bluuebunny/crossref_metadata_2025 huggingface dataset:
ARTERIAL HYPERTENSION DOES NOT SLEEP
Authors: Pantea Rebecca , Zara Cornelia , Iancu Valeria , Baban Dominic
Published: June 2023

Objective:

Sleep apnea is a secondary cause of hypertension and is suggested by non-dipper profile at ambulatory blood pressure monitoring (ABPM). The prevalence is estimated between 30-50% in hypertensive patients.

Design and method:

A 60 year-old man with cardiovascular risk factors (hypertension, diabetes, dislipidemia, obesity, transient ischemic attack) presented to the outpatient clinic with high values of self-monitoring blood pressure despide multiple lowering blood pressure therapy. On physical examination his body mass index was 39.6 kg/m2, neck circumference 50 cm. The ECG was in sinus rhythm with hypertrophic phenotype confirmed by echocardiogram, which also showed left ventricle preserved ejection fraction, grade III diastolic dysfunction, mildly enlarged left atrium. Laboratory tests exluded endocrinologic and renal causes. Despite lifestyle changes and a good adherence to multiple associated antihypertensive treatment, ABPM revealed a non-dipper profile (dipping index 4.86%) (figure 1). The patient underwent the polygraphy test which showed the apnea-hypopnea index (AHI) of 10.6, which led to a diagnosis of mild sleep apnea, the t90% of 57 pointed out severe hypoxia and high pulse variances 104 (figure 1). The further Holter monitoring revealed episodes of atrial flutter and atrial fibrillation.

Results:

After 3 months of continuous positive airways pressure (CPAP) therapy, on top of the same antihypertensive drugs and anticoagulation, led to optimal blood pressure values and normal ABPM profile (figure 2). The polygraphy parameters AHI, t90% and pulse variances normalised too. (figure 1)

Conclusions:

Obstructive sleep apnea is a prevalent secondary cause of hypertension and atrial arythmias, still greatly underdiagnosed. It is associated with abdominal obesity, large neck, snoring, daytime fatigue and a decrease in the quality of life. Polygraphy is a feasible method for diagnose sleep apnea and monitoring the treatment. CPAP treatment abolishes apnea, normalises blood oxigenation thereby prevents arterial pressure surges, restoring the nocturnal ‘dipping’ pattern and normal sinus rythm.
MINIMUM OXYGEN SATURATION LEVELS AND CAROTID ATHEROMATOSIS
Authors: Rocha Daniela , Cameirão Ana , Pós-De-Mina Vanda , Mateus Sónia
Published: June 2023

Objective:

Verify the relationship between the presence carotid atheromatosis getting by cervical Doppler echo and the variation of minimum levels oxygen saturation assessed by polysomnography.

Design and method:

Analytical, observacional and cross-sectional study was conducted with a sample of 63 individuals who had cervical Doppler echo examination and polysomnography in one year, recording multiple modifiable and no-modifiable vascular risk factors.

Results:

The sample consisted of 63 individuals, 29 female and 34 male. The mean age was 61.83, aged between 35 and 82 years (+/- 12.64). Regarding the presence of other risk factors under analysis, most of the sample has high prevalence of hypertension (44 individuals - 69.8%), mellitus diabetes (23 individuals - 36.5%) and dyslipidemia (36 individuals - 57.1%). In cervical Doppler echo 51 individuals (81%) have thickening of the intima-media layer and in polysomnography the minimum oxygen saturation levels has a mean value of 77.7%, between the minim of 47% and the maxim of 90% (+/- 9.71). There is a significant relationship between the presence of minimum oxygen saturation levels and the presence of the intimae-media layer thickening (p = 0.0001) and with carotid atheromatosis with hemodynamic repercussions (p = 0.0001).

Conclusions:

In this sample, it is possible to conclude that the minimum levels of oxygen saturation are lower in presence of carotid atheromatosis, regardless of the degree of hemodynamic compromise, with hypertension being a common risk factor.
INVESTIGATING NEW THERAPEUTIC OPPORTUNITIES FOR HYPERTENSION THROUGH TRANSCRIPTOMIC AND PROTEOMIC ANALYSIS OF THE KIDNEY RENIN-ANGIOTENSIN SYSTEM
Authors: Saluja Sushant , Eales James , Xu Xioguang , Rubin Sebastien , Drzal Maciej , Scannali David , Prestes Priscilla , Danser A.H. Jan , Lennon Rachel , Cordell Heather , Keavney Bernard , Morris Andrew , Lay Abigail , Charchar Fadi , Tomaszewski Maciej
Published: June 2023

Objective:

We systematically characterised the expression of all renin-angiotensin system (RAS) genes in the human kidney and searched in silico for new pharmacological therapeutic opportunities to modify RAS.

Design and method:

We compiled data from open access resources to characterise all components of the RAS pathway. We used transcriptomic profiles of 73 human kidney tissues from the Genotype-Tissue Expression Project, integrated genome-wide DNA genotypes and RNA-sequencing-derived transcriptome profiles of 478 human kidneys from Human Kidney Tissue Resource and, kidney tissue proteomics from 72 samples recruited by Clinical Proteomic Tumour Analysis Consortium. Additionally, we used an independent single-cell RNA sequencing data and gene expression datasets curated from the Kidney Precision Medicine Project (KPMP) and Enrichr (web-based enrichment analysis tool). Lastly, we integrated the Connectivity Map and Drug Gene Interaction Database to identify drug repurposing opportunities for treatment of hypertension targeting the RAS genes.

