bluuebunny/crossref_metadata_2025_split huggingface dataset:
P085 BLOOD PRESSURE AND THE CARDIOMETABOLIC PROFILE IN YOUNG ADULTS ASSISTED IN PRIMARY HEALTH CARE – LapARC MULTICENTRIC STUDY
Authors: de Araujo Sousa Randerson José , Parente Bernardes Gabriel , Massaranduba Silva Clara Serique , Naim Rayan Moura Patrik , Gomes Silva Bruno Antônio , da Silva Oliveira Clara Sofia , Carvalho Veiga Danna , Guizzo Maria Eduarda Bazzanelli , Fernandes Ana Cristina Tenório , Filgueiras Ligia Amaral , Muxfeldt Elizabeth Silaid 
Published: September 2024

Introduction:
Hypertension, diabetes mellitus, dyslipidemia, obesity and smoking are risk factors that impact the emergence of subclinical lesions and contribute to increased cardiovascular (CV) morbidity and mortality.

Objective:
to evaluate the cardiometabolic profile and blood pressure levels in young adults treated in primary care in the Brazilian Unified Health System.

Methods:
Multicenter cross-sectional population study (arm of the LapARC study – Rio de Janeiro) approved by the Ethics Committee under registration: 5,046,133. Our center is located in the municipality of Santarém, Pará, Brazilian Amazon. Young adults (20 to 50 years old) were evaluated in relation to their cardiovascular risk profile, sociodemographic, anthropometry and laboratory tests. Office blood pressure (BP) was measured and patients underwent Home Blood Pressure Monitoring (HBPM), with a seven-day protocol.

Results:
161 individuals were included (81.4% female; mean age 39.6 ± 7.9 years), 90% declared themselves black and mixed race and 27.3% had low education. More than half of the population has 3 or more CV risk factors (55.9%), with dyslipidemia being the most prevalent (60.2%), followed by hypertension (55.9%) and women with significantly more abdominal obesity (67.2% vs 30.0%, p<0.001). Among hypertensives, 84.4% knew the diagnosis, of which 71 were treated, with only 31.1% reaching blood pressure control. The most frequently mentioned antihypertensives were renin-angiotensin-aldosterone system inhibitors (36.6%) and diuretics (18.6%). Men had higher office and home systolic BP levels than women (136 ± 22 vs 128 ± 23 and 127 ± 21 vs 116 ± 15, p<0.05), respectively. Furthermore, the mean ankle-brachial index was 1.12 [1.07-1.20]. After HBPM, 20.9% of individuals were identified with masked hypertension, only 1.2% with white coat hypertension and 26.7% with sustained hypertension.

Conclusion:
although apparently healthy, this population have an adverse cardiometabolic profile, marked by low blood pressure control and the prevalence of masked hypertension, which justifies the continuation of the study.
P086 MAY MEASURE MONTH 2023: AN ANALYSIS OF BLOOD PRESSURE SCREENING RESULTS FROM NEPAL
Authors: Yao Zhengbang , Inagaki Y , Koirala S , McLachlan CS , Devkota S , Adhikari TB , Khanal P , Neupane D 
Published: September 2024

Background and Objective:
May Measure Month (MMM) is a global annual blood pressure (BP) screening campaign raising awareness about prