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1.  Observation on Renal Outcomes in the Veterans Affairs Diabetes Trial 
Diabetes Care  2011;34(9):2090-2094.
The Veterans Affairs Diabetes Trial (VADT) was a randomized, prospective, controlled trial of 1,791 patients with type 2 diabetes to determine whether intensive glycemic control would reduce cardiovascular events compared with standard control. The effect of intensive glycemic control and selected baseline variables on renal outcomes is reported.
Baseline mean age was 60.4 years, mean duration of diabetes was 11.5 years, HbA1c was 9.4%, and blood pressure was 132/76 mmHg. The renal exclusion was serum creatinine >1.6 mg/dL. Renal outcomes were sustained worsening of the urine albumin-to-creatinine ratio (ACR) and sustained worsening by one or more stages in the estimated glomerular filtration rate (eGFR).
Intensive glycemic control did not independently reduce ACR progression but was associated with a significant attenuation in the progression of ACR in those who had baseline photocoagulation, cataract surgery, or both. The beneficial effect of intensive glycemic control increased with increasing BMI and with decreasing diastolic blood pressure (DBP). Intensive glycemic control was associated with less worsening of eGFR with increasing baseline ACR and insulin use. Baseline systolic blood pressure, triglycerides, and photocoagulation were associated with worsening of eGFR.
Intensive glycemic control had no significant effect on the progression of renal disease in the whole cohort but was associated with some protection against increasing ACR in those with more advanced microvascular disease, lower baseline DBP, or higher baseline BMI and on worsening of eGFR in those with high baseline ACR.
PMCID: PMC3161270  PMID: 21775749
2.  Motivators and Barriers to Blood Donation in African American College Students 
An adequate blood supply depends on volunteer non-remunerated blood donors. African Americans have lower blood donation rates than whites. To improve African American blood donation rates, the motivators and barriers to African Americans must be explored. To study the differences in motivators and barriers to blood donation between donor and non-donor African American college students.
African Americans college students at two Historically Black Colleges and Universities completed a 41-item, self-administered questionnaire, which assessed participant’s donation frequency, motivators and barriers toward donation, and knowledge and beliefs towards blood donation.
364 primarily female college students (96% African Americans, 93% female) completed the questionnaire. 49% reported prior blood donation experience (donors) and 51% were non-donors. The primary motivator for donors and non-donors was convenience (89% donor, 82% non-donor). Donors were more likely than non-donors to disagree with statements regarding blood donation as being too painful (82% donor, 44% non-donor), resulting in feeling faint, dizzy, or nauseated (61% donor, 29% non-donor). Donors more often agreed that the blood supply is safe (77% donor, 58% non-donor), less often concerned about receiving a transfusion (61% donor, 73% non-donor), and more often aware of local blood shortages (50% donor, 35% non-donor).
African Americans female college students are willing to donate blood given convenience and support from their university. Educational campaigns to increase knowledge regarding the safety of the blood donation process and the ongoing needs of an adequate blood supply might be effective methods to increase blood donation.
PMCID: PMC2784155  PMID: 19782000
3.  Assessment of differential branch pulmonary blood flow: a comparative study of phase contrast magnetic resonance imaging and radionuclide lung perfusion imaging 
Heart  2006;92(7):963-968.
To test whether magnetic resonance (MR) imaging can be used to assess differential lung blood flow as accurately as isotope lung perfusion studies in patients investigated for congenital heart disease.
Methods and results
Radionuclide lung perfusion and MR imaging were performed in 12 children with suspected unilateral branch pulmonary artery stenosis (mean age 12.1 (5.9) years, range 3.1–17.2 years). A non‐breath hold, fast gradient echo phase contrast MR sequence was used to measure flow in the pulmonary trunk and one pulmonary artery to calculate differential flow. Good agreement was shown between the two imaging methods by Bland‐Altman analysis. There was excellent correlation between the radionuclide and MR phase contrast calculated total lung blood flow (r  =  0.98, p < 0.0001).
MR phase contrast is an accurate method for measuring differential total right and left lung blood flow. If MR imaging is performed to assess the branch pulmonary arteries, differential lung blood flow can be also measured, avoiding the need for an additional radionuclide lung perfusion scan and reducing the overall radiation burden to this group of patients.
PMCID: PMC1860721  PMID: 16775104
branch pulmonary stenosis; magnetic resonance imaging; phase contrast
4.  Role of atrial septostomy in the treatment of children with pulmonary arterial hypertension 
Heart  2005;92(7):969-972.
To assess in retrospect the safety and effectiveness of atrial septostomy in children with severe pulmonary arterial hypertension without an intracardiac communication.
20 patients were reviewed retrospectively, 19 with idiopathic pulmonary arterial hypertension. The mean age at septostomy was 8.4 years (range 3 months to 17 years). Graded balloon septostomy alone was carried out in eight patients, a blade septostomy was done in two, a blade septostomy plus graded balloon septostomy was done in three, and a fenestrated device was inserted in seven.
There were no fatalities. Four children suffered complications during the procedure. None had further syncope and all improved symptomatically with a significant (p < 0.01) decrease in World Health Organization functional class (mean shift −0.6) and a significant improvement in the semiquantitative echocardiographic assessment of right ventricular function (p < 0.03). The mean oxygen saturation decreased by 7.8 percentage points. The atrial communication closed in two children, necessitating a repeat procedure. After a mean follow up of 2.1 years (range one month to 6.7 years), 18 of 20 children are still alive.
Atrial septostomy improved symptoms and quality of life in a group of children deteriorating with severe pulmonary arterial hypertension. This procedure is to be recommended for severely symptomatic children, before they become critically ill. Fenestrated devices may help ensure indefinite patency of the atrial communication.
PMCID: PMC1860701  PMID: 16278272
paediatric pulmonary hypertension; idiopathic pulmonary arterial hypertension; atrial septostomy
5.  Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement 
Heart  2002;88(2):163-166.
Objective: To study the prevalence of hypertension in a cohort of patients using the current strategy of repair in early childhood.
Patients: The cohort of patients with coarctation of the aorta born between 1983 and 1992.
Intervention: Casual (mean of three resting readings) and 24 hour blood pressure were measured in 119 children and compared with data from 1034 normal controls. The arch repair and left ventricular parameters were assessed using Doppler echocardiography.
Results: Median ages at first intervention and at blood pressure measurement were 0.2 years (interquartile range 0.04–2.0) and 12.0 years (9.0–14.5), respectively. Doppler velocity in the descending aorta was significantly associated with blood pressure (r = 0.28, p = 0.002 for casual systolic blood pressure (SBP); r = 0.26, p = 0.005 for mean 24 hour SBP). Patients were classified as having “no” (n = 70) or “mild” (n = 49) arch obstruction. Casual SBP was > 95th centile in 28% (34 of 119) overall and in 21% (15 of 70) of the no arch obstruction group. Mean 24 hour SBP was > 95th centile in 30% (36 of 119) overall and in 19% (13 of 70) of the no obstruction group. The sensitivity and specificity of casual SBP in detecting increased 24 hour SBP were 66% and 88%, respectively.
Conclusions: This unique study of a large cohort of patients treated for coarctation in early childhood showed that a disappointingly high prevalence of hypertension is already apparent in children aged 7–16 years in the absence of significant arch obstruction, whether assessed by 24 hour or by casual blood pressure measurement.
PMCID: PMC1767207  PMID: 12117846
blood pressure; coarctation of the aorta; hypertension
6.  Abnormalities of right ventricular long axis function after atrial repair of transposition of the great arteries 
Heart  2001;86(2):203-206.
BACKGROUND—While volume derived global indices of right ventricle (RV) function are frequently abnormal after the Mustard procedure, the mechanism for these abnormalities is poorly understood. RV muscle fibres are predominantly arranged longitudinally and thus indices derived in the long axis may better describe RV function.
METHODS—20 survivors of the Mustard operation were studied (age 7.8-37.3 years, median 14.2 years). Long axis recordings from the apical four chamber view were obtained with the M mode cursor positioned through the lateral angle of the tricuspid valve annulus. M mode traces were recorded on paper and later digitised to derive total atrioventricular ring excursion, peak lengthening rate, and peak shortening rate. These data were averaged and compared with control data for the normal RV and left ventricle (LV).
RESULTS—RV total atrioventricular ring excursion was lower than that for the RV (p < 0.0001) or LV (p < 0.005) of controls. Peak lengthening rate was lower than the normal RV (p < 0.0001) and LV (p < 0.0001) rates. Furthermore, peak shortening rate was less than that of normal RV (p < 0.0001) and normal LV (p < 0.005) controls.
CONCLUSION—Systemic RV long axis function is notably reduced compared with that of either the normal subpulmonary RV or the systemic LV. This presumably reflects the response of the predominantly longitudinally arranged myocardial fibres to increased afterload. However, such measurements may provide a more sensitive marker for progressive changes in global function during long term follow up.