Results:

We identified 37 genes encoding components of the RAS pathway with measurable expression in human kidney tissue. 15% of these gene-pairs demonstrated a positive (r>0.5) correlation in kidney expression most consistent with a functionally integrated network of interacting molecules. Angiotensinogen (AGT), the key component of the pathway - showed the highest level of mRNA expression in the liver, and we demonstrated that its hepatic mRNA expression correlates most strongly with its mRNA expression in the kidney (r = 0.71, P = 2.60e-06). Expression levels of mRNA for 92% of RAS genes correlated positively with their protein abundance in the kidney, where renin had the strongest positive correlation (r = 0.64, P<0.01). Enrichr and KPMP revealed that RAS gene expression was enriched in mesangial and epithelial cell types. Existing genetic evidence for correlation between glutamyl aminopeptidase (ENPEP) and systolic blood pressure might relate to its capacity to generate angiotensin III acting on dilator angiotensin II type 2 receptors. This raises potential repurposing opportunities for ENPEP inhibitors like firibastat and tosedostat for the treatment of hypertension.

Conclusions:

Collectively, this study confirmed synchronized expression of RAS genes in the kidney at both mRNA and protein levels and identified new therapeutic opportunities for treatment of hypertension, through drug repurposing.
EPLERENONE VS IRBESARTAN AS FIRST LINE THERAPY IN OBESE HYPERTENSIVE PATIENTS: BASELINE CHARACTERISTICS FROM HEBRO STUDY
Authors: Iliakis Panagiotis , Kouremeti Maria , Drogkaris Sotirios , Siafi Eirini , Andrikou Ioannis , Dimitriadis Kyriakos , Konstantinidis Dimitrios , Thomopoulos Costas , Tsioufis Konstantinos
Published: June 2023

Objective:

Obesity is significantly associated with adverse cardiovascular outcomes. The relationship between obesity and hypertension is well described. However, little is known about the impact of aldosterone blockade using eplerenone on hypertensive obese patients as first line therapy. The aim of this study is to compare the efficacy between eplerenone-based strategy and irbesartan-based strategy in obese hypertensive individuals.

Design and method:

A prospective, randomized, open-labeled, multicenter trial enrolled 80 hypertensive patients aged 30 to 75 years old, with obesity [body mass index BMI >or = 30 kg/m2)], evaluated by home BP, office BP and ambulatory BP measurements. Subjects randomly received 25mg eplerenone twice or 150mg irbesartan once daily. The primary endpoint is the difference in ambulatory BP measurements after 6 months follow-up period and the secondary endpoints are the differences in left ventricular hypertrophy and albuminuria after 6 months follow-up period.

Results:

At baseline, there were no significant differences between the two study arms regarding gender (men 49,3%, p = 0.732), age (53.9± 10.4 in the eplerenone arm vs. 56.1 ± 10 in the irbesartan arm, p = 0.326), BMI (34.2 ± 3.3 vs. 34.9 ± 3.3, p = 0.376, respectively), renal function (mean eGFR 84.6 ± 16.4 vs. 81.3± 13.1, p = 0.358, respectively) and the presence of diabetes mellitus (9.8% vs 10.5%, p = 0.910, respectively).

Moreover, there were no significant differences regarding home BP (142.5/88.5 mmHg ± 8.6/7.3 vs. 141.8/89.4 mmHg ± 8.3/6.7, p = 0.716 and p = 0.558 respectively), office BP (146.3/91.3 mmHg ± 8.2/9.4 vs. 145.1/92.3 mmHg ± 9.1/9.1, p = 0.506 and p = 0.547 respectively) and ambulatory BP (140.9/85.5 mmHg ± 8.4/8.8 vs. 140.1/84.7 mmHg ±7.8/7.5, p = 0.662 and p = 0.667 respectively).

Regarding left atrial geometry, evaluated by left atrial volume index (LAVI), there was no significant difference (30.7 mL/m2± 11.1 vs. 30.6 mL/m2 ± 16.9, p = 0.979, respectively). Finally, regarding arterial stiffness evaluated by pulse-wave velocity, there was no significant difference (9.5 m/s ± 1.7 vs. 10.1 m/s ± 2.4, p = 0.435, respectively)

Conclusions:

In conclusion, the two study arms did not differ in most baseline characteristics, suggesting true homogeneity among comparison arms. Soon, we anticipate the results from the primary endpoint completion.
SEQUENTIAL NEPHRON BLOCKADE VERSUS DUAL RENIN-ANGIOTENSIN SYSTEM BLOCKADE IN TRUE RESISTANT HYPERTENSIVE PATIENTS: A SYSTEMATIC REVIEW
Authors: Yugar Louise Buonalumi Tacito , Prado Luis Gustavo Sedenho , Melo Silvia Elaine Ferreira , Tacito Lucia Helena Bonalume , Vilela-Martin José Fernando , Junior Heitor Moreno , Toledo Juan Carlos Yugar
Published: June 2023

Objective:

True resistant hypertension (RHTN) is a challenging medical condition in which the blood pressure remains uncontrolled despite the use of three different classes of antihypertensive agents at maximum tolerated dose. In order to reduce the sodium and volume overload in these patients and bring the blood pressure to acceptable levels, several pharmacologic agents that promote sequential nephron blockade (SNB) or dual renin- angiotensin system blockade (DRASB) can be used. Therefore, this review aims to evaluate the data presented in some clinical trials comparing the SNB to the DRASB.

