1
|
Oliveira AC, Barroso WKS, de Oliveira Vitorino PV, Sousa ALL, Fagundes RR, de Deus GD, Guimarães GC, Barbosa E, Xaplanteris P, Vlachopoulos C. A SAGE score cutoff that predicts high-pulse wave velocity as measured by oscillometric devices in Brazilian hypertensive patients. Hypertens Res 2021; 45:315-323. [PMID: 34754085 DOI: 10.1038/s41440-021-00793-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/19/2021] [Accepted: 09/23/2021] [Indexed: 11/09/2022]
Abstract
We aimed to identify the optimal cutoff SAGE score for Brazilian hypertensive patients who had their pulse wave velocity (PWV) measured with oscillometric devices. A retrospective analysis of patients who underwent central blood pressure measurement using a validated oscillometric device, the Mobil-O-Graph® (IEM, Stolberg, Germany), between 2012 and 2019 was performed. Patients with arterial hypertension and available data on all SAGE parameters were selected. An ROC curve was constructed using the Youden index to define the best score to identify patients at high risk for high PWV. A total of 837 patients met the criteria for SAGE and diagnosis of hypertension. The median age was 59.0 years (interquartile range [IQR]: 47.0-68.0), and 50.7% of the patients were women. The following comorbidities and conditions were present: dyslipidemia (37.4%), diabetes (20.7%), a body mass index score ≥30 kg/m2 (36.6%), use of antihypertensive drugs (69.5%), and smoking (18.3%). The median peripheral blood pressure was 128 mmHg (IQR: 117-138 mmHg) for systolic and 81 mmHg (IQR: 73-90 mmHg) for diastolic blood pressure. The median PWV was 8.3 m/s (7.1-9.8 m/s), and the prevalence of high PWV (≥10 m/s) was 22.9% (192 patients). A cutoff SAGE score ≥8 was effective at identifying a high risk of PWV ≥ 10 m/s, achieving 67.19% sensitivity (95% CI: 60.1-73.8) and 93.95% specificity (95% CI: 91.8-95.7). With this cutoff point, 1 out of every 5 treated hypertensive patients would be referred for a PWV measurement. A SAGE score of ≥8 identified Brazilian hypertensive patients with a high risk of future cardiovascular events (PWV ≥ 10 m/s).
Collapse
Affiliation(s)
- Adriana Camargo Oliveira
- Hypertension League and Postgraduate Program, Medical School-Federal University of Goiás-Brazil, Goiânia, Brazil.
| | - Weimar Kunz Sebba Barroso
- Hypertension League and Postgraduate Program, Medical School-Federal University of Goiás-Brazil, Goiânia, Brazil
| | | | - Ana Luiza Lima Sousa
- Hypertension League and Postgraduate Program, Medical School-Federal University of Goiás-Brazil, Goiânia, Brazil
| | - Rayne Ramos Fagundes
- Hypertension League and Postgraduate Program, Medical School-Federal University of Goiás-Brazil, Goiânia, Brazil
| | | | - Gilberto Campos Guimarães
- Hypertension League and Postgraduate Program, Medical School-Federal University of Goiás-Brazil, Goiânia, Brazil
| | - Eduardo Barbosa
- Hypertension League of Porto Alegre-Brazil, Porto Alegre, Brazil
| | - Panagiotis Xaplanteris
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.,Cardiology Department, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Charalambos Vlachopoulos
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| |
Collapse
|
2
|
Castro N, Diana J, Blackwell J, Faulkner J, Lark S, Skidmore P, Hamlin M, Signal L, Williams MA, Stoner L. Social Jetlag and Cardiometabolic Risk in Preadolescent Children. Front Cardiovasc Med 2021; 8:705169. [PMID: 34692778 PMCID: PMC8529028 DOI: 10.3389/fcvm.2021.705169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/10/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: Childhood cardiometabolic disease risk (CMD) has been associated with short sleep duration. Its relationship with other aspects of sleep should also be considered, including social jetlag (SJL) which represents the difference between a person's social rhythms and circadian clock. This study investigated whether childhood CMD risk is associated with sleep duration, sleep disturbances, and SJL. Study Design: The observational study included 332 children aged 8–10 years (48.5% female). The three independent variables were sleep duration, sleep disturbances, and SJL. SJL was calculated as the variation in hours between the midpoint of sleep during free (weekend) days and work/school days. Eleven cardiometabolic biomarkers were measured, including central blood pressure, lipids, glycated hemoglobin, arterial wave reflection, and glucose. Underlying CMD risk factors were identified using factor analysis. Results: Four underlying CMD risk factors were identified using factor analysis: blood pressure, cholesterol, vascular health, and carbohydrate metabolism. Neither sleep disturbances nor sleep duration were significantly associated with any of the four CMD factors following adjustments to potential confounders. However, SJL was significantly linked to vascular health (p = 0.027) and cholesterol (p = 0.025). Conclusion: These findings suggest that SJL may be a significant and measurable public health target for offsetting negative CMD trajectories in children. Further studies are required to determine biological plausibility.
Collapse
Affiliation(s)
- Nicholas Castro
- School of Health and Applied Human Sciences, University of North Carolina, Wilmington, NC, United States
| | - Jake Diana
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jade Blackwell
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - James Faulkner
- School of Sport, Health, and Community, University of Winchester, Winchester, United Kingdom
| | - Sally Lark
- School of Sport, Exercise, and Nutrition, Massey University, Wellington, New Zealand
| | - Paula Skidmore
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Michael Hamlin
- Department of Tourism, Sport and Society, Lincoln University, Christchurch, New Zealand
| | - Leigh Signal
- Sleep-Wake Research Centre, Massey University, Wellington, New Zealand
| | - Michelle A Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| |
Collapse
|
3
|
Bjelakovic B, Stefanutti C, Reiner Ž, Watts GF, Moriarty P, Marais D, Widhalm K, Cohen H, Harada-Shiba M, Banach M. Risk Assessment and Clinical Management of Children and Adolescents with Heterozygous Familial Hypercholesterolaemia. A Position Paper of the Associations of Preventive Pediatrics of Serbia, Mighty Medic and International Lipid Expert Panel. J Clin Med 2021; 10:4930. [PMID: 34768450 PMCID: PMC8585021 DOI: 10.3390/jcm10214930] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 12/23/2022] Open
Abstract
Heterozygous familial hypercholesterolaemia (FH) is among the most common genetic metabolic lipid disorders characterised by elevated low-density lipoprotein cholesterol (LDL-C) levels from birth and a significantly higher risk of developing premature atherosclerotic cardiovascular disease. The majority of the current pediatric guidelines for clinical management of children and adolescents with FH does not consider the impact of genetic variations as well as characteristics of vascular phenotype as assessed by recently developed non-invasive imaging techniques. We propose a combined integrated approach of cardiovascular (CV) risk assessment and clinical management of children with FH incorporating current risk assessment profile (LDL-C levels, traditional CV risk factors and familial history) with genetic and non-invasive vascular phenotyping. Based on the existing data on vascular phenotype status, this panel recommends that all children with FH and cIMT ≥0.5 mm should receive lipid lowering therapy irrespective of the presence of CV risk factors, family history and/or LDL-C levels Those children with FH and cIMT ≥0.4 mm should be carefully monitored to initiate lipid lowering management in the most suitable time. Likewise, all genetically confirmed children with FH and LDL-C levels ≥4.1 mmol/L (160 mg/dL), should be treated with lifestyle changes and LLT irrespective of the cIMT, presence of additional RF or family history of CHD.
