Clinical Associate Professor, Psychiatry and Behavioral Sciences - Child & Adolescent Psychiatry and Child Development
Clinical Associate Professor, Pediatrics - Cardiology
Fellowship: Stanford University Pain Management Fellowship (2011) CA
Professional Education: Nova Southeastern University Office of the Registrar (2010) FL
Internship: Lucile Packard Children's Hospital (2010) CA
Design and Rationale of RE-ENERGIZE FONTAN: RandomizEd Exercise iNtERvention desiGned to maximIZE fitness in FONTAN patients.
American heart journal
In this manuscript, we describe the design and rationale of a randomized controlled trial in pediatric Fontan patients to test the hypothesis that a live-video-supervised exercise (aerobic+resistance) intervention will improve cardiac and physical capacity; muscle mass, strength, and function; and endothelial function. Survival of children with single ventricles beyond the neonatal period has increased dramatically with the staged Fontan palliation. Yet, long-term morbidity remains high. By age 40, 50% of Fontan patients will have died or undergone heart transplantation. Factors that contribute to onset and progression of heart failure in Fontan patients remain incompletely understood. However, it is established that Fontan patients have poor exercise capacity which is associated with a greater risk of morbidity and mortality. Furthermore, decreased muscle mass, abnormal muscle function, and endothelial dysfunction in this patient population is known to contribute to disease progression. In adult patients with two ventricles and heart failure, reduced exercise capacity, muscle mass, and muscle strength are powerful predictors of poor outcomes, and exercise interventions can not only improve exercise capacity and muscle mass, but also reverse endothelial dysfunction. Despite these known benefits of exercise, pediatric Fontan patients do not exercise routinely due to their chronic condition, perceived restrictions to exercise, and parental overprotection. Limited exercise interventions in children with congenital heart disease have demonstrated that exercise is safe and effective; however, these studies have been conducted in small, heterogeneous groups, and most had few Fontan patients. Critically, adherence is a major limitation in pediatric exercise interventions delivered on-site, with adherence rates as low as 10%, due to distance from site, transportation difficulties, and missed school or workdays. To overcome these challenges, we utilize live-video conferencing to deliver the supervised exercise sessions. Our multidisciplinary team of experts will assess the effectiveness of a live-video-supervised exercise intervention, rigorously designed to maximize adherence, and improve key and novel measures of health in pediatric Fontan patients associated with poor long-term outcomes. Our ultimate goal is the translation of this model to clinical application as an "exercise prescription" to intervene early in pediatric Fontan patients and decrease long-term morbidity and mortality.
View details for DOI 10.1016/j.ahj.2023.02.006
View details for PubMedID 36796574
A systematic review of social determinants of health in pediatric organ transplant outcomes.
BACKGROUND: Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods.METHODS: Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases.RESULTS: Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent.CONCLUSION: This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
View details for DOI 10.1111/petr.14418
View details for PubMedID 36321186
Bereaved Caregiver Perspectives on the End of Life in Pediatric Patients With Ventricular Assist Devices.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
OBJECTIVES: Ventricular assist devices (VADs) are increasingly used in pediatric heart failure as bridges to heart transplantation, although 25% will die with VADs. Family experiences in this population are not well-described. The objective is to understand bereaved families' perspectives on VAD and end-of-life decision-making.DESIGN: Semistructured interviews with bereaved caregivers of pediatric VAD patients.SETTING: Tertiary children's hospital.PATIENTS: Families of six pediatric VAD patients who died from 2014 to 2020.INTERVENTIONS: Not available.MEASUREMENTS AND MAIN RESULTS: Applying a grounded theory framework, interviews were coded by two independent readers using qualitative software. Themes were discussed in iterative multidisciplinary meetings. Participants were interviewed at a median 2.4 years after their child died. Three major themes emerged: 1) "lack of regret" for VAD implantation despite the outcome; 2) "caregiver-child accord" (via patient's verbal assent or physical cues) at implantation and end-of-life was important in family decision-making; and 3) development of a "local surrogate family" (medical team and peer families) provided powerful support.CONCLUSIONS: Bereaved families' perspectives provide insight into quality decision-making for major interventions and end-of-life care in pediatric patients with chronic illness who face decisions regarding technology dependence.