Design and method:

A systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted in MEDLINE, Cochrane Library, EMBASE and LILACS, resulting in a total of 123 articles. One abstract and 4  randomized controlled trials were selected to be assessed in this review.

Results:

Both treatments decreased systolic blood pressure and diastolic blood pressure in ambulatory blood pressure monitoring. In one of the protocols, the decreases in the SNB group were significantly greater than in the DRASB group. A sub-analysis showed that the improvements in blood pressure were significant only in those with acceptable adherence to treatment. The two interventions reduced office blood pressure, with one study indicating that the reduction was superior in SNB. In markers of arterial stiffening and aging, there were no significant improvements. Pulse wave velocity and common carotid artery stiffness were similar in both groups and tended to decrease. One of the studies showed improvement in echocardiographic parameters for diastolic dysfunction.

Conclusions:

Despite the improvements in blood pressure in both groups, SNB therapy has a higher potential as a treatment for RHTN, especially when there is good adherence to the medication. Also, SNB tended to improve arterial stiffness and diastolic dysfunction. Nonetheless, there is a need for more studies for a better evaluation of these outcomes.
AORTIC STIFFNESS IS INDEPENDENTLY ASSOCIATED WITH INTRACRANIAL CAROTID ARTERY CALCIFICATION IN PATIENTS WITH ISCHEMIC STROKE
Authors: Gozdalski Jacek , Nowicki Tomasz , Kwarciany Mariusz , Kowalczyk Kamil , Narkiewicz Krzysztof , Gasecki Dariusz
Published: June 2023

Objective:

Intracranial carotid artery calcification (ICAC), as a strong contributor to the occurrence of ischemic stroke, might be present in the medial or intimal arterial layer. Traditional vascular risk factors are associated with ICAC; however, its association with new markers of vascular function are less understood. The paper aims to evaluate the relationship between carotid-femoral pulse wave velocity (CF-PWV) and ICAC subtypes.

Design and method:

We enrolled 65 patients with acute ischemic stroke. CF-PWV, systolic, diastolic and mean blood pressure, and pulse pressure (SBP, DBP, MBP, PP) were measured within 6±2 days of stroke onset.

CT was performed within 24 hours of stroke onset and ICAC on the stroke site was classified by two methods: volume- and score-based. Tertiles of ICAC volume were determined, and low-grade ICAC (T1) was regarded as a reference. According to the score-based method, medial and intimal ICAC subtypes were determined. Data were analyzed with multivariate logistic regression.

Results:

Medial and intimal ICAC subtypes were found in 34 (52%) and 24 (37%) patients, respectively. In 11% of patients no ICAC calcifications were found. CF-PWV was higher in patients with high-grade ICAC (OR = 1.56, 95%CI = 1.03-2.35, p = 0.035). CF-PWV was higher in patients with the medial ICAC subtype than in patients with the intimal ICAC subtype (OR = 1.60, 95%CI = 1.00-2.55, p = 0.049) after adjustment for age, MBP, diabetes mellitus, arterial hypertension, hyperlipidemia, and smoking status.

Conclusions:

Our study demonstrates that among patients with ischemic stroke, aortic stiffness is independently associated with ICAC, and that medial ICAC, compared with intimal ICAC, is accompanied by more advanced aortic stiffness.
ISCHEMIC STROKE AFTER CORONARY BYPASS SURGERY IN PATIENTS WITH TYPE 2 DIABETES, HYPERTENSION, AND TRIPLE VESSEL DISEASE
Authors: Jain Rajesh , Husseini Siyamak Jalal , Shogli Mohammadreza , Fesseha Hermon Eyob
Published: June 2023

Objective:

We want to investigate this case, what are the various Risk factors for Ischaemic stroke as a major complication, and how to reduce this life-threatening complication in high-risk patients with diabetes, hypertension, and triple vessel disease.

Design and method:

A 55-year-old patient with TVD Tripple vessel disease without acute MI (myocardial infarction) needed CABG. His angiographic score and uncontrolled diabetes suggested open heart surgery.

He did not have carotid or aortic plaque or other issues during the pre-op examination.

He underwent on-pump CABG, cardiac aortic bypass with two saphenous veins (on the RCA and OM1), and anastomosis of the left internal thoracic artery on the LAD.

The pumping duration was 150 minutes. The patient was weaned from the pump, the surgery was completed, the sternum was closed, and the patient was transferred to the intensive care unit.

When we decided to extubate the patient after 12 hours, we noticed his limb movement was not symmetrical. He was paralyzed on the left side.

There was significant left hemisphere ischemia on brain CT, which was consistent with CVA.

Once brain hemorrhage was excluded, the neurologists started administering heparin to treat the ischemic stroke.

Results:

Patients with severe stenosis and 3VD require intervention or CABG treatment; however, in this instance, the areas of stenosis were not appropriate for stenting, and the patient's uncontrolled diabetes was another reason suggestive of open-heart surgery.

Three crucial aspects have shocked us and that all surgeons may find challenging.

