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Shelley D, Cleland CM, Nguyen T, Van Devanter N, Siman N, Van M H, Nguyen NT. Effectiveness of a multicomponent strategy for implementing guidelines for treating tobacco use in Vietnam Commune Health Centers. Nicotine Tob Res 2021; 24:196-203. [PMID: 34543422 DOI: 10.1093/ntr/ntab189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs). METHODS We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n=26) in Vietnam. Arm 1 included training and a tool kit (e.g., reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As+R). Provider surveys were conducted at baseline, six- and 12-months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As. RESULTS Adoption of the 4As increased significantly across both study arms (all p<.001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling. CONCLUSION The study demonstrated the effectiveness of a multicomponent and multilevel strategy (i.e., provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam. IMPLICATIONS Improving implementation of evidence-based tobacco dependence treatment (TDT) guidelines is a necessary step towards reducing the growing burden of non-communicable disease (NCDs) and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam, and offers a potentially scalable model for meeting FCTC Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a community health worker for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.
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Affiliation(s)
- D Shelley
- New York University School of Global Public Health, New York, NY
| | - C M Cleland
- New York University Grossman School of Medicine, Department of Population Health, NY
| | - T Nguyen
- Institute of Social and Medical Studies, My Dinh Ward, South Tu Liem District, Ha Noi, Vietnam
| | - N Van Devanter
- Rory Myers College of Nursing, New York University, New York, NY
| | - N Siman
- New York University Grossman School of Medicine, Department of Population Health, NY
| | - Hoang Van M
- Minh Hoang Van, MD, Hanoi University of Public Health, Duc Thang Ward, North Tu Liem district, Hanoi, Vietnam
| | - N T Nguyen
- Institute of Social and Medical Studies, My Dinh Ward, South Tu Liem District, Ha Noi, Vietnam
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Cave DGW, Shelley D, Michael H, Garg P, Greenwood JP, Plein S, Olaru MA, Van Der Geest RJ, Bissell MM. Diagnostic accuracy of 4D flow MRI comparing 2mm3 and 3mm3 spatial resolution. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health Research, UK University of Leeds
Background
Cardiac magnetic resonance (CMR) examinations requiring repeated breath-holds are challenging in younger patients. While 4-dimensional phase-contrast (4D flow) CMR does not require breath-holds, acquisition has been lengthy. Therefore to date spatial resolution has been influenced mainly by scan length. With accelerated sequences becoming available, higher spatial resolution is becoming clinically feasible.
Purpose
We therefore evaluated the minimum spatial resolution in 4D flow CMR necessary for accurate clinical assessment.
Methods
Ten healthy volunteers (mean age 24.8 years) underwent cardiac examinations on a 3T scanner using a 4D Flow prototype sequence at 2x2x2mm3 (4DFlow2) and 3x3x3mm3 (4DFlow3) spatial resolution. Net forward flow (FF) and peak velocity (PV) using valve tracking were calculated with commercially available software and kinetic energy (KE) in the left ventricle (LV) was analysed using a research tool. Bland-Altman analysis was used for statistical assessment and is reported as bias ± limits of agreement.
Results
Aortic valve flow metrics were similar in 4DFlow2 (FF 94ml; PV 133cm/s) and 4DFlow3 (FF 95ml; PV 130cm/s), and both showed good agreement with 2D PC MRI (FF 93ml, Bland-Altman:1.6 ± 9.7 and 2.2 ± 13.5, respectively). Similar results were obtained for pulmonary valve flow (FF 138cm/s; Bland-Altman:4.7 ± 15.1 and 8.1 ± 18.2, respectively). Branch pulmonary artery (PA) FF showed good agreement with the main PA FF in 2D and 4DFlow2 (Bland-Altman:1.1 ± 15.9 and 1.1 ± 10.6, respectively), but not in 4DFlow3 (Bland-Altman:1.1 ± 32.5). Global LV KE measured by 4DFlow3 was on average 12% lower compared to 4DFlow2, whereas maximum systolic LV KE was similar in both acquisition methods.
