Focused Cardiac Ultrasound to Guide the Diagnosis of Heart Failure in Pregnant Women in India.

BACKGROUND: Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of this study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings. METHODS: A cross-sectional study was conducted among 301 pregnant and postpartum women recruited from 10 hospitals across three states in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from focus-assessed transthoracic echocardiography protocol. It included parasternal long-axis, parasternal short-axis, and apical four-chamber views on two-dimensional and color Doppler. Independent image interpretation was performed remotely by two experts, in the United Kingdom and India, using a standard semiquantitative assessment protocol. Interrater agreement between the experts was examined using Cohen's κ. Diagnostic accuracy of the method was examined in a subsample for whom both focused and conventional scans were available. RESULTS: Cardiac abnormalities identified using the focused method included valvular abnormalities (27%), rheumatic heart disease (6.6%), derangements in left ventricular size (4.7%) and function (22%), atrial dilatation (19.5%), and pericardial effusion (30%). There was substantial agreement on the cardiac parameters between the two experts, ranging from 93.6% (κ = 0.84) for left ventricular ejection fraction to 100% (κ = 1) for valvular disease. Image quality was graded as good in 79% of parasternal long-axis, 77% of parasternal short-axis and 64% of apical four-chamber views. The chance-corrected κ coefficients indicated fair to moderate agreement (κ = 0.28-0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement), compared in 36 participants. CONCLUSIONS: The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings

Effect of moderate to high intensity aerobic exercise on blood pressure in young adults : the TEPHRA open, two-arm, parallel superiority randomized clinical trial

Background Exercise is advised for young adults with elevated blood pressure, but no trials have investigated efficacy at this age. We aimed to determine whether aerobic exercise, self-monitoring and motivational coaching lowers blood pressure in this group. Methods The study was a single-centre, open, two-arm, parallel superiority randomized clinical trial with open community-based recruitment of physically-inactive 18–35 year old adults with awake 24 h blood pressure 115/75mmHg-159/99 mmHg and BMI37 weeks) to the intervention group, who received 16-weeks aerobic exercise training (three aerobic training sessions per week of 60 min per session at 60–80% peak heart rate, physical activity self-monitoring with encouragement to do 10,000 steps per day and motivational coaching to maintain physical activity upon completion of the intervention. The control group were sign-posted to educational materials on hypertension and recommended lifestyle behaviours. Investigators performing statistical analyses were blinded to group allocation. The primary outcome was 24 h awake ambulatory blood pressure (systolic and diastolic) change from baseline to 16-weeks on an intention-to-treat basis. Clinicaltrials.gov registered on March 30, 2016 (NCT02723552). Findings Enrolment occurred between 30/06/2016-26/10/2018. Amongst the 203 randomized young adults (n = 102 in the intervention group; n = 101 in the control group), 178 (88%; n = 76 intervention group, n = 84 control group) completed 16-week follow-up and 160 (79%; n = 68 intervention group, n = 69 control group) completed 52-weeks follow-up. There were no group differences in awake systolic (0·0 mmHg [95%CI, -2·9 to 2·8]; P = 0·98) or awake diastolic ambulatory blood pressure (0·6 mmHg [95%CI, -1·4. to 2·6]; P = 0·58). Aerobic training increased peak oxygen uptake (2·8 ml/kg/min [95%CI, 1·6 to 4·0]) and peak wattage (14·2watts [95%CI, 7·6 to 20·9]) at 16-weeks. There were no intervention effects at 52-weeks follow-up. Intepretation These results do not support the exclusive use of moderate to high intensity aerobic exercise training for blood pressure control in young adults. Funding Wellcome Trust, British Heart Foundation, National Institute for Health Research, Oxford Biomedical Research Centre

Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

No abstract available

Identification of pre-clinical cardiovascular imaging phenotypes related to blood pressure in young adults