Uncontrolled diabetes can significantly contribute to the damage of medium and small blood vessels, and chronic hypertension can cause micro tears and blood clots in the vessels. These three variables can result in tiny damage. Long pump time and these two variables contributed to blood stagnation in the patient. In addition, the patient may have been more vulnerable to ischemic attacks.

Conclusions:

We may have avoided this complication by administering the following measures
HEMODIALYSIS EFFECTS ON AUTONOMIC FUNCTION: RESULTS OF LINEAR AND NON-LINEAR ANALYSIS OF HEART-RATE-VARIABILITY AT REST AND IN RESPONSE TO PHYSICAL AND MENTAL STRESS TESTS
Authors: Faitatzidou Danai , Dipla Konstantina , Theodorakopoulou Marieta , Koutlas Aggelos , Karagiannidis Artemios , Tsouchnikas Ioannis , Giamalis Panagiotis , Dimitriadis Chrysostomos , Zafeiridis Andreas , Papagianni Aikaterini , Sarafidis Pantelis
Published: June 2023

Objective:

Cardiac arrhythmias are the most common cause of death in hemodialysis. Autonomic dysfunction plays a central role in this arrhythmogenic background. Previous studies on hemodialysis-related changes in heart-rate-variability(HRV) give contradictory results. This study investigated HRV indices both at rest and in response to physical and mental stimulation maneuvers at multiple time-points around and during the hemodialysis procedure.

Design and method:

Autonomic function was assessed by linear and non-linear HRV indices at pre-dialysis, during-dialysis(3 equal time-periods), post-dialysis, and on the non-dialysis day in 36 hemodialysis patients. Continuous measurement of beat-by-beat heart-rate was recorded with Finometer-PRO(The Netherlands) at rest and after orthostatic, sit-to-stand, handgrip and mental-arithmetic test.

Results:

The RMSSD, SD1, and SD2 indices significantly increased during dialysis(early-HD, mid-HD, late-HD periods) compared with the pre-dialysis levels(p<0.05) and returned to baseline post-dialysis(RMSSD: 54.39±83.73 vs 137.98±109.53* vs 119.85±97.34* vs 144.47±88.74* vs 85.82±121.43msec, *p<0.05 vs pre-dialysis and post-dialysis). No differences were detected in the above indices between the pre-dialysis and non-dialysis day. However, post-dialysis, the HRV responses to orthostatic and sit-to-stand tests were more exaggerated than in the pre-dialysis measurements (p<0.05). The HRV responses both at resting and physical tests in the non-dialysis day were similar to the pre-dialysis levels. HRV indices in mental-arithmetic test during hemodialysis were much higher than at the non-dialysis day(RMSSD: 77.05 (180.41) vs 19.75 (105.47)msec; p = 0.031) were detected.

Conclusions:

Hemodialysis causes marked changes in autonomic function. Resting HRV indices return to baseline post-dialysis, but HRV responses to physical stress remain exaggerated and return to baseline on the non-dialysis day. Detecting patients with significant autonomic dysfunction may help towards reduction of arrhythmia risk through individualized approaches.
HIGH SALT DIET ALTERS CEREBROVASCULAR RESISTANCE IN RESPONSE TO ORTHOSTATIC TEST IN HEALTHY YOUNG INDIVIDUALS
Authors: Drenjancevic Ines , Dumancic Dijana , Stupin Ana , Goswami Nandu
Published: June 2023

Objective:

High salt (HS) diet has been shown to impairs vascular reactivity in animal models, by increasing vasoconstriction to different stimuli. Response to orthostasis occurs via activation of baroreceptor reflex leading to increase in total peripheral resistance that prevents significant fall of arterial blood pressure (ABP) while standing up, aiming to preserve cerebral perfusion pressure. We recently showed that HS diet physiologically suppresses sympathetic arm of autonomic control in healthy humans (Stupin et al. Nutrients 2021; 13:1731. https://doi.org/10.3390/nu13051731). Present study aimed to assess the effect of HS diet on cerebral vasoreactivity in response to orthostatic load.

Design and method:

Twenty-seven young healthy participants (F:21, M:6, age range 19–24) consumed 7-day low-salt (LS) diet (<2.3 g NaCl /day) and afterwards 7-day HS diet (>11.2 g NaCl/day). In response to orthostatic test cerebral and systemic hemodynamic parameters, arterial blood pressure, heart rate variability and heart rate, and were recorded simultaneously with transcranial Doppler ultrasound and The Task Force® Monitor.

Results:

Subjects maintained normotension during HS diet. Diastolic blood pressure, as well as mean cerebral blood flow (CBF) and the velocity time integral decreased, while cerebral pulsatility index increased after standing up following both dietary protocols. However, while no change was observed in total peripheral resistance, cerebrovascular resistance significantly increased in response to orthostasis only after HS diet. Baroreflex sensitivity (BRS), sympathetic neural control, serum plasma renin activity and aldosterone, and urine noradrenaline and vanillylmandelic acid concentration was significantly decreased in HS diet.

Conclusions:

Results demonstrated that following 7-day HS diet, enhanced cerebral autoregulation preserves CBF and is manifested as increased cerebral vascular resistance, in conditions with blunted BRS and sympathetic activity.