Conclusions
3mm3 spatial resolution appears to be sufficient for clinical evaluation of aortic and pulmonary valves. Smaller vessels such as branch pulmonary arteries require higher resolution for accurate assessment. While no gold standard is available for kinetic energy assessment, our results suggest that some parameters LV energetic assessment is spatial resolution sensitive. Differences in SNR might also contribute to the differing results.
Abstract Figure. Bland-Altman plots for 4D flow MRI
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Affiliation(s)
- DGW Cave
- University of Leeds, Leeds, United Kingdom of Great Britain & Northern Ireland
| | - D Shelley
- University of Leeds, Leeds, United Kingdom of Great Britain & Northern Ireland
| | - H Michael
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom of Great Britain & Northern Ireland
| | - P Garg
- University of Sheffield, Sheffield, United Kingdom of Great Britain & Northern Ireland
| | - JP Greenwood
- University of Leeds, Leeds, United Kingdom of Great Britain & Northern Ireland
| | - S Plein
- University of Leeds, Leeds, United Kingdom of Great Britain & Northern Ireland
| | - MA Olaru
- Siemens Healthcare Limited, Frimley, United Kingdom of Great Britain & Northern Ireland
| | | | - MM Bissell
- University of Leeds, Leeds, United Kingdom of Great Britain & Northern Ireland
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Koshy A, Gierula J, Paton M, Swoboda P, Toms A, Saunderson C, Shelley D, Broadbent D, Plein S, Kearney M, Witte K. Partial normalisation of cardiac mechanics with active CRT in patients with chronic failure: a novel application of 3.0T CMR. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cardiac resynchronisation therapy (CRT) is a routine treatment for chronic heart failure (CHF) with reduced ejection fraction and conduction delay to improve prognosis. Cardiac mechanics in patients with CHF are believed to be altered from controls based on invasive and echocardiographic based data. Technological advancements in cardiac magnetic resonance (CMR) and devices enable investigation of the cardiac response to CRT over a range of heart rates.
Methods
Patients with a CRT-D device were enrolled from heart failure clinics at Leeds General Infirmary, UK. After a MRI safety assessment, a baseline device check was conducted by a cardiac physiologist. Left ventricular (LV) volumes and systolic BP were measured at baseline and heart rates of 75, 90, 100, 115, 125, and 140 (randomised order) with CRT active and intrinsic conduction. All scans were conducted using a 3.0 T Siemens Prisma MRI scanner. Analysis of the scans used commercially available software. LV contractility was derived as a ratio of the LV end systolic volume and systolic BP. A post scan device interrogation was conducted to assess for scanning safety. Control participants with a 3.0T MR-conditional dual chamber pacemakers completed a similar protocol.
Results
Scanning was conducted in 17 CRT patients and 13 controls with a pre and post device and lead interrogation. No patient experienced symptoms related to scanning or device failure. The mean LV ejection fraction at baseline in the CRT cohort was 33.7±12.9%. Left ventricular ejection fraction fell across both cohorts as paced heart rate increased with reduced deterioration in control patients and those with CRT active. Peak LV cardiac output was significantly higher during active CRT (p<0.05). LV contractility was relatively static with CRT disabled (r2=0.13, p=0.38) and improved with CRT active (r2=0.91, p=0.01) and in controls (r2=0.74, p=0.01). Peak LV strain occurred at 100bpm during active CRT and in control patients whereas CRT disabled resulted in earlier deterioration.