Collapse
Affiliation(s)
- Bojko Bjelakovic
- Clinic of Pediatrics, Clinical Center, Medical Faculty, University of Nis, 18000 Nis, Serbia
| | - Claudia Stefanutti
- Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Immunohematology and Transfusion Medicine, Department of Molecular Medicine, “Umberto I” Hospital, “Sapienza” University of Rome, I-00161 Rome, Italy
| | - Željko Reiner
- Department of Internal Diseases, University Hospital Center Zagreb, 10000 Zagreb, Croatia;
- School of Medicine, Zagreb University, 10000 Zagreb, Croatia
| | - Gerald F. Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine, University of Western Australia, Crawley 6009, Australia;
| | - Patrick Moriarty
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO 66104, USA;
| | - David Marais
- Division of Chemical Pathology, Department of Pathology, University of Cape Town Health Sciences, 6.33 Falmouth Building, Anzio Rd, Observatory, Cape Town 7925, South Africa;
| | - Kurt Widhalm
- Academic Institute for Clinical Nutrition, Alserstraße 14/4, 3100 Vienna, Austria;
- Department of Gastroenterology and Hepatology, Austria Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Hofit Cohen
- The Bert W. Strassburger Lipid Center, The Chaim Sheba Medical Center, Tel-Hashomer Israel, Sackler Faculty of Medicine, Tel Aviv University Israel, Tel Aviv 39040, Israel;
| | - Mariko Harada-Shiba
- Mariko Harada-Shiba Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shinmachi, Suita 564-8565, Japan;
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Cardiology and Congenital Diseases in Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland
- Cardiovascular Research Centre, University of Zielona Gora, 65-038 Zielona Gora, Poland
| |
Collapse
|
4
|
Dobe IS, Mocumbi AO, Majid N, Ayele B, Browne SH, Innes S. Earlier antiretroviral initiation is independently associated with better arterial stiffness in children living with perinatally acquired HIV with sustained viral suppression in Mozambique. South Afr J HIV Med 2021; 22:1282. [PMID: 34858652 PMCID: PMC8603154 DOI: 10.4102/sajhivmed.v22i1.1282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiovascular disease is a major driver of morbidity and mortality in adults living with HIV. The drivers of cardiovascular disease in children living with perinatally acquired HIV (PHIV) with sustained HIV viral suppression are unclear. OBJECTIVES We explored the contribution of HIV-specific risk factors to arterial stiffness independently of traditional risk factors (metabolic syndrome [MetS]) in prepubertal children with PHIV with sustained viral suppression in a low-income country in Africa. METHOD For this cross-sectional analysis, arterial stiffness was assessed by pulse wave velocity z-score (PWVz), measured using a Vicorder device. Metabolic syndrome components were measured. We retrospectively collected the antiretroviral therapy (ART) exposures, HIV stage, CD4 count and HIV viral load. A multivariate linear regression model was constructed for MetS components, retaining age and gender as obligatory variables. We then added HIV-related metrics to assess whether these had an independent or additive effect. RESULTS We studied 77 virally suppressed children with PHIV without evidence of cardiovascular disease (from medical history and physical examination). In the initial model, the PWVz was independently associated with each MetS component. The PWVz was higher in participants with proportionally greater visceral fat (waist/height ratio), elevated lipids (triglyceride/high-density lipoprotein ratio) and insulin resistance (log homeostatic model assessment [HOMA]). The addition of age at ART initiation increased the model R 2 value from 0.36 to 0.43. In the resulting model, younger age at ART initiation was independently associated with a better PWVz (P < 0.001). CONCLUSION Earlier ART initiation was independently associated with lower large artery stiffness. This effect was independent of the effect of elevated lipids, visceral fat and insulin resistance.
Collapse
Affiliation(s)
- Igor S. Dobe
- Division Non-Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Ana O. Mocumbi
- Division Non-Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
- Department of Internal Medicine, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Birhanu Ayele
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Science, Stellenbosch University, Stellenbosch, South Africa
| | - Sara H. Browne
- Department of Medicine, Division of Infectious Diseases, University of California San Diego, San Diego, United States of America
| | - Steve Innes
- Department of Paediatrics and Child Health, Family Centre for Research with Ubuntu (FAMCRU), Stellenbosch University, Cape Town, South Africa
- Desmond Tutu HIV Centre, University of Cape Town, South Africa
| |
Collapse
|
5
|
Kosger P, Akin T, Kiztanir H, Ucar B. Arterial Stiffness and Left Ventricular Myocardial Function in Children with a Well-Functioning Bicuspid Aortic Valve. Arq Bras Cardiol 2021; 117:1126-1133. [PMID: 34550169 PMCID: PMC8757143 DOI: 10.36660/abc.20200657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 01/20/2021] [Indexed: 12/04/2022] Open
Abstract
Fundamento: A rigidez arterial é um importante preditor de aortopatia e remodelamento miocárdico em pacientes com válvula aórtica bicúspide, podendo estar aumentada na infância. Objetivo: Avaliar a rigidez arterial e a função miocárdica do ventrículo esquerdo em crianças com válvula aórtica bicúspide funcional. Métodos: Quarenta e quatro crianças com válvula aórtica bicúspide e 41 pares saudáveis com válvula aórtica tricúspide foram incluídos neste estudo caso-controle. Foram obtidos os diâmetros e os escores-z relacionados da raiz aórtica e da aorta ascendente. Quanto à função miocárdica do ventrículo esquerdo, juntamente com as velocidades de fluxo mitral e parâmetros do Modo M, as velocidades miocárdicas e os intervalos de tempo foram avaliados com Doppler tecidual. A análise da onda de pulso foi realizada por aparelho oscilométrico (Mobil-o-Graph). Um valor de p<0,05 foi considerado significativo. Resultados: O índice da massa ventricular esquerda, a velocidade A do fluxo mitral, o diâmetro e o escore z da aorta ascendente e o índice de desempenho miocárdico estavam significativamente maiores nos pacientes (p = 0,04, p = 0,02, p = 0,04, p <0,001 e p <0,001 respectivamente). O índice de desempenho miocárdico correlacionou-se positivamente com o diâmetro da aorta ascendente e a velocidade A (r=0,272; p=0,01, r=356; p=0,001, respectivamente). A análise multivariada revelou que o índice de desempenho miocárdico estava relacionado ao diâmetro da aorta ascendente (p = 0,01). O índice de aumento e a velocidade da onda de pulso foram semelhantes entre os grupos (p> 0,05). Conclusão: De acordo com a análise da onda de pulso oscilométrico, as crianças com válvula aórtica bicúspide funcional apresentam rigidez arterial semelhante a seus pares saudáveis. O diâmetro da aorta ascendente foi estabelecido como preditor independente da função miocárdica do ventrículo esquerdo. A rigidez arterial pode não ser um fator de risco grave em pacientes pediátricos sem dilatação acentuada da aorta ascendente.