The study has been published in Eur J Appl Physiol. 2023 Jan 4. doi: 10.1007/s00421-022-05124-w. Online ahead of print.
USE OF ANTIHYPERTENSIVE DRUG CLASSES DURING THE COVID-19 PANDEMIC. A CROSS-SECTIONAL, NATION-WIDE STUDY 2019-2021
Authors: Dobrowolski Piotr , Prejbisz Aleksander , Bozek Gabriel , Kon Beata , Machnie Aneta , Urbanski Filip , Madry Roman Topor , Kreutz Reinhold , Januszewicz Andrzej , Milkowski Maciej
Published: June 2023

Objective:

To assess changes in the use of antihypertensive drug classes during the COVID-19 pandemic, data of all patients who filled a prescription for an antihypertensive drug in Poland were analyzed.

Design and method:

Patients who filled at least one prescription from ATC groups C02-03, C07-10, C10BX in each of the years 2019, 2020 and 2021 were extracted from the obligatory prescription database of the National Health Service in Poland. We have excluded patients with a diagnosis of heart failure. The frequencies of use of antihypertensive drug classes – beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), calcium channel blockers (CCB), thiazide diuretics (TD), thiazide-like diuretics (TLD), loop diuretics (LD), mineralocorticoid receptor antagonists (MRA) and alpha-blockers (AB) - and their combinations were analyzed for the years 2019, 2020 and 2021 respectively.

Results:

In the years 2019, 2020 and 2021 – 10,328,341, 9,478,949 and 9,637,595 patients fulfilled the inclusion criteria. Among the main groups of antihypertensive drugs, the most used drug groups were BB (62.0, 62.8 and 63.7%), ACEi (52.9, 52.7 and 46.8%) and CCB (34.5, 35.2 and 35.9%). ARB were used by 26.8, 27.3 and 28.2% of patients. Diuretics were used by: TD 14.2, 13.9 and 14.1%; TLD 23.3, 22.8 and 22.6%, LD 13.0, 12.8 and 12.9%, AA 8.5%, 8.3%, 8.5%. AB were rarely used (4.5, 4.5, and 4.5%). Among patients taking two anithypertenisve drugs, the most common combination was BB+ACEi 23.5, 19.7 and 18.7%. BB+other anithypertensive drugs was used by 48.6, 46.9 and 45.7% of patients. ACEi/ARB+TD/TLD and ACEi/ARB+CCB combinations were used by 24.3, 23.4 and 23.6% and 17.4, 17.6 and 18.4% of patients, respectively. Among patients taking three drugs, BB+ACEi/ARB+TD/TLD combination was used by 29.8, 26.4, 25.7% of patients, followed by combinations: BB+ACEi/ARB+CCB 21.3, 19.8 and 19.9% and ACEi/ARB+CCB+TD/TLD 15.2, 17.2 and 18.5% of patients.

Conclusions:

The COVID-19 pandemic had little impact on changes in the frequency of use of individual antihypertensive drug groups. A slight increase in the use of the two and three drugs’ combinations recommended by the ESC/ESH 2018 guidelines was observed in 2021 compared to 2019.
THERAPEUTIC COMPLIANCE IN HYPERTENSIVE PATIENTS: A CROSS SECTIONAL STUDY
Authors: Karim Hatim Amine Zahidi Badaoui , Haboub Meryem , Arous Salim , Bennouna El Ghali , Drighil Abdenasser , Azzouzi Leila , Habbal Rachida
Published: June 2023

Objective:

The improvement of medication compliance is a necessity for a better management of arterial hypertension (AH), especially in cardiac patients, with a high risk of progression to heart failure.

We aim to evaluate the level of therapeutic compliance in hypertensive patients followed in cardiology consultation, and to seek the factors related to a bad compliance.

Design and method:

Through a descriptive and cross-sectional epidemiological study, we evaluated the therapeutic compliance of 154 hypertensive patients treated for 6 months, using a questionnaire called the compliance evaluation test to define patients with good therapeutic compliance, those with minimal compliance problems and those with poor compliance. The factors of poor compliance were sought in univariate analysis and then in multivariate analysis

Results:

In our hypertensive population, the compliance evaluation test showed 34.8% of patients with good compliance, 46.8% with minimal compliance problem and 18.4% with poor compliance to antihypertensive treatment. Poor compliance was associated with older age, male sex, lack of health insurance, and low education. But in multivariate analysis, only the presence of complications was an independent risk factor for poor compliance.

Conclusions:

Our study showed low adherence to antihypertensive therapy, particularly among those who already have complications from hypertension. Our health care system needs to develop a management plan that addresses our own determinants of adherence to improve adherence to antihypertensive medications.
GENETIC VARIATION AND PREDICTED PHENOTYPES IN CYP2C9, CYP2C19, CYP3A4, CYP3A5 AND CYP2D6 GENES AMONG 552 PATIENTS WITH UNCONTROLLED TREATED HYPERTENSION
Authors: Rognstad Stine , Halvorsen Lene Vernås , Søraas Camilla Lund , Aune Arleen , Brobak Karl Marius , Olsen Eirik , Bergland Ola Undrum , Kjær Vibeke Nordheim , Hjørnholm Ulla , Tuv Silja Skogstad , Nordal Kristin Reiersen , Svarstad Anja Camilla , Gerdts Eva , Mo Rune , Høieggen Aud , Kjeldsen Sverre Erik , Rostrup Morten , Larstorp Anne Cecilie K. , Opdal Mimi Stokke
Published: June 2023

Objective:

Altered drug metabolism may be a contributing factor to uncontrolled hypertension. Beta-blockers, alpha-blockers, calcium antagonists and angiotensin receptor blockers undergo hepatic metabolism by cytochrome P450 (CYP) enzymes. Genetic variation can contribute to interindividual variation, lack of treatment response or side effects with discontinuation of treatment. We aimed to determine common CYP gene variations in patients with treated but uncontrolled hypertension and to compare the distribution with the prevalence in the overall Caucasian population.