Conclusion
We have demonstrated improvements in cardiac output and contractility consequent to active CRT using 3.0T CMR and subsequently validated via strain analysis. CRT appears to partially normalise cardiac mechanics across the range of heart rates studied. Further work is required to explore this phenomenon on a cellular or metabolic level.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AK is supported by an unconditional grant provided by Medtronic
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Affiliation(s)
- A Koshy
- University of Leeds, Leeds, United Kingdom
| | - J Gierula
- University of Leeds, Leeds, United Kingdom
| | - M Paton
- Leeds General Infirmary, Leeds, United Kingdom
| | - P Swoboda
- University of Leeds, Leeds, United Kingdom
| | - A.G Toms
- Leeds General Infirmary, Leeds, United Kingdom
| | | | - D Shelley
- Leeds General Infirmary, Leeds, United Kingdom
| | - D Broadbent
- Leeds General Infirmary, Leeds, United Kingdom
| | - S Plein
- University of Leeds, Leeds, United Kingdom
| | | | - K.K Witte
- University of Leeds, Leeds, United Kingdom
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Nguyen A, Siman N, Barry M, Cleland C, Pham‐Singer H, Ogedegbe O, Berry C, Shelley D. Patient‐Physician Race/Ethnicity Concordance Improves Adherence to Cardiovascular Disease Guidelines. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- A.M. Nguyen
- NYU Langone Health New York NY United States
| | - N. Siman
- NYU Langone Health New York NY United States
| | - M. Barry
- NYU Langone Health New York NY United States
| | - C.M. Cleland
- New York University School of Medicine New York NY United States
| | - H. Pham‐Singer
- New York City Department of Health and Mental Hygiene Long Island City NY United States
| | - O. Ogedegbe
- New York University School of Medicine New York NY United States
| | - C. Berry
- Department of Population Health NYU Langone Health New York NY United States
| | - D. Shelley
- NYU College of Global Public Health New York NY United States
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Stevens ER, Shelley D, Boden-Albala B. Perceptions of barriers and facilitators to engaging in implementation science: a qualitative study. Public Health 2020; 185:318-323. [PMID: 32721770 DOI: 10.1016/j.puhe.2020.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/02/2020] [Accepted: 06/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Understanding barriers and facilitators to engaging with implementation science (IS) research can provide insight into how to improve efforts to encourage more researchers to participate in IS research. STUDY DESIGN The study design used is a grounded theory qualitative study. METHODS We conducted semistructured telephone interviews with 20 health researchers familiar with IS that both report engaging in IS research and those that do not. We explored perceptions of barriers and facilitators to engaging in IS research. Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. Interview topics were informed by the result of an online survey of health researchers in the US. RESULTS Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. While accessible mentorship, exposure to formative experiences that develop interest in IS research and an increasing IS visibility were described as motivators for engaging in IS research. CONCLUSIONS These results highlight the importance of mentorship and exposure to IS ideas in motivating engagement in IS research and the presence of training and methodological barriers to engagement. Future research should expand this line of inquiry to include the perspectives of more junior researchers and students to better reflect the current IS environment.
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Affiliation(s)
- E R Stevens
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
| | - D Shelley
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA; College of Global Public Health, NYU, New York, NY, USA
| | - B Boden-Albala
- Susan and Henry Samueli College of Health Sciences, UC Irvine, Irvine, CA, USA
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Koshy A, Gierula J, Paton M, Swoboda P, Toms A, Saunderson C, Shelley D, Plein D, Cubbon R, Kearney M, Witte K. P1236Revealing cardiac mechanics with CMR whilst CRT is active: the first step. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Cardiac resynchronisation therapy (CRT) is a routine treatment for heart failure with reduced ejection fraction and conduction delay to improve symptoms and prognosis. Technological advancements both in cardiac magnetic resonance (CMR) and devices (MRI-conditional modes) now enable investigation of the haemodynamic response to CRT over a range of heart rates.