Collapse
Affiliation(s)
- Pelin Kosger
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Pediatric Cardiology, Eskisehir - Turquia
| | - Tugcem Akin
- Eskisehir State Hospital, Pediatric Cardiology Clinic, Eskisehir - Turquia
| | - Hikmet Kiztanir
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Pediatric Cardiology, Eskisehir - Turquia
| | - Birsen Ucar
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Pediatric Cardiology, Eskisehir - Turquia
| |
Collapse
|
6
|
Effects of aerobic, resistance and concurrent exercise on pulse wave reflection and autonomic modulation in men with elevated blood pressure. Sci Rep 2021; 11:760. [PMID: 33436986 PMCID: PMC7804273 DOI: 10.1038/s41598-020-80800-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/28/2020] [Indexed: 12/03/2022] Open
Abstract
The acute effects of exercise modes on pulse wave reflection (PWR) and their relationship with autonomic control remain undefined, particularly in individuals with elevated blood pressure (BP). We compared PWR and autonomic modulation after acute aerobic (AE), resistance (RE), and concurrent exercise (CE) in 15 men with stage-1 hypertension (mean ± SE: 34.7 ± 2.5 years, 28.4 ± 0.6 kg/m2, 133 ± 1/82 ± 2 mmHg). Participants underwent AE, RE, and CE on different days in counterbalanced order. Applanation tonometry and heart rate variability assessments were performed before and 30-min postexercise. Aortic pressure decreased after AE (− 2.4 ± 0.7 mmHg; P = 0.01), RE (− 2.2 ± 0.6 mmHg; P = 0.03), and CE (− 3.1 ± 0.5 mmHg; P = 0.003). Augmentation index remained stable after RE, but lowered after AE (− 5.1 ± 1.7%; P = 0.03) and CE (− 7.6 ± 2.4% P = 0.002). Systolic BP reduction occurred after CE (− 5.3 ± 1.9 mmHg). RR-intervals and parasympathetic modulation lowered after all conditions (~ 30–40%; P < 0.05), while the sympathovagal balance increased after RE (1.2 ± 0.3–1.3 ± 0.3 n.u., P < 0.05). Changes in PWR correlated inversely with sympathetic and directly with vagal modulation in CE. In conclusion, AE, RE, and CE lowered central aortic pressure, but only AE and CE reduced PWR. Overall, those reductions related to decreased parasympathetic and increased sympathetic outflows. Autonomic fluctuations seemed to represent more a consequence than a cause of reduced PWR.
Collapse
|
7
|
Mynard JP, Kondiboyina A, Kowalski R, Cheung MMH, Smolich JJ. Measurement, Analysis and Interpretation of Pressure/Flow Waves in Blood Vessels. Front Physiol 2020; 11:1085. [PMID: 32973569 PMCID: PMC7481457 DOI: 10.3389/fphys.2020.01085] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/06/2020] [Indexed: 01/10/2023] Open
Abstract
The optimal performance of the cardiovascular system, as well as the break-down of this performance with disease, both involve complex biomechanical interactions between the heart, conduit vascular networks and microvascular beds. ‘Wave analysis’ refers to a group of techniques that provide valuable insight into these interactions by scrutinizing the shape of blood pressure and flow/velocity waveforms. The aim of this review paper is to provide a comprehensive introduction to wave analysis, with a focus on key concepts and practical application rather than mathematical derivations. We begin with an overview of invasive and non-invasive measurement techniques that can be used to obtain the signals required for wave analysis. We then review the most widely used wave analysis techniques—pulse wave analysis, wave separation and wave intensity analysis—and associated methods for estimating local wave speed or characteristic impedance that are required for decomposing waveforms into forward and backward wave components. This is followed by a discussion of the biomechanical phenomena that generate waves and the processes that modulate wave amplitude, both of which are critical for interpreting measured wave patterns. Finally, we provide a brief update on several emerging techniques/concepts in the wave analysis field, namely wave potential and the reservoir-excess pressure approach.
Collapse
Affiliation(s)
- Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Avinash Kondiboyina
- Heart Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Remi Kowalski
- Heart Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Michael M H Cheung
- Heart Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
8
|
Elliot CA, Hamlin MJ, Lizamore CA. Inter-operator Reliability for Measuring Pulse Wave Velocity and Augmentation Index. Front Cardiovasc Med 2020; 7:72. [PMID: 32411729 PMCID: PMC7198861 DOI: 10.3389/fcvm.2020.00072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Arterial stiffness is a reversible precursor to hypertension. However, research is needed to determine the minimum amount of training required before acceptable arterial stiffness measurements are collected by novice operators. Objective: To compare novice vs. experienced operator measurements over a 2-week training period to assess when expert-like measures are achieved by the novice operator. Method: Forty-one participants (18 males, 23 females, age: 46.6 ± 14.9 years; BMI: 25.2 ± 3.8; systolic blood pressure: 122.8 ± 14.7 mmHg) received alternating novice and experienced operator arterial stiffness assessments. Measurements included: pulse wave velocity (PWV; using the automatic-capture time-periods of 5-, 10-, and 20-s) and augmentation index (AIx75) measurements using the SphygmoCor XCEL System v1 (AtCor Medical Pty Ltd., Sydney, Australia). Data were chronologically arranged into quintiles. Results: The intraclass correlation coefficient for PWV substantially improved from quintile 1 (r < 0.8) to quintile 2 and beyond (typically r > 0.8) while AIx75 improved consistently (r = 0.7 in quintile 1 and r = 0.97 in quintile 5). The coefficient of variation was lowest in quintile 4 (PWV: 4.7-6% across the three measurement time-periods; and 15% for AIx75) but increased in quintile 5 (PWV: 6.2-10.5%; and 25% for AIx75). All measurements demonstrated acceptable to excellent reliability after quintile 2. Conclusion: To achieve expert-like PWV measurements in this study, the novice operator underwent a familiarization session including guided practice measurements on 5 different people, for 10-15 min per person on two occasions (~2.5 h). The novice operator then required ≥14 practice measurements, with accuracy continuing to improve up to 30 participants. At least 30 training measurements are recommended for novices to take acceptable AIx75 measurements after a familiarization training.