View details for DOI 10.1097/PCC.0000000000003089
View details for PubMedID 36194025
Post-Traumatic Stress Disorder in pediatric Implantable Cardioverter Defibrillator patients and their parents.
An ICD in the pediatric patient (and the precipitating events that led to ICD placement) can be traumatic for patients and their families and may lead to PTSD.This study aimed to estimate the prevalence of PTSD in pediatric ICD patients and their parents and identify the factors associated with PTSD incidence.Pediatric participants with an ICD ages 8-21 years and parents of youth ages 0-21 years completed surveys that included demographics and PTSD measures. Pediatric participants completed additional psychosocial measures, such as anxiety and depression self-report questionnaires.Fifty youth (30% female) and 43 parents (70% female) completed the measures. Six youth (12%) met the screening criteria for a likely PTSD diagnosis, while 20 parents (47%) met the cutoff for PTSD on the screening measure. Children with PTSD were more likely to have had a secondary prevention ICD (83% vs 17%, p=0.021), meet the clinical cutoff for depression (67% vs 16%, p=.005), and had higher shock anxiety (31.7 vs 17.9, p=0.003) than children without PTSD. Female gender (57% vs 23%, p=0.043) and patient depression (31% vs 5%, p=.042) were associated with PTSD among parents.Parents were found to be more likely to meet the criteria for PTSD than youth. Among youth, PTSD was associated with medical and psychosocial factors whereas PTSD among parents was associated with being female and child depression. Clinic based screenings and management planning of emotional functioning are warranted to address psychological distress in patients and parents.
View details for DOI 10.1016/j.hrthm.2022.06.025
View details for PubMedID 35772698
Feasibility of Assessing Adolescent and Young Adult Heart Transplant Recipient Mental Health and Resilience Using Patient-Reported Outcome Measures
JOURNAL OF THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY
2022; 63 (2): 153-162
View details for Web of Science ID 000778353700006
A Framework for Navigating Requests for Nondisclosure in Pediatric Palliative Care
CLINICAL PRACTICE IN PEDIATRIC PSYCHOLOGY
2021; 9 (3): 296-307
View details for DOI 10.1037/cpp0000415
View details for Web of Science ID 000708786500008
Feasibility of assessing adolescent and young adult heart transplant recipient mental health and resilience using patient-reported outcome measures.
Journal of the Academy of Consultation-Liaison Psychiatry
BACKGROUND: Although adolescents and young adults (AYA) may be particularly prone to mental health symptoms following heart transplant, screening practices are variable. This study examined the feasibility of using patient-reported outcome (PRO) measures to assess mental health, functional status, and resiliency in post-transplant AYA patients.METHODS: Patients transplanted between ages 15-25 years at three centers completed six PRO instruments via web-based platforms: PROMIS instruments for anxiety, depression, satisfaction with social roles, and physical functioning; the Posttraumatic Stress Diagnostic Scale for DSM-V (PDS-5); and the Connor-Davidson Resilience Scale-10 (CD-RISC-10). Feasibility (completion, time to completion, and measure missingness) and PRO results were described and compared between congenital heart disease (CHD) and cardiomyopathy (CM) patients.RESULTS: Nineteen patients (median age at transplant 17.7 years [IQR 16.3,19.2 years], 84% male) were enrolled at an average of 3 ± 1.8 years post-transplant. Enrollment was 90% among eligible patients. Measure missingness were zero. The average completion time was 12 ± 15 minutes for all instruments. Timely PRO completion was facilitated by in-clinic application. The PRO results indicated that 9 patients (47%) had at least mild PTSD symptoms (≥11 points on PDS-5). Among them, 4 patients had scores >28 suggestive of probable PTSD. Two (11%) and 6 (32%) patients had anxious and depressive symptoms, respectively. The CM cohort had a higher median PDS-5 score than that of the CHD subgroup (11.0 vs 6.0; p = 0.015). Twelve (63%) had resiliency scores that were lower than the population average. No significant differences were found in PRO results between CM and CHD patients apart from the PTSD assessment.CONCLUSIONS: This novel PRO-based approach to psychiatric screening of AYA patients after transplant appears feasible for assessing mental health, functional status, and resiliency, with excellent enrollment and completion rates. These instruments characterized the burden of mental health symptoms within this AYA heart transplant cohort, with a high prevalence of PTSD symptoms. Resiliency scores were lower than in a comparison population. Electronically- administered PRO administration could facilitate more consistent mental health screening in this at-risk group.