Methods
Patients with a CRT-D device were enrolled from heart failure clinics at a single tertiary centre. A complete device system assessment and baseline device check was conducted to ensure MRI compatibility and suitability. Left ventricular (LV) volumes and systolic blood pressure were measured at baseline and heart rates of 75, 90, 100, 115, 125, and 140 bpm (randomised order) with CRT active and intrinsic conduction (AOO). MRI conditional mode parameters were replicated through standard parameter modification to ensure biventricular pacing during CRT active scans. All scans were conducted using a 3.0 T Siemens Prisma MRI scanner with analysis on commercially available software. Contractility was derived from the systolic blood pressure and left ventricular end systolic volume. A post scan device and lead assessment was conducted to assess for scanning safety.
Results
Scanning was conducted in 22 patients (safety cohort). Post scan battery voltage reduced by 2.9±1.0%. Mean change in atrial, right ventricular and left ventricular lead impedance was 0.5±0.06%, 3.0±0.04% and −1.7±0.05% respectively. Mean change in atrial, right ventricular and left ventricular pacing threshold was 0.0±0.3%, 8.3±0.3% and 5.6±0.3%. No patient experienced symptoms related to scanning or device failure.
Preliminary data for patients with CRT on and off have been analysed (paired analysis cohort, n=8, 6 men). Mean age was 71.1±8.2, aetiology was primarily ischaemic (62.5%) with the remainder dilated cardiomyopathy. The mean LV ejection fraction at baseline was 29.4±12.9%. Biventricular pacing led to acute improvements in ejection fraction (p=0.005), left ventricular cardiac output (p<0.0001) and contractility (p=0.05) over the entire range of heart rates studied. We also noted an improvement in the force frequency relationship during biventricular pacing with a higher peak contractility (p=0.05), a higher heart rate at which this occurred (HR=130) and a generally up sloping relationship when compared with intrinsic conduction.
Conclusion
We have demonstrated for the first time, the mechanistic improvements in cardiac contractility consequent to CRT using CMR and also that MRI scans of conditional devices can be safe with CRT active.
Acknowledgement/Funding
Dr A Koshy is conducting a PhD supported by grant from Medtronic. Dr Klaus Witte has received honoraria from Medtronic
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Affiliation(s)
- A Koshy
- University of Leeds, Leeds, United Kingdom
| | - J Gierula
- University of Leeds, Leeds, United Kingdom
| | - M Paton
- University of Leeds, Leeds, United Kingdom
| | - P Swoboda
- University of Leeds, Leeds, United Kingdom
| | - A Toms
- Leeds General Infirmary, Leeds, United Kingdom
| | | | - D Shelley
- Leeds General Infirmary, Leeds, United Kingdom
| | - D Plein
- University of Leeds, Leeds, United Kingdom
| | - R Cubbon
- University of Leeds, Leeds, United Kingdom
| | - M Kearney
- University of Leeds, Leeds, United Kingdom
| | - K Witte
- University of Leeds, Leeds, United Kingdom
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Abstract
SummaryZonal myrmekitic and granophyric intergrowths in plagioclase and K-feldspar phenocrysts are described. There are two such zones in the feldspars of the Late Granite, G2, but only one in the Early Granite, G1. The zonal granophyric intergrowths are the end-product of the replacement of myrmekitic plagioclases by K-feldspar. Transitional stages of this replacement, which took place in the solid state, are represented in numerous examples. The zones of myrmekite, which also represent growth in the solid state, occur between zones of magmatic plagioclase, which is oscillatory-zoned. It is concluded that the granites evolved at depth under the influence of at least three phases of volcanic activity. Each of these phases resulted in the partial melting of the country rocks with subsequent magmatic crystallization, followed further, under the slow cooling conditions, by extensive reaction in the solid state. During each of the final two phases, some of the granite was intruded as a crystal mush to form G1 and G2, in which the phenocrysts retain evidence of their evolution at depth whilst the ground-mass gives evidence of the final magmatic crystallization.