Collapse
Affiliation(s)
- Catherine A. Elliot
- Department of Tourism, Sport and Society, Lincoln University, Christchurch, New Zealand
| | - Michael J. Hamlin
- Department of Tourism, Sport and Society, Lincoln University, Christchurch, New Zealand
| | - Catherine A. Lizamore
- Department of Tourism, Sport and Society, Lincoln University, Christchurch, New Zealand
- Department of Nursing, Midwifery and Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand
| |
Collapse
|
9
|
James ML, Christian D, Scott SC, Todd CE, Stratton G, Demmler J, McCoubrey S, Halcox JPJ, Audrey S, Ellins EA, Brophy ST. Active Children Through Individual Vouchers Evaluation: A Mixed-Method RCT. Am J Prev Med 2020; 58:232-243. [PMID: 31859172 PMCID: PMC6955646 DOI: 10.1016/j.amepre.2019.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Physical activity declines in adolescence, especially among those in deprived areas. Research suggests this may result from accessibility barriers (e.g., cost and locality). The Active Children Through Individual Vouchers Evaluation RCT aimed to improve the fitness and heart health of teenagers in Wales with the help of teenagers who co-produced the study. STUDY DESIGN This study was a mixed-method RCT. SETTING/PARTICIPANTS Before data collection, which took place at baseline, 6 months, and 12 months for both arms, 7 schools were randomized by an external statistician (4 intervention schools, n=524; 3 control schools, n=385). INTERVENTION The Active Children Through Individual Vouchers Evaluation intervention included provision of activity vouchers (£20 per month), a peer mentoring scheme, and support worker engagement for 12 months between January and December 2017. Data analysis occurred February-April 2018. MAIN OUTCOME MEASURES Data included measures of cardiovascular fitness, cardiovascular health (blood pressure and pulse wave analysis), motivation, and focus groups. RESULTS The intervention showed a trend to improve the distance ran (primary outcome) and was significant in improving the likelihood of intervention teenagers being fit (OR=1.21, 95% CI=1.07, 1.38, p=0.002). There was a reduction in teenagers classified as having high blood pressure (secondary outcome) in the intervention group (baseline, 5.3% [28/524]; 12 months, 2.7% [14/524]). Data on where teenagers used vouchers and evidence from focus groups showed that teenagers wanted to access more unstructured, informal, and social activities in their local areas. CONCLUSIONS Active Children Through Individual Vouchers Evaluation identified methods that may have a positive impact on cardiovascular fitness, cardiovascular health, and perspectives of activity. Consulting with teenagers, empowering them, and providing more local opportunities for them to take part in activities that are fun, unstructured, and social could positively impact teenage physical activity. TRIAL REGISTRATION ISRCTN, ISRCTN75594310.
Collapse
Affiliation(s)
- Michaela L James
- Swansea University Medical School, Swansea University, Swansea, United Kingdom.
| | - Danielle Christian
- Department of Sport and Physical Activity, Edge Hill University, Ormskirk, United Kingdom
| | - Samantha C Scott
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| | - Charlotte E Todd
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| | - Gareth Stratton
- College of Engineering, Bay Campus, Swansea University, Swansea, United Kingdom
| | - Joanne Demmler
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| | | | - Julian P J Halcox
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| | | | - Elizabeth A Ellins
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| | - Sinead T Brophy
- Swansea University Medical School, Swansea University, Swansea, United Kingdom
| |
Collapse
|
10
|
Stoner L, Pontzer H, Barone Gibbs B, Moore JB, Castro N, Skidmore P, Lark S, Williams MA, Hamlin MJ, Faulkner J. Fitness and Fatness Are Both Associated with Cardiometabolic Risk in Preadolescents. J Pediatr 2020; 217:39-45.e1. [PMID: 31759583 DOI: 10.1016/j.jpeds.2019.09.076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/27/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the associations between cardiorespiratory fitness (CRF) and fatness (overweight-obesity) with cardiometabolic disease risk among preadolescent children. STUDY DESIGN This cross-sectional study recruited 392 children (50% female, 8-10 years of age). Overweight-obesity was classified according to 2007 World Health Organization criteria for body mass index. High CRF was categorized as a maximum oxygen uptake, determined using a shuttle run test, exceeding 35 mL·kg-1·minute-1 in girls and 42 mL·kg-1·minute-1 in boys. Eleven traditional and novel cardiometabolic risk factors were measured including lipids, glucose, glycated hemoglobin, peripheral and central blood pressure, and arterial wave reflection. Factor analysis identified underlying cardiometabolic disease risk factors and a cardiometabolic disease risk summary score. Two-way analysis of covariance determined the associations between CRF and fatness with cardiometabolic disease risk factors. RESULTS Factor analysis revealed four underlying factors: blood pressure, cholesterol, vascular health, and carbohydrate-metabolism. Only CRF was significantly (P = .001) associated with the blood pressure factor. Only fatness associated with vascular health (P = .010) and carbohydrate metabolism (P = .005) factors. For the cardiometabolic disease risk summary score, there was an interaction effect. High CRF was associated with decreased cardiometabolic disease risk in overweight-obese but not normal weight children (P = .006). Conversely, high fatness was associated with increased cardiometabolic disease risk in low fit but not high fit children (P < .001). CONCLUSIONS In preadolescent children, CRF and fatness explain different components of cardiometabolic disease risk. However, high CRF may moderate the relationship between fatness and cardiometabolic disease risk. TRIAL REGISTRATION ACTRN 12614000433606.
Collapse
Affiliation(s)
- Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Herman Pontzer
- Department of Evolutionary Anthropology, Duke University, Durham, NC; Duke Global Health Institute, Duke University, Durham, NC
| | - Bethany Barone Gibbs
- Department of Health and Physical Activity, University of Pittsburgh, Pittsburgh, PA
| | - Justin B Moore
- Department of Family & Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Nicholas Castro
- School of Sport & Exercise, Massey University, Wellington, NZ; School of Kinesiology and Nutrition, University of Southern Mississippi, Hattiesburg, MS
| | - Paula Skidmore
- Department of Medicine, University of Otago, Christhcurch, NZ
| | - Sally Lark
- School of Sport & Exercise, Massey University, Wellington, NZ
| | - Michelle A Williams
- Depepartment of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael J Hamlin
- Department of Tourism, Sport and Society, Lincoln University, Christchurch, NZ
| | - James Faulkner
- Sport & Exercise, University of Winchester, Winchester, United Kingdom
| |
Collapse
|
11
|
James M, Christian D, Scott S, Todd C, Stratton G, Demmler J, McCoubrey S, Halcox JP, Audrey S, Ellins EA, Brophy S. Predictors of cardiovascular health in teenagers (aged 13-14 years): a cross-sectional study linked with routine data. Open Heart 2019; 6:e001147. [PMID: 31749974 PMCID: PMC6827787 DOI: 10.1136/openhrt-2019-001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/19/2019] [Accepted: 10/14/2019] [Indexed: 11/03/2022] Open
Abstract
Objective To examine the predictors of cardiovascular health in teenagers (aged 13-14 years). Methods Measures of arterial stiffness (augmentation index (AIx)), blood pressure and cardiovascular fitness were taken from 234 teenage children (n=152 boys) and subsequently linked to routine data (birth and general practice records, education data and hospital admission data). Deprivation at school and at individual level was measured at birth, at 1 year old, at 13 years old and at secondary school using the Welsh Index of Multiple Deprivation. Multivariate regression analysis determined associations between routinely collected data and cardiovascular measures. Results Teenagers had higher AIx (2.41 (95% CI 1.10 to 3.72)), ran fewer metres (-130.08 m (95% CI -234.35 to -25.78)) in the Cooper Run Test if they attended a more deprived school. However, higher individual level deprivation was associated with greater fitness (199.38 m (95% CI 83.90 to 314.84)). Higher systolic blood pressure was observed in first born children (10.23 mm Hg (95% CI 1.58 to 18.88)) and in those who were never breastfed (4.77 mm Hg (95% CI 1.10 to 8.42)). Conclusions Improving heart health in deprived areas requires multilevel action across childhood namely, active play and programmes that promote physical activity and fitness and, the promotion of breastfeeding. Recognition of the important early indicators and determinants of cardiovascular health supports further development of the evidence base to encourage policy-makers to implement preventative measures in young people.