Keywords: Mustard procedure; right ventricular function; transposition of the great arteries
PMCID: PMC1729843  PMID: 11454843
7.  Natural and unnatural history of pulmonary atresia 
Heart  2000;84(5):499-503.
OBJECTIVE—To investigate mortality, cause of death, survival, and quality of life in all types of cardiac malformation with congenital pulmonary atresia.
DESIGN—Retrospective analysis.
SETTING—The resident population of one health region with a single tertiary referral centre.
PATIENTS—All babies with pulmonary atresia live born in 1980 to 1995.
MAIN OUTCOME MEASURES—Anatomical classification, total mortality, cause of death, duration of survival, exercise ability. All cases were classified as pulmonary atresia with intact septum (PA-IVS), pulmonary atresia with ventricular septal defect (PA-VSD), or pulmonary atresia with complex cardiac malformation (complex pulmonary atresia).
RESULTS—129 cardiac malformations with congenital pulmonary atresia were identified from 601 635 live births (21.4/100 000): 29 had PA-IVS, 60 had PA-VSD, and 40 had complex pulmonary atresia. Total mortality was 72/129 (56%), with 15 deaths in the first week and 49 in the first year. There were 23 surgical deaths, 33 hospital deaths (not related to surgery), and 16 sudden deaths, 12 of which remained unexplained. The sudden death rate was 29/1000 patient years of follow up. Of the 57 survivors, 39% have exercise ability I or II and 61% III or IV. Definitive surgical repair produced better exercise ability.
CONCLUSIONS—Early mortality is high in all types of pulmonary atresia, although survival has improved in recent years. Most children who have not undergone definitive repair have significant exercise limitation.