View details for DOI 10.1016/j.jaclp.2021.08.002
View details for PubMedID 34438097
PSYCHOSOCIAL PRETRANSPLANT EVALUATION: STANFORD PEDIATRIC PSYCHOSOCIAL OPTIMIZATION TOOL FOR TRANSPLANT (SPPOTT)
ELSEVIER SCIENCE INC. 2021: S92
View details for DOI 10.1016/j.jaac.2021.07.386
View details for Web of Science ID 000707082800313
An exploratory assessment of pediatric patient and parent needs after implantable cardioverter defibrillator implant.
Pacing and clinical electrophysiology : PACE
Placement of an ICD is often accompanied by psychological adjustment issues in pediatric patients and their parents. While anxiety, depression, and lowered QOL have been seen in these patients, no studies have investigated patient or parent reported needs. This exploratory study describes the needs of pediatric ICD patients and parents and assesses whether patient factors of age, gender, depression, and anxiety are associated with specific needs.ICD patients ages 8-21 and their parents completed a needs analysis survey assessing various domains of functioning. Patients also completed self-reported measures of depression and anxiety.Thirty-two patients (28% female) and their parents (72% mothers) completed the survey. Patients' most frequently endorsed needs involved educational issues: understanding their cardiac event/diagnosis (34%), medications (34%), and how the ICD would change their lifestyle (31%). Parents' most frequently endorsed needs involved family issues; almost half of parents (47%) were concerned about their children's frustration with their overprotectiveness and 28% were concerned with their child feeling depressed or anxious. Patients who reported feeling overprotected (12.1 ± 3.4 vs 17.4 ± 3.5 years, p = .001) were significantly younger than those who did not. Experiencing peer issues was more frequently endorsed by females than males (33% of females vs 4% of males, p = .026).ICD patients and parents endorsed markedly different needs. Patients focused on understanding their ICD, while parents were more focused on their children's emotional needs. Novel ways of educating patients about their device and clinic based screenings of emotional functioning may serve to meet these needs. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/pace.13876
View details for PubMedID 31971265
A Case of Abulia From Left Middle Cerebral Artery Stroke in an Adolescent Treated Successfully With Short Duration Olanzapine.
; 43 (3): 86–89
Abulia is defined as a pathological state of amotivation, apathy, and global absence of willpower. It presents with a challenging array of overlapping symptoms, making effective identification and treatment difficult.We describe the first known report of an adolescent with a ventricular assist device who developed abulia following a left middle cerebral artery (MCA) stroke who responded successfully to treatment with olanzapine.The neurobiological etiology of abulia is still unclear but is postulated to be related to deficits in the dopaminergic reward circuitry in the frontal-subcortical-mesolimbic regions. There have been reports of poststroke patients with abulia being treated by modulating this dopamine circuitry and in some cases with short-term low-dose olanzapine.Further research is needed to develop a better understanding of the pathophysiology of abulia leading to more effective treatment algorithms including more specific diagnostic tools and effective pharmacological interventions.
View details for DOI 10.1097/WNF.0000000000000389
View details for PubMedID 32384311