Collapse
Affiliation(s)
| | - Danielle Christian
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | | | | | - Gareth Stratton
- College of Engineering, Swansea University, Swansea, Swansea, UK
| | | | - Sarah McCoubrey
- Sport Development, City and County of Swansea Council, Swansea, UK
| | - Julian P Halcox
- Medical School, Institute of Life Science, Swansea University, Swansea, UK
| | - Suzanne Audrey
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | | |
Collapse
|
12
|
Ambulatory blood pressures and central blood pressures are associated with cardiovascular morbidity in adolescent and young adult patients receiving chronic hemodialysis. Pediatr Nephrol 2019; 34:1261-1268. [PMID: 30778828 DOI: 10.1007/s00467-019-04208-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) and arterial stiffness measured by pulse wave velocity (PWV) are independent predictors of cardiovascular (CV) mortality in adults receiving chronic dialysis. Hypertension strongly associates with elevated left ventricular mass index (LVMI) and PWV, with ambulatory blood pressure monitoring (ABPM), and central blood pressure (CBP) superior to office blood pressures (BP) in predicting CV morbidity. Few studies have described associations of office BP, ABPM, and CBP with LVMI and PWV in adolescent and young adult patients receiving hemodialysis (HD). METHODS Cross-sectional study of 22 adolescents and young adults receiving chronic HD. Pre- and post-dialysis office BP and CBP using applanation tonometry were obtained. Twenty-four-hour ABPM was obtained midweek post-dialysis. Pre- and post-dialysis carotid-brachial PWV were obtained same day as BP measurements. Annual echocardiograms for standard care were reviewed for LVH. RESULTS Pre-dialysis CBP index correlated with LVMI (r = 0.3, p = 0.04) and PWV (r = 0.48, p = 0.02). Hypertensive patients identified by ABPM had worse LVMI; daytime ABPM systolic BP index correlated with LVMI (r = 0.5, p = 0.02). Office BP was not associated with LVMI; only office diastolic BP was associated with PWV (r = 0.46, p = 0.02). There was no correlation of LVMI or PWV with bone health parameters, anemia, interdialytic weight gain, or residual renal function. CONCLUSIONS Ambulatory blood pressure monitoring is superior to casual office BP obtained at time of dialysis in delineating cardiovascular morbidity in adolescent and young adult HD patients. CBP is easily performed and correlates with LVMI and PWV in adolescent and young adult HD patients; however, large-scale normative data is needed.
Collapse
|
13
|
Modifiable Clinical Correlates of Vascular Health in Children and Adolescents with Dyslipidemia. Pediatr Cardiol 2019; 40:805-812. [PMID: 30759268 DOI: 10.1007/s00246-019-02071-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Abstract
Atherosclerosis promoting cardiovascular disease risk factors (CVDrf) are highly prevalent among youth in the U.S. Determining which standard modifiable clinical measures (SMCMs) has the greatest impact on vascular structure and function is valuable for the health care provider to help identify children at highest risk. The aim of this study was to determine modifiable outpatient clinical predictors of vascular health in youth with CVDrf. Children and adolescents with CVDrf (n = 120, 13.1 ± 1.9 years, 49% female) were recruited from a pediatric preventive cardiology clinic. The SMCMs included BMI z-score, waist-to-height ratio (WTHR), lipid panel, hemoglobin A1c, blood pressure (BP), presence of tobacco smoke exposure, and presence of hypertriglyceridemic waist (HTW) phenotype (triglycerides ≥ 110 mg/dL and waist circumference ≥ 90 percentile). Vascular function and structure were measured with pulse wave velocity (PWV), central systolic BP (CSP), augmentation index (AIx), and carotid artery intima-media thickness (cIMT). Sex and height specific z-scores for PWV, CSP, and cIMT were used. Multiple linear regression with backwards selection identified SMCMs which strongly predicted vascular function and structure. Among SMCMs, WTHR and HTW were the most frequent predictors of vascular function (PWV: R2 = 0.32; CSP: R2 = 0.35; AIx R2 = 0.13). Other predictors of vascular function included hemoglobin A1C, BP, and BMI z-score. Systolic BP and LDL cholesterol were predictors of vascular structure (cIMT: R2 = 0.14). The strongest predictors of vascular health in youth with CVDrf were related to measures of central obesity. Targeting these SMCM in lieu of vascular testing in outpatient clinic setting may be practical to identify children and adolescents at greatest risk for CVD.
Collapse
|
14
|
Verburg PE, Roberts CT, McBean E, Mulder ME, Leemaqz S, Erwich JJHM, Dekker GA. Peripheral maternal haemodynamics across pregnancy in hypertensive disorders of pregnancy. Pregnancy Hypertens 2019; 16:89-96. [PMID: 31056165 DOI: 10.1016/j.preghy.2019.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 12/17/2018] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Evaluating maternal haemodynamics across pregnancy in uncomplicated pregnancies and those complicated by hypertensive disorders of pregnancy (HDP). STUDY DESIGN Prospective cohort study from 2015 to 2018 of healthy, nulliparous, singleton-bearing women. Maternal haemodynamics assessed by Uscom BP+ at 9-16 and 32-36 weeks' gestation in pregnancies complicated by HDP [preeclampsia with severe (sPE n = 12) and without severe clinical features (nsPE n = 49), gestational hypertension (GH n = 25), transient gestational hypertension (TGH n = 33)] were compared to uncomplicated pregnancies (n = 286) using mixed-effects linear modelling. MAIN OUTCOME MEASURES Maternal haemodynamic adaptation in uncomplicated pregnancies and those complicated by HDP. RESULTS Between the two measurements, haemodynamic adaptation in women with sPE and nsPE was significantly different compared to those with uncomplicated pregnancies. An additional increase was observed for peripheral systolic blood pressure [SBP; 14.3 mmHg, 8.6-20.1 (sPE)], peripheral diastolic blood pressure [DBP; 7.7 mmHg, 3.3-12.1 (sPE); 2.6 mmHg, 3.3-12.1 (nsPE)] peripheral mean arterial pressure [MAP; 10.6 mmHg, 5.8-15.5 (sPE); 3.4 mmHg, 0.8-6.0 (nsPE)], peripheral pulse pressure [PP; 6.6 mmHg, 2.1-11.1 (sPE)], central SBP [15.8 mmHg, 10.4-21.2 (sPE); 2.9 mmHg, 0.1-5.8 (nsPE)], central DBP [8.3 mmHg, 3.9-12.6 (sPE); 2.5 mmHg, 0.2-4.8 (nsPE), central MAP [10.8 mmHg, 6.4-15.2 (sPE); 2.6 mmHg, 0.3-5.0 (nsPE)] and central PP [7.6 mmHg, 3.9-11.3 (sPE)]. Augmentation index (AIx) decreased less (15.5%, 6.3-24.6 (sPE); 9.0%, 4.2-13.6 (nsPE)] compared to uncomplicated pregnancies. Haemodynamic adaptation across pregnancy in women with GH and TGH was not different from those with uncomplicated pregnancies. CONCLUSION Women who develop preeclampsia show an altered, while those who develop GH or TGH demonstrate a comparable haemodynamic adaptation compared to uncomplicated pregnancies. TGH is not a benign condition.
