong>Main Outcomes and Measures: </strong>Instantaneous reproduction number (Rt), or cases generated by each incident case at a given time, estimated from daily case incidence data.</p>

<p><strong>Results: </strong>The 211 counties contained 178 892 208 of 326 289 971 US residents (54.8%). Median (interquartile range) population density was 1022.7 (471.2-1846.0) people per square mile. The mean (SD) peak reduction in visits to nonessential business between April 6 and April 19, as the country was sheltering in place, was 68.7% (7.9%). Median (interquartile range) daily wet-bulb temperatures were 7.5 (3.8-12.8) °C. Median (interquartile range) case incidence and fatality rates per 100 000 people were approximately 10 times higher for the top decile of densely populated counties (1185.2 [313.2-1891.2] cases; 43.7 [10.4-106.7] deaths) than for counties in the lowest density quartile (121.4 [87.8-175.4] cases; 4.2 [1.9-8.0] deaths). Mean (SD) Rt in the first 2 weeks was 5.7 (2.5) in the top decile compared with 3.1 (1.2) in the lowest quartile. In multivariable analysis, a 50% decrease in visits to nonessential businesses was associated with a 45% decrease in Rt (95% CI, 43%-49%). From a relative Rt at 0 °C of 2.13 (95% CI, 1.89-2.40), relative Rt decreased to a minimum as temperatures warmed to 11 °C, increased between 11 and 20 °C (1.61; 95% CI, 1.42-1.84) and then declined again at temperatures greater than 20 °C. With a 70% reduction in visits to nonessential business, 202 counties (95.7%) were estimated to fall below a threshold Rt of 1.0, including 17 of 21 counties (81.0%) in the top density decile and 52 of 53 counties (98.1%) in the lowest density quartile.2.</p>

<p><strong>Conclusions and Relevance: </strong>In this cohort study, social distancing, lower population density, and temperate weather were associated with a decreased Rt for SARS-CoV-2 in counties across the United States. These associations could inform selective public policy planning in communities during the coronavirus disease 2019 pandemic.</p>

10.1001/jamanetworkopen.2020.16099

JAMA Netw Open

32701162