Hypertension prevalence in young adults is rising and is associated with an increased risk of stroke and cardiovascular disease in later life. However, hypertension management guidelines for patients below the age of 40 years remain conservative as their absolute risk of imminent vascular events is low. Additionally, due to the relatively short duration of exposure to hypertension, traditional measures of target organ damage such as left ventricular hypertrophy are often normal. In this thesis, I sought to identify pre-clinical cardiovascular phenotypes associated with blood pressure elevation in young adults, which might be of value for monitoring disease progression in young people. A cohort of young participants aged 18 to 40 years with a range of blood pressure measures were recruited through clinical studies conducted at the Cardiovascular Clinical Research Facility for multi-dimensional assessment of cardiovascular health. Detailed cardiac structure and function assessment was performed using a range of imaging modalities including resting and stress echocardiography imaging. First, I established that participants with suboptimal blood pressure (≥120/80 mmHg) have novel changes in cardiovascular remodelling identifiable with echocardiography. Specifically, I identified a reduction in left ventricular systolic function during physical exercise, which was associated with altered left atrial pump function at rest. Then, I studied whether it was possible to combine multiple echocardiographic measures using a contrastive trajectory inference machine learning model to describe the progression of cardiovascular remodelling in young adults with hypertension, and place participants on a pseudo-temporal trajectory of disease, with a corresponding score, from health (zero) to disease (one). I demonstrated feasibility of this approach and the practicality of summarising this disease progression as a single score. Finally, I demonstrated that longer duration of treatment was associated with higher score and was consistent with an established modifiable cardiovascular risk score and fitness levels. Therefore, I have demonstrated that there are progressive changes in cardiac structure and function, identifiable with echocardiography, in young adults with suboptimal blood pressure. Further work is now needed to determine whether these measures could be used clinically to better manage blood pressure in younger patients

Comparison between the effect of glass-ionomer and composite restorations on streptococcus mutans level in UAE children

PLEASE NOTE: This work is protected by copyright. Downloading is restricted to the BU community: please click Download and log in with a valid BU account to access. If you are the author of this work and would like to make it publicly available, please contact [email protected] (MSD) --Boston University Institute for Dental Research and Education, Dubai, 2012 (Pediatric Dentistry).Includes bibliographic references: leaves 77-112.Introduction: Dental caries remains a major public health problem in spite of the advances in the dental care in the United Arab Emirates (UAE). Epidemiological studies have provided evidence for the association of Streptococcus mutans with dental caries. Various treatment measures have been applied to impose an effect on Streptococcus mutans. It was reported that GIC can establish a cariostatic environment and reduce Streptococcus mutans levels through its ability to release fluoride; however, there has been a disparity regarding the anticariogenic effect of GIC restorations and the ability of the material to prevent the development of new carious lesions. Study objective: was to compare the effects of restorative treatment with glass-ionomer versus composite restorative materials on the oral count of Streptococcus mutans. Materials and Methods: the study included 20 subjects, 13 female and 7 male who were either caries free or with at least 3 carious primary teeth. The mean age was 6.72[plus or minus]2 years. The clinical indices utilized were the dmft and DMFT for primary and permanent teeth respectively. Subjects were randomly assigned to one of the treatment groups, group 1 consisted of five subjects who were treated with GIC restorations (KetacTM Fil Plus) and group 2 consisted of eleven subjects who were treated with composite restorations (TPHR SpectrumR3) and SSCs (Primary Crowns, 3MTM). The four caries free subjects comprised the control group which was the third study group. Dentocult-SMR Strip Mutans test (Orion Diagnostica) was used for microbiological analysis of both saliva and plaque samples. Microbial samples were collected at baseline, after prophylaxis, after the completion of the treatment by one week, one month and three month. Results: There were no statistically significant reductions (P = 0.622) in the level of Streptociccus mutans CFU/ml in saliva and plaque samples when baseline test was compared with the 3 month test for both GIC and composite groups. However, there was a statistically significant drop (P = 0.035) in Streptococcus mutans CFU/ml in plaque samples within both groups at one month. In addition, the results demonstrated a statistically significant reduction (P= 0.010) in the level of Streptococcus mutans CFU/ml in plaque samples between the various time periods regardless of the treatment group. There was a statistically significant correlation between DMFT scores and age (P = 0.006) and a statistically significant correlation between the saliva and plaque Streptococcus mutans CFU/ml at all time periods except after prophylaxis. Conclusions: 1. None of the compared restorative materials were superior to the other in terms of causing a significant decrease in the level of Streptococcus mutans in both saliva and plaque samples. But both GIC and composite restorative materials were able to cause a statistically significant drop in Streptociccus mutans CFU/ml in plaque samples after one month. 2. Plaque samples showed a statistically significant reduction in Streptococcus mutans CFU/ml between the various time periods regardless of the treatment group. This conclusion might indicate that plaque is a more reliable method to study changes in bacterial counts in the oral cavity