Design and method:

In this national multicenter study we mapped CYP2D6, CYP2C9, CYP2C19, CYP3A4 and CYP3A5 polymorphisms in 552 patients prescribed > = 2 antihypertensive agents and with systolic daytime ambulatory blood pressure (ABPM) > = 135 mmHg. On the (MALDI-TOF) MassARRAY analyzer, single nucleotide variants and small insertions/deletions (indels) were investigated with the VeriDose Core Panel and CYP2D6 copy-number variation with the VeriDose CYP2D6 CNV Panel (Agena Biosciences). Each allele is associated with either normal, decreased, absent, increased or unknown enzyme function based on activity scores defined by the The Clinical Pharmacogenetics Implementation Consortium (CPIC) and describe function and phenotypes for genes (IM = Intermediate metabolizer, PM = poor metabolizer, RM = rapid metabolizer and UM = ultra-rapid metabolizer).

Results:

94% of patients were Caucasian. Mean daytime ABPM was 146/84 mmHg (135-190/55-106 mmHg), median age 63 (26-86) years and 35% were female. The distributions of the predicted phenotypes (illustrated in colors in Figure) for each enzyme did not differ from that reported in Caucasian population by The Pharmacogenomics Knowledgebase (PharmGK) (gray). 11% had normal phenotype in all five enzymes whereas 49% had > = 2 enzymes affected by gene variants.

Conclusions:

The phenotype distribution of five relevant CYP genes in patients with uncontrolled hypertension did not differ from the general Caucasian population. Dosing guidelines based on CYP2D6 genotype currently exist for metoprolol, but for other antihypertensive drugs further investigation is needed. The low proportion of patients with five normal enzymes and the high proportion with > = 2 enzymes affected suggest that pharmacogenetic CYP-testing may be useful for individualizing drug treatment in patients with uncontrolled hypertension.
SUPER HYPERTENSION OR VERY SEVERE HYPERTENSION IN A SUB-SAHARAN COUNTRY: EPIDEMIOLOGICAL, CLINICAL, THERAPEUTICAL AND EVOLUTIVE OF THESE PARTICULAR PATTERNS
Authors: Ouankou Christian Ngongang , Kapi Leana Oriane Chendjou , Kuate Liliane Mfeukeu , Njonnou Sylvain Raoul Simeni , Lekpa Fernando Kemta , Folifack François Jérôme Kaze , Choukem Simeon Pierre
Published: June 2023

Objective:

To describe the epidemiological, clinical, therapeutical and evolutive patterns of super hypertension in Yaounde University Teaching Hospital.

Design and method:

This study is an observation cohort over a period of 9 months (January 2016 to September 2016). We recruited from members of the public who accepted voluntary blood pressure screening offered in various localities in Yaounde, and were aged 18 years or over.

Results:

Of a total of 6.519 people, 1.875 (28.8%) presented a high blood presure. Amongst them, 37 presented a super hypertension (a systolic blood pressure 250 mmHg and/or diastolic blood pressure 150 mmHg in presence or not of complications), corresponding to a prevalence of 2% of all hypertensive patients. Our cohort comprised 33 of these individuals who accepted the invitation to participate in the study. The mean age was 49.3 years, with a sex- ratio of 0.7. Twenty-three (70%) of the patients were known hypertensive for a mean time of 10 years, out of 9% were regularly rewieved, but none on medications. The mean of cardiovascular risk factors was 7, with 91% who had an excess salt intake. Dyspnea and headache were the main symptoms. The means systolic blood pressure and diastolic blood pressure were respectively 244.9 mmHg and 144.8 mmHg. Twenty-six (78.8) patients were either overweight or obese. We noticed a fundoscopy stage II or III in 21.1% of the cases. Seventy percent of the cases had left ventricular hypertrophy on electrocardiogram and 18.2 on echography. Complications were noticed on admission in 60.6% of all cases, it's was mainly signs of renal failure. Acute kidney injury occurred in 15.15% of the cases during follow-up. The average rate of blood pressure control over 6 months was 3%. The main cause of poor blood pressure control was lack of therapeutic compliance. We noticed refractory high blood pressure in 4 (12.1%) cases and registered one death at the 3rd month of follow up due to acute kidney injury.

Conclusions:

Super hypertension is a youth's pathology. Its early detection reduces significantly the high morbi-mortality. However, its efficient management needs minimal additional resources.
Reduced Compared With Traditional Schedules for Routine Antenatal Visits
Authors: Balk Ethan M. , Danilack Valery A. , Bhuma Monika Reddy , Cao Wangnan , Adam Gaelen P. , Konnyu Kristin J. , Peahl Alex Friedman
Published: June 2023

OBJECTIVE:

To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules.

DATA SOURCES:

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION:

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS:

Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists–recommended services and patient experience measures.

CONCLUSION:

The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits.