Keywords: congenital heart disease; pulmonary atresia; sudden death; quality of life
PMCID: PMC1729492  PMID: 11040008
8.  Pulmonary vascular-bronchial interactions: acute reduction in pulmonary blood flow alters lung mechanics 
Heart  2000;84(3):284-289.
BACKGROUND—Postoperative pulmonary hypertension in children after congenital heart surgery is a risk factor for death and is associated with severe acute changes in both pulmonary vascular resistance and lung mechanics.
OBJECTIVE—To examine the impact of changes in pulmonary blood flow on lung mechanics in preoperative children with congenital heart disease, in order to assess the cause-effect relation of pulmonary vascular-bronchial interactions.
DESIGN—Prospective, cross sectional study.
SETTING—Cardiac catheterisation laboratory, general anaesthesia with mechanical ventilation.
INTERVENTIONS—Variation of pulmonary blood flow (Qp) by either balloon occlusion of an atrial septal defect before interventional closure, or by complete occlusion of the pulmonary artery during balloon pulmonary valvuloplasty for pulmonary valve stenosis.
MAIN OUTCOME MEASURES—Ventilatory tidal volume (Vt), dynamic respiratory system compliance (Cdyn), respiratory system resistance (Rrs).
RESULTS—28 occlusions were examined in nine patients with atrial septal defect (median age 9.5 years) and 22 in eight patients with pulmonary stenosis (median age 1.2 years). Normalisation of Qp during balloon occlusion of atrial septal defect caused no significant change in airway pressures and Rrs, but there was a small decrease in Vt (mean (SD): 9.61 (0.85) to 9.52 (0.97) ml/kg; p < 0.05) and Cdyn (0.64 (0.11) to 0.59 (0.10) ml/cm H2O*kg; p < 0.01). These changes were more pronounced when there was complete cessation of Qp during balloon valvuloplasty in pulmonary stenosis, with a fall in Vt (9.71 (2.95) to 9.32 (2.84) ml/kg; p < 0.05) and Cdyn (0.72 (0.29) to 0.64 (0.26) ml/cm H2O*kg; p < 0.001), and there was also an increase in Rrs (25.1 (1.7) to 28.8 (1.6) cm H2O/litre*s; p < 0.01). All these changes exceeded the variability of the baseline measurements more than threefold.
CONCLUSIONS—Acute changes in pulmonary blood flow are associated with simultaneous changes in lung mechanics. While these changes are small they may represent a valid model to explain the pathophysiological impact of spontaneous changes in pulmonary blood flow in clinically more critical situations in children with congenital heart disease.

Keywords: pulmonary blood flow; lung mechanics; catheter intervention; cardiopulmonary interaction
PMCID: PMC1760956  PMID: 10956291
9.  Ambulatory blood pressure in schoolchildren 
Archives of Disease in Childhood  1999;80(6):529-532.
OBJECTIVE—To define the range and variability of ambulatory blood pressure in normal schoolchildren.
DESIGN—Prospective study.
METHODS—Resting blood pressure of 1121 schoolchildren from Newcastle upon Tyne was recorded. An ambulatory blood pressure device, which uses both auscultatory (Korotkoff) and oscillometric methods of blood pressure measurement, was then put in place for 24hours.
RESULTS—The day was divided into three time periods: school, home, and night time. Normal centiles for blood pressure for each of these time periods were obtained and many daytime readings were outside reported normal resting levels. The normal variation of blood pressure was quantified by comparing each of these time periods with the resting readings. Resting systolic blood pressure did not predict 24 hour mean systolic blood pressure.
CONCLUSIONS—The availability of normal ambulatory blood pressure data on the level and variation of blood pressure in children may facilitate the early identification of hypertension in this age group.

PMCID: PMC1717942  PMID: 10332001

Results 1-13 (13)