Collapse
Affiliation(s)
- Petra E Verburg
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Adelaide Medical School, University of Adelaide, Adelaide, Australia.
| | - Claire T Roberts
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Emma McBean
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Mylene E Mulder
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Shalem Leemaqz
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Jan Jaap H M Erwich
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gus A Dekker
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia; Department of Obstetrics and Gynaecology, Lyell McEwin Hospital, Elizabeth Vale, Australia
| |
Collapse
|
15
|
Etyang AO, Wandabwa CK, Kapesa S, Muthumbi E, Odipo E, Wamukoya M, Ngomi N, Haregu T, Kyobutungi C, Williams TN, Makale J, Macharia A, Cruickshank JK, Smeeth L, Scott JAG. Blood Pressure and Arterial Stiffness in Kenyan Adolescents With the Sickle Cell Trait. Am J Epidemiol 2018; 187:199-205. [PMID: 28992220 PMCID: PMC5860135 DOI: 10.1093/aje/kwx232] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/22/2017] [Indexed: 01/28/2023] Open
Abstract
The potential association between sickle cell trait (SCT) and increased arterial stiffness/blood pressure (BP) has not been evaluated in detail despite its association with stroke, sudden death, and renal disease. We performed 24-hour ambulatory BP monitoring and arterial stiffness measurements in adolescents raised in a malaria-free environment in Kenya. Between December 2015 and June 2016, 938 randomly selected adolescents (ages 11–17 years) who had been continuous residents of Nairobi from birth were invited to participate in the study. Standard clinic BP measurement was performed, followed by 24-hour ambulatory BP monitoring and arterial stiffness measurement using an Arteriograph24 (TensioMed Ltd., Budapest, Hungary) device. SCT status was determined using DNA genotyping in contemporaneously collected blood samples. Of the 938 adolescents invited to participate, 609 (65%) provided complete data for analysis. SCT was present in 103 (15%). Mean 24-hour systolic and diastolic BPs were 116 (standard deviation (SD), 11.5) mm Hg and 64 (SD, 7) mm Hg, respectively, in children with SCT and 117 (SD, 11.4) mm Hg and 64 (SD, 6.8) mm Hg, respectively, in non-SCT children. Mean pulse wave velocity (PWV) was 7.1 (SD, 0.8) m/second and 7.0 (SD, 0.8) m/second in SCT and non-SCT children, respectively. We observed no differences in PWV or in any clinic or ambulatory BP-derived measures between adolescents with and without SCT. These data suggest that SCT does not independently influence BP or PWV.
Collapse
Affiliation(s)
- Anthony O Etyang
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Emily Odipo
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Nicholas Ngomi
- African Population and Health Research Center, Nairobi, Kenya
| | - Tilahun Haregu
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Thomas N Williams
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- Imperial College London, London, United Kingdom
| | | | - Alex Macharia
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - J Anthony G Scott
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
16
|
Phillips RA, Smith BE, Madigan VM. Stroke Volume Monitoring: Novel Continuous Wave Doppler Parameters, Algorithms and Advanced Noninvasive Haemodynamic Concepts. CURRENT ANESTHESIOLOGY REPORTS 2017; 7:387-398. [PMID: 29200974 PMCID: PMC5696447 DOI: 10.1007/s40140-017-0235-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Adequate oxygen delivery is essential for life, with hypoxia resulting in dysfunction, and ultimately death, of the cells, organs and organism. Blood flow delivers the oxygen bound in the blood, while haemodynamics is the science of blood flow. Stroke volume (SV) is the fundamental unit of blood flow, and reflects the interdependent performance of the heart, the vessels and the autonomic nervous system. However, haemodynamic management remains generally poor and predominantly guided by simple blood pressure observations alone. RECENT FINDINGS Doppler ultrasound measures SV with unequalled clinical precision when operated by trained personnel. Combining SV with BP measurements allows calculation of flow-pressure based measures which better reflect cardiovascular performance and allows personalised physiologic and pathophysiologic modelling consistent with Frank's and Starling's observations. SUMMARY Doppler SV monitoring and novel flow-pressure parameters may improve our understanding of the cardiovascular system and lead to improved diagnosis and therapy. This review examines the physics and practice of Doppler SV monitoring and its application in advanced haemodynamics.
Collapse
Affiliation(s)
- R. A. Phillips
- Ultrasound and Cardiovascular Monitoring, Critical Care Research Group, School of Medicine, The University of Queensland, Brisbane, Australia
| | - B. E. Smith
- Discipline of Intensive Care, University of Notre Dame Australia, Sydney, Australia
- Department of Anaesthetics and Intensive Care, Bathurst Base Hospital, Bathurst, NSW Australia
| | - V. M. Madigan
- University of Notre Dame Australia, Sydney, Australia
| |
Collapse
|
17
|
Stoner L, Weatherall M, Skidmore P, Castro N, Lark S, Faulkner J, Williams MA. Cardiometabolic Risk Variables in Preadolescent Children: A Factor Analysis. J Am Heart Assoc 2017; 6:e007071. [PMID: 29021277 PMCID: PMC5721889 DOI: 10.1161/jaha.117.007071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/09/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atherosclerosis begins during preadolescence and is occurring at an accelerated rate. This acceleration has been linked to poor lifestyle behaviors and subsequent cardiometabolic complications. Although the clustering of cardiometabolic risk factors has been recognized for over 2 decades, previous studies in children have predominantly examined the relationships between atherosclerosis and individual cardiometabolic risk factors or have grouped together preadolescent and adolescent children. Further, no known studies have included glycated hemoglobin or central hemodynamic measures such as central systolic blood pressure and augmentation index. METHODS AND RESULTS Principal component analysis was performed on a cross-sectional sample of 392 children (aged 9.5 years, 50% girls) from 3 representative sample sites across New Zealand. Four factors explained 60% of the variance in the measured variables. In order of variance explained, the factors were: blood pressure (central systolic blood pressure and peripheral systolic and diastolic blood pressure), adiposity (waist circumference, body mass index, and glycated hemoglobin), lipids (total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol), and vascular (augmentation index, heart rate, and fasting blood glucose). CONCLUSIONS In accordance with previous findings in adults and adolescents, one common factor is unlikely to define cardiometabolic health in preadolescent children. Each of the factors, except vascular, which was predominantly explained by augmentation index, are in agreement with previous findings in adolescents. An additional novel finding was that glycated hemoglobin and fasting blood glucose loaded onto different factors, supporting previous work suggesting that fasting blood glucose indicates short-term glycemic control, whereas glycated hemoglobin reflects chronic glycemic control. CLINICAL TRIAL REGISTRATION URL: www.anzctr.org.au/. ID: ACTRN12614000433606.