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Abstract
The eye is involved in several pathologies where precise identification of the underlying condition is essential for the optimal patient care. This preliminary report presents the potential of high-resolution microscopy coil magnetic resonance imaging (HR-MRI) to undertake this task being actively used in the clinical setting. We used a commercially available MRI scanner and a microscopy surface coil. Exquisite anatomic detail of the eye and orbit with depiction of previously unobserved structures and clear demonstration of the underlying pathology was achieved. This report supports the idea that orbital imaging can be revolutionized with the introduction of HR-MRI with broad clinical implications.
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Affiliation(s)
- T Georgouli
- Eye Department, School of Medicine, University of Leeds, UK.
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Shelley D, Hoffman E, Menitoff R, Maraldo P. Quality in women's health: the organizing principles for the NAWH (National Association for Women's Health) trade association. Qual Manag Health Care 2001; 8:65-74. [PMID: 11183585 DOI: 10.1097/00019514-200008040-00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Quality in women's health care has been assessed with preventive measures such as mammograms and pap smears, and obstetrical measures, such as prenatal care. Although awareness about sex and gender differences among researchers, health professionals, and women themselves has grown dramatically over the last 10 years, health care policy and medical education have not been influenced to any significant degree. Sex and gender differences have not been developed for a wider range of services, such as diagnosis and treatment of acute or chronic conditions, outside of reproductive health. This article reviews contemporary women's health issues and discusses the need for collaboration among multiple stakeholder groups within the health care industry to address quality in women's health care.
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Affiliation(s)
- D Shelley
- Office of Health Promotion and Disease Prevention, New York City Department of Health, New York, USA
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Hosenpud JD, Stibolt TA, Atwal K, Shelley D. Abnormal pulmonary function specifically related to congestive heart failure: comparison of patients before and after cardiac transplantation. Am J Med 1990; 88:493-6. [PMID: 2337106 DOI: 10.1016/0002-9343(90)90428-g] [Citation(s) in RCA: 99] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE A variety of abnormalities in pulmonary function have been attributed to, or are believed to be, exacerbated by congestive heart failure. Separating out specific contributions from cardiac versus pulmonary disease is difficult. In order to investigate the impact of cardiac disease on pulmonary function, we performed spirometry on patients immediately before and after cardiac transplantation. PATIENTS AND METHODS Seventeen patients (13 men, 4 women) with a mean age of 44 years (range: 20 to 62 years) were studied before and 15 +/- 10 (mean +/- SD) months after cardiac transplantation. Eleven patients had a significant smoking history. RESULTS In comparing pre- and post-transplant spirometric results, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) increased substantially after transplant (3.34 +/- 0.96 L versus 3.89 +/- 1.00 L, p = 0.0054, and 2.63 +/- 0.80 L versus 2.95 +/- 0.83 L, p = 0.042, respectively). FEV1/FVC was not significantly different between study states in the entire group (0.78 +/- 0.10 versus 0.76 +/- 0.10, p = NS), nor was it different in those patients with and without a smoking history (0.76 +/- 0.11 versus 0.72 +/- 0.10, p = NS, and 0.87 +/- 0.06 versus 0.84 +/- 0.02, p = NS, respectively). Furthermore, normal lung volumes were obtained after transplant in those patients without a smoking history in contrast to those with a smoking history. Finally, the increase in FVC after cardiac transplantation directly correlated with the decrease in cardiac volume with cardiac replacement (r = 0.83, p less than 0.0001). CONCLUSION We conclude that in patients selected as cardiac transplant candidates (those without severe obstructive lung disease), restrictive but not obstructive pulmonary physiology can be attributed in part to congestive heart failure, and a major part of the reduction in lung volumes is secondary to the space occupied by a large heart. Other factors, such as accompanying pleural effusions and interstitial edema, likely contribute to the reduction in lung volumes. Abnormal pulmonary function secondary to chronic congestive heart failure in this selected population is completely reversible with normalization of cardiovascular physiology and anatomy.
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Affiliation(s)
- J D Hosenpud
- Department of Medicine, Oregon Health Sciences University, Portland 97201
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