Differing Impact of Preterm Birth on the Right and Left Atria in Adulthood

BACKGROUND: Preterm birth affects 10% of live births and is associated with an altered left ventricular and right ventricular phenotype and increased cardiovascular disease risk in young adulthood. Because left atrial (LA) and right atrial (RA) volume and function are known independent predictors of cardiovascular outcomes, we investigated whether these were altered in preterm-born young adults. METHODS AND RESULTS: Preterm-born (n=200) and term-born (n=266) adults aged 18 to 39 years underwent cardiovascular magnetic resonance imaging. LA and RA maximal and minimal volumes (absolute, indexed to body surface area, and as a ratio to ventricular volumes) were obtained to study atrial morphology, while LA and RA stroke volume, strain, and strain rate were used to assess atrial function. Secondary analyses consisted of between-group comparisons based on degree of pre-maturity. Absolute RA volumes and RA volumes indexed to right ventricular volumes were significantly smaller in preterm-born compared with term-born adults. In addition, RA reservoir and booster strain were higher in preterm-born adults, possibly indicating functional compensation for the smaller RA volumes. LA volumes indexed to left ventricular volumes were significantly greater in preterm-born adults as compared with term-born adults, although absolute LA volumes were similar between groups. LA and RA changes were observed across gestational ages in the preterm group but were greatest in those born very-to-extremely preterm. CONCLUSIONS: Preterm-born adults show changes in LA and RA structure and function, which may indicate subclinical cardiovascular disease. Further research into underlying mechanisms, opportunities for interventions, and their prognostic value is warranted

Aerobic exercise increases brain vessel lumen size and blood flow in young adults with elevated blood pressure. Secondary analysis of the TEPHRA randomized clinical trial

Importance: Cerebrovascular changes are already evident in young adults with hypertension and exercise is recommended to reduce cardiovascular risk. To what extent exercise benefits the cerebrovasculature at an early stage of the disease remains unclear. Objective: To investigate whether structured aerobic exercise increases brain vessel lumen diameter or cerebral blood flow (CBF) and whether lumen diameter is associated with CBF. Design: Open, parallel, two-arm superiority randomized controlled (1:1) trial in the TEPHRA study on an intention-to-treat basis. The MRI sub-study was an optional part of the protocol. The outcome assessors remained blinded until the data lock. Setting: Single-centre trial in Oxford, UK. Participants: Participants were physically inactive (37 weeks). Intervention: Study participants were randomised to a 16 week aerobic exercise intervention targeting 3×60 min sessions per week at 60 to 80 % peak heart rate. Main outcomes and Measures: cerebral blood flow (CBF) maps from ASL MRI scans, internal carotid artery (ICA), middle cerebral artery (MCA) M1 and M2 segments, anterior cerebral artery (ACA), basilar artery (BA), and posterior cerebral artery (PCA) diameters extracted from TOF MRI scans. Results: Of the 135 randomized participants (median age 28 years, 58 % women) who had high quality baseline MRI data available, 93 participants also had high quality follow-up data available. The exercise group showed an increase in ICA (0.1 cm, 95 % CI 0.01 to 0.18, p =.03) and MCA M1 (0.05 cm, 95 % CI 0.01 to 0.10, p =.03) vessel diameter compared to the control group. Differences in the MCA M2 (0.03 cm, 95 % CI 0.0 to 0.06, p =.08), ACA (0.04 cm, 95 % CI 0.0 to 0.08, p =.06), BA (0.02 cm, 95 % CI −0.04 to 0.09, p =.48), and PCA (0.03 cm, 95 % CI −0.01 to 0.06, p =.17) diameters or CBF were not statistically significant. The increase in ICA vessel diameter in the exercise group was associated with local increases in CBF. Conclusions and Relevance: Aerobic exercise induces positive cerebrovascular remodelling in young people with early hypertension, independent of blood pressure. The long-term benefit of these changes requires further study. Trial Registration: Clinicaltrials.gov NCT02723552, 30 March 201