Collapse
Affiliation(s)
- Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, NC
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Paula Skidmore
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Nicholas Castro
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - Sally Lark
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - James Faulkner
- Department of Sport & Exercise, University of Winchester, United Kingdom
| | - Michelle A Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| |
Collapse
|
18
|
Central blood pressure and pulse wave amplification across the spectrum of peripheral blood pressure in overweight and obese youth. J Hypertens 2017; 34:1389-95. [PMID: 27088634 DOI: 10.1097/hjh.0000000000000933] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To identify vascular phenotypes across blood pressure (BP) conditions in overweight and obese youths, by assessing office BP (oBP), and central BP (cBP), and pulse pressure (PP) amplification. Whether or not 24-h ambulatory BP monitoring (ABPM) and pulse wave velocity (PWV) add insight to the issue has also been examined. METHODS White youths of both sexes with overweight or obesity and of European origin, ranging from 8 to 18 years of age, were included. oBP, cBP, PWV, and 24-h ABPM were measured. oBP conditions and 'white-coat' hypertension were defined as recommend by European Society Hypertension Guidelines in Children and Adolescents. Patients were divided into subgroups of 'normal' or 'high' according to cBP and PP ratio. RESULTS A total of 593 patients (mean age, 12.2 ± 2.3 years; 275 women) were included in the study. The largest differences between office SBP and central SBP correspond to the isolated systolic hypertension (ISH) group, in which only 25% of patients have high cBP, in contrast to 50% of the systo-diastolic hypertension (SDH) group. Two patterns emerged based on cBP and PP ratio - while the highest cBP was among the SDH, the highest PP amplitude was in the ISH group. Ninety percent of the SDH were confirmed with 24-h ABPM, in contrast to 75% of the ISH, who were white-coat hypertensive. PWV showed a progressive increment across the groups from normotension to SDH. Significant differences were observed only when compared with the normotensive, but not among all other groups. CONCLUSION In overweight and obese hypertensive patients, ISH is prevalent, posing a challenge for the clinician of whether these may therefore be diagnosed and managed as hypertensive patients. Until prospective studies can give more knowledge, 24-h ABPM can offer information for making clinical decisions.
Collapse
|
19
|
|
20
|
|
21
|
|
22
|
Reliability of oscillometric central blood pressure and wave reflection readings: effects of posture and fasting. J Hypertens 2016; 33:1588-93. [PMID: 26136065 DOI: 10.1097/hjh.0000000000000604] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Oscillometric pulse wave analysis devices have recently emerged, presenting suitable options for investigating central hemodynamic properties in clinical practice. This study sought to examine whether the between-day reliability of central SBP (cSBP) and systemic arterial wave reflection (augmentation index, AIx) readings exceed the criterion for acceptable reliability or are affected by posture (supine and seated) and fasting state. METHODS Twenty healthy adults (50% female, 27.9 years, 24.2 kg/m) were tested on six different mornings: 3 days fasted and 3 days nonfasted. On each occasion, participants were tested in supine and seated postures. Oscillometric pressure waveforms were recorded on left upper arm. RESULTS For cSBP, there was nonsignificant main effect for fasting state (P = 0.819) but there was a main effect for posture (P = 0.002). Conversely, for AIx, there was nonsignificant main effect for posture (P = 0.537) but there was a large main effect for fasting state (P = < 0.001). The criterion intraclass correlation coefficient value of 0.75 was exceeded for both variables when participants were assessed under the combined supine-fasted condition. For cSBP, the reliability coefficient was lowest (best) when supine fasted (6.8 mmHg) and greatest (worst) when seated nonfasted (8.6 mmHg). For AIx, the reliability coefficient was lower for the supine (11.4-11.7%) compared with the seated (14.0-15.2%) posture. CONCLUSION Findings from this study suggest that oscillometric assessments of central hemodynamic variables exceed the criterion for acceptable reliability and are most reliable when participants are evaluated while supine and fasted.
Collapse
|
23
|
Stoner L, Bonner C, Credeur D, Lambrick D, Faulkner J, Wadsworth D, Williams MA. Reliability of oscillometric central hemodynamic responses to an orthostatic challenge. Atherosclerosis 2015; 241:761-5. [PMID: 26142686 DOI: 10.1016/j.atherosclerosis.2015.06.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/29/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Monitoring central hemodynamic responses to an orthostatic challenge may provide important insight into autonomic nervous system function. Oscillometric pulse wave analysis devices have recently emerged, presenting clinically viable options for investigating central hemodynamic properties. The purpose of the current study was to determine whether oscillometric pulse wave analysis can be used to reliably (between-day) assess central blood pressure and central pressure augmentation (augmentation index) responses to a 5 min orthostatic challenge (modified tilt-table). METHODS Twenty healthy adults (26.4 y (SD 5.2), 55% F, 24.7 kg/m(2) (SD 3.8)) were tested on 3 different mornings in the fasted state, separated by a maximum of 7 days. Central hemodynamic variables were assessed on the left arm using an oscillometric device. RESULTS Repeated measures analysis of variance indicated a significant main effect of the modified tilt-table for all central hemodynamic variables (P < 0.001). In response to the tilt, central diastolic pressure increased by 4.5 mmHg (CI: 2.6, 6.4), central systolic blood pressure increased by 2.3 (CI: 4.4, 0.16) mmHg, and augmentation index decreased by an absolute - 5.3%, (CI: -2.7, -7.9%). The intra-class correlation coefficient values for central diastolic pressure (0.83-0.86), central systolic blood pressure (0.80-0.87) and AIx (0.79-0.82) were above the 0.75 criterion in both the supine and tilted positions, indicating excellent between-day reliability. CONCLUSION Central hemodynamic responses to an orthostatic challenge can be assessed with acceptable between-day reliability using oscillometric pulse wave analysis.
Collapse
Affiliation(s)
- Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, Private Bag 756, Wellington, 6140, New Zealand.
| | - Chantel Bonner
- Department of Epidemiology, Harvard School of Public Health, USA
| | - Daniel Credeur
- School of Human Performance and Recreation, University of Southern Mississippi, USA
| | | | - James Faulkner
- Department of Sport & Exercise, University of Winchester, UK
| | - Daniel Wadsworth
- School of Sport and Exercise, Massey University, Wellington, Private Bag 756, Wellington, 6140, New Zealand
| | | |
Collapse
|
24
|
Milne L, Keehn L, Guilcher A, Reidy JF, Karunanithy N, Rosenthal E, Qureshi S, Chowienczyk PJ, Sinha MD. Central aortic blood pressure from ultrasound wall-tracking of the carotid artery in children: comparison with invasive measurements and radial tonometry. Hypertension 2015; 65:1141-6. [PMID: 25824246 DOI: 10.1161/hypertensionaha.115.05196] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022]
Abstract
Differences between central aortic root (c) and peripheral (p) systolic blood pressure (SBP) may be particularly marked in children, but noninvasive methods for assessing cSBP in children have not been validated. We compared estimates of cSBP obtained from radiofrequency ultrasound wall tracking of the carotid artery (ART.LAB system) with that measured directly by a catheter in the aortic root at the time of arterial cannulation. Carotid waveforms were calibrated from invasive measurements of mean and diastolic pressures. In 9 children aged 10.5 ± 5.0 years (mean ± SD), cSBP obtained from carotid wall tracking was highly correlated with invasive measures of cSBP (r=0.99) with mean (± SD) difference 3.9 ± 2.5 mm Hg. Second, we compared values of cSBP obtained from the carotid with those obtained using noninvasive applanation tonometry at the radial artery and a radial-to-aortic transfer function (SphygmoCor). Both carotid and radial tonometric measurements were calibrated from the same peripheral mean and diastolic measurements of blood pressure obtained by sphygmomanometry. In 84 children aged 13.2 ± 3.2 years, there was excellent agreement between the 2 methods (r=0.95; P<0.001) with mean difference 0.71 ± 3.7 mm Hg (95% confidence interval =-1.53 to 1.01). This invasive validation study confirms that cSBP as estimated by carotid wall tracking provides an acceptable measurement of true cSBP when calibration is from true mean and diastolic pressures. Close agreement of cSBP obtained by carotid wall tracking and radial tonometry suggests that these provide similar results when calibrated from the same peripheral blood pressure measurements.