SYSTEMATIC REVIEW REGISTRATION:

PROSPERO, CRD42021272287.
Televisits Compared With In-Person Visits for Routine Antenatal Care
Authors: Balk Ethan M. , Danilack Valery A. , Cao Wangnan , Bhuma Monika Reddy , Adam Gaelen P. , Konnyu Kristin J. , Peahl Alex Friedman
Published: June 2023

OBJECTIVE:

To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care.

DATA SOURCES:

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION:

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS:

Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82–1.28) or preterm births (summary OR 0.93, 95% CI 0.84–1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported.

CONCLUSION:

People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes.

SYSTEMATIC REVIEW REGISTRATION:

PROSPERO, CRD42021272287.
Validated Calculators Predicting Cesarean Delivery After Induction
Authors: Shao Shirley J. , Teal E. Nicole , Lewkowitz Adam K. , Gaw Stephanie L. , Sobhani Nasim C.
Published: June 2023

OBJECTIVE:

To evaluate the performance of two previously published calculators in predicting cesarean delivery after induction of labor in an external population.

METHODS:

This was a cohort study including all nulliparous pregnant patients with singleton, term, vertex fetuses; intact membranes; and unfavorable cervices who underwent induction of labor between 2015 and 2017 at an academic tertiary care institution. Individual predicted cesarean risk scores were calculated with two previously published calculators. For each calculator, patients were stratified into three risk groups (lower, middle, and upper thirds) of approximately equivalent size. Predicted and observed incidences of cesarean delivery were compared with two-tailed binomial tests of probability in the overall population and in each risk group.

RESULTS:

A total of 846 patients met inclusion criteria, and 262 (31.0%) had cesarean deliveries, which was significantly lower than overall predicted rates of 40.0% and 36.2% with the two calculators (both P<.01). Both calculators significantly overestimated risk of cesarean delivery in higher risk tertiles (all P<.05). The areas under the receiver operating characteristic for both calculators were 0.57 or less in the overall population and in each risk group, suggesting poor predictive value. Higher predicted risk tertile in both calculators was not associated with any maternal or neonatal outcomes except wound infection.

CONCLUSION:

Both previously published calculators had poor performance in this population, with neither calculator accurately predicting the incidence of cesarean delivery. Patients and health care professionals might be discouraged regarding trial of labor induction by falsely high predicted risk-of-cesarean scores. We caution against widespread implementation of these calculators without further population-specific refinement and adjustment.
BCL2 Inhibition: A New Paradigm for the Treatment of AML and Beyond
Authors: Wei Andrew H. , Roberts Andrew W.
Published: June 2023

Altering the natural history of acute myeloid leukemia (AML) in unfit and older patients has proved a highly challenging hurdle, despite several decades of concerted clinical trial effort. The arrival of venetoclax (VEN) to the clinical stage represents the most important therapeutic advance to date for older patients with AML. In this review, we will explain how and why VEN works, summarize its remarkable pathway to regulatory approval, and highlight the key milestones that have been important for its successful development in AML. We also provide perspectives on some of the challenges associated with using VEN in the clinic, emerging knowledge regarding mechanisms of treatment failure, and current clinical research directions likely to shape how this drug and others in this new class of anticancer agents are used in the future.
Orbital Artifacts on MRI
Authors: Rana Khizar , Juniat Valerie , Patel Sandy , Avey Greg , Lucarelli Mark J. , Selva Dinesh
Published: June 2023

Purpose:

To describe artifacts on orbital MRI, which led to an incorrect radiology report.

Methods:

Retrospective chart review of patients identified from the orbital databases at the Royal Adelaide Hospital and University of Wisconsin Hospital. Patients who had artifacts on orbital MRI that led to an incorrect radiology report were included. Records were evaluated for age at imaging, gender, MRI sequence, laterality, and location of artifact, radiological characteristics and misdiagnosis, and cause of artifact.

Results:

Data were collected from 7 patients (3 male) who had a median age of 61 years at the time of imaging. Five artifacts resulted from fat-suppression failure with 4 of these cases misdiagnosed as inflammatory changes and 1 misdiagnosed as neoplastic infiltration. The OD was involved in 4 cases. Six cases were in the inferior orbit region.

Conclusions:

Fat-suppression failure artifacts may arise in the inferior orbit region and can be mistaken for inflammatory or neoplastic orbital disease. This may prompt additional investigations such as orbital biopsy. Clinicians should be aware of artifacts which can affect orbital MRI and lead to potential misdiagnosis.
Overuse of thyroid ultrasound
Authors: Acosta Gonzalo J. , Singh Ospina Naykky , Brito Juan P.
Published: June 2023

Purpose of review

Thyroid ultrasound (TUS) is a common diagnostic test that can help guide the management of patients with thyroid conditions. Yet, inappropriate use of TUS can lead to harmful unintended consequences. This review aims to describe trends in the use and appropriateness of TUS in practice, drivers and consequences of inappropriate use, and potential solutions to decrease overuse.

Recent findings

TUS use has increased in the U.S. and is associated with increased diagnosis of thyroid cancer. Between 10–50% of TUSs may be ordered outside of clinical practice recommendations. Patients who receive an inappropriate TUS and are incidentally found to have a thyroid nodule may experience unnecessary worry, diagnostic interventions, and potential overdiagnosis of thyroid cancer. The drivers of inappropriate TUS use are not yet fully understood, but it is likely that a combination of clinician, patient, and healthcare system factors contribute to this problem.