Collapse
Affiliation(s)
- Laura Milne
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Louise Keehn
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Antoine Guilcher
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John F Reidy
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Narayan Karunanithy
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eric Rosenthal
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shakeel Qureshi
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Phil J Chowienczyk
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Manish D Sinha
- From the Department of Clinical Pharmacology, King's College London, British Heart Foundation Centre, United Kingdom (L.M., L.K., A.G., P.J.C., M.D.S.); and Departments of Interventional Radiology (J.F.R., N.K.), Paediatric Cardiology (E.R., S.Q.), and Paediatric Nephrology (M.D.S.), Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom.
| |
Collapse
|
25
|
Elmenhorst J, Hulpke-Wette M, Barta C, Dalla Pozza R, Springer S, Oberhoffer R. Percentiles for central blood pressure and pulse wave velocity in children and adolescents recorded with an oscillometric device. Atherosclerosis 2014; 238:9-16. [PMID: 25461733 DOI: 10.1016/j.atherosclerosis.2014.11.005] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/29/2014] [Accepted: 11/12/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In adults with arterial hypertension, measuring arterial stiffness by pulse wave velocity (PWV) can determine the extent of cardiovascular subclinical organ damage. PWV has independent predictive value for cardiovascular events, but there are currently no recommendations for measuring PWV in children. In addition, central systolic blood pressure (cSBP) strongly reflects vascular changes. The aim of this study was to establish percentiles for cSBP and PWV in children and adolescents to evaluate and classify altered vascular function in youths. METHODS AND RESULTS We measured PWV and cSBP with an oscillometric device with inbuilt ARCSolver-algorithm (estimated by using the brachial waveform) and calculated smoothed reference percentiles for 1445 children and young adults (49.5% female; 13.41 ± 2.80 years, range 8-22 years; PWV 4.67 ± 0.34 m/s; cSBP 100.7 ± 8.9 mmHg) using the LMS-method based on age and height. PWV and cSBP increased with age and height, but slightly differently for girls and boys, possibly reflecting different growth patterns. Between 8 and 21 years, PWV increased from 4.29 ± 0.32 to 4.98 ± 0.33 m/s in girls and from 4.27 ± 0.18 to 5.22 ± 0.46 m/s in boys. While girls showed a minor increase in cSBP (91.2 ± 7.5 to 109.1 ± 8.6 mmHg), the cSBP in boys ranged from 90.0 ± 5.8 to 110.5 ± 9.6 mmHg with a more pronounced increase between 14 and 17 years. CONCLUSION These percentiles for PWV and cSBP can help define arterial stiffness in youths and contribute to risk stratification for cardiovascular disease. For example, in children with prehypertension or isolated systolic hypertension, PWV and cSBP can provide additional information about the function of the vascular system, thereby strengthening intervention strategies.
Collapse
Affiliation(s)
- Julia Elmenhorst
- Institute of Preventive Pediatrics, Department of Sport and Health Sciences, Technische Universität, München, Germany.
| | | | - Christiane Barta
- Institute of Preventive Pediatrics, Department of Sport and Health Sciences, Technische Universität, München, Germany
| | - Robert Dalla Pozza
- Großhadern/Dr. von Hauner'sches Kinderspital, Ludwigs-Maximilians-Universität, München, Germany
| | - Stephan Springer
- Klinik Hochried der Katholischen Jugendfürsorge Augsburg, Murnau, Germany
| | - Renate Oberhoffer
- Institute of Preventive Pediatrics, Department of Sport and Health Sciences, Technische Universität, München, Germany
| |
Collapse
|
26
|
Castro N, Faulkner J, Skidmore P, Williams M, Lambrick DM, Signal L, Thunders M, Muller D, Lark S, Hamlin M, Lane AM, Kingi TK, Stoner L. Pre-Adolescent Cardio-Metabolic Associations and Correlates: PACMAC methodology and study protocol. BMJ Open 2014; 4:e005815. [PMID: 25234509 PMCID: PMC4170204 DOI: 10.1136/bmjopen-2014-005815] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Although cardiovascular disease is typically associated with middle or old age, the atherosclerotic process often initiates early in childhood. The process of atherosclerosis appears to be occurring at an increasing rate, even in pre-adolescents, and has been linked to the childhood obesity epidemic. This study will investigate the relationships between obesity, lifestyle behaviours and cardiometabolic health in pre-pubescent children aged 8-10 years, and investigates whether there are differences in the correlates of cardiometabolic health between Māori and Caucasian children. Details of the methodological aspects of recruitment, inclusion/exclusion criteria, assessments, statistical analyses, dissemination of findings and anticipated impact are described. METHODS AND ANALYSIS Phase 1: a cross-sectional study design will be used to investigate relationships between obesity, lifestyle behaviours (nutrition, physical activity/fitness, sleep behaviour, psychosocial influences) and cardiometabolic health in a sample of 400 pre-pubescent (8-10 years old) children. Phase 2: in a subgroup (50 Caucasian, 50 Māori children), additional measurements of cardiometabolic health and lifestyle behaviours will be obtained to provide objective and detailed data. General linear models and logistic regression will be used to investigate the strongest correlate of (1) fatness; (2) physical activity; (3) nutritional behaviours and (4) cardiometabolic health. ETHICS AND DISSEMINATION Ethical approval will be obtained from the New Zealand Health and Disabilities Ethics Committee. The findings from this study will elucidate targets for decreasing obesity and improving cardiometabolic health among preadolescent children in New Zealand. The aim is to ensure an immediate impact by disseminating these findings in an applicable manner via popular media and traditional academic forums. Most importantly, results from the study will be disseminated to participating schools and relevant Māori health entities.
Collapse
Affiliation(s)
- Nicholas Castro
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - James Faulkner
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - Paula Skidmore
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Michelle Williams
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Danielle M Lambrick
- Institute of Food Nutrition and Human Health, Massey University, Wellington, New Zealand
| | - Leigh Signal
- Sleep/Wake Research Centre, Massey University, Wellington, New Zealand
| | - Michelle Thunders
- Institute of Food Nutrition and Human Health, Massey University, Wellington, New Zealand
| | - Diane Muller
- Sleep/Wake Research Centre, Massey University, Wellington, New Zealand
| | - Sally Lark
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| | - Mike Hamlin
- Department of Environment, Society, and Design, Lincoln University, Christchurch, New Zealand
| | - Andrew M Lane
- Faculty of Health, Education and Well-being, University of Wolverhampton, Wolverhampton, UK
| | - Te Kani Kingi
- Research Centre for Maori Health and Development, Massey University, Wellington, New Zealand
| | - Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, New Zealand
| |
Collapse
|