Inappropriate TUS is a factor leading to the overdiagnosis of thyroid nodules and thyroid cancer, resulting in increased healthcare costs and potential harm to patients. To effectively address the overuse of this diagnostic test, it is necessary to gain a deeper understanding of the frequency of inappropriate TUS use in clinical practice and the factors that contribute to it. With this knowledge, interventions can be developed to reduce the inappropriate use of TUS, leading to improved patient outcomes and more efficient use of healthcare resources.
Soluble urokinase plasminogen activator receptor and procalcitonin for risk stratification in patients with a suspected infection in the emergency department: a prospective cohort study
Authors: Tong-Minh Kirby , Endeman Henrik , Ramakers Christian , Gommers Diederik , van Gorp Eric , van der Does Yuri
Published: June 2023

Background and importance

Early identification of patients at risk of clinical deterioration may improve prognosis of infected patients in the emergency department (ED). Combining clinical scoring systems with biomarkers may result in a more accurate prediction of mortality than a clinical scoring system or biomarker alone.

Objective

The objective of this study is to investigate the performance of the combination of National Early Warning Score-2 (NEWS2) and quick Sequential Organ Failure Assessment (qSOFA) score with soluble urokinase plasminogen activator receptor (suPAR) and procalcitonin to predict 30-day mortality in patients with a suspected infection in the ED.

Design, settings and participants

This was a single-center prospective observational study, conducted in the Netherlands. Patients with suspected infection in the ED were included in this study and followed-up for 30 days. The primary outcome of this study was all cause 30-day mortality. The association between suPAR and procalcitonin with mortality was assessed in subgroups of patients with low and high qSOFA (<1 and ≥1) and low and high NEWS2 (<7 and ≥7).

Main results

Between March 2019 and December 2020, 958 patients were included. A total of 43 (4.5%) patients died within 30 days after ED visit. A suPAR ≥ 6 ng/ml was associated with an increased mortality risk: 5.5 vs. 0.9% (P < 0.01) in patients with qSOFA = 0 and 10.7 vs. 2.1% (P = 0.02) in patients with qSOFA ≥ 1. There was also an association between procalcitonin ≥0.25 ng/ml and mortality: 5.5 vs. 1.9% (P = 0.02) for qSOFA = 0 and 11.9 vs. 4.1% (P = 0.03) for qSOFA ≥ 1. Similar associations were found within patients with a NEWS < 7 (5.9 vs. 1.2% for suPAR and 7.0 vs. 1.7% for procalcitonin, P < 0.001).

Conclusion

In this prospective cohort study, suPAR and procalcitonin were associated with increased mortality in patients with either a low or high qSOFA and patients with low NEWS2.
Development and Implementation of a Maryland State Program Providing Hospital Payment Incentives for Reduction in Readmission Disparities
Authors: Rice Kyle , Schuster Alyson , Pack Allan , Dougherty Geoff B.
Published: June 2023

Background:

Social factors are a key determinant of hospital readmission. We describe the development of the country’s first statewide policy providing hospitals with financial incentives to reduce readmission disparities.

Objective:

To describe the development and evaluation of a novel program that measures hospital-level disparity in readmission and rewards hospitals for improvement.

Research Design:

Observational study using inpatient claims.

Participants:

Baseline data included 454,372 all-cause inpatient discharges in 2018 and 2019. Of the included discharges, 34.01% involved Black patients, 40.44% involved female patients, 33.1% involved patients covered by Medicaid, and 11.76% involved patients who were readmitted. Mean age was 55.18.

Measures:

The key measure was the percentage change over time within the hospital in readmission disparity. Readmission disparity was measured using a multilevel model that gauged the association between social factors and readmission risk at a given hospital. Three social factors (Race, Medicaid coverage, and Area Deprivation Index) were combined into an index reflecting exposure to social adversity.

Results:

Of the State’s 45 acute-care hospitals, 26 exhibited improved disparity performance in 2019.

Limitations:

The program is limited to inpatients within a single state; the analysis does not provide evidence on the causal relationship between the intervention and readmission disparities.

Conclusion:

This represents the first large-scale effort in the US to link disparities to hospital payment. Because the methodology relies on claims data, it could easily be adopted elsewhere. The incentives are directed to within-hospital disparities, thus mitigating concerns about penalizing hospitals with patients with greater social exposure. This methodology could be used to measure disparity in other outcomes.
d-Mannose for Recurrent Urinary Tract Infection Prevention in Postmenopausal Women Using Vaginal Estrogen: A Randomized Controlled Trial
Authors: Lenger Stacy M. , Chu Christine M. , Ghetti Chiara , Durkin Michael J. , Jennings Zoe , Wan Fei , Sutcliffe Siobhan , Lowder Jerry L.
Published: June 2023

(Abstracted from Urogynecology (Phila) 2023;29:367–377

Up to 25% of women experience recurring urinary tract infections, which are typically managed through long-term antibiotic prophylaxis intended for common urogenital pathogens. Unfortunately, prolonged use of antibiotics can lead to several adverse effects such as allergic reactions, sequelae from microbiome alterations, drug interactions/toxicities, and antibiotic resistance. One commonly prescribed prophylactic therapy, vaginal estrogen therapy (VET), is used as a first-line nonantibiotic therapy for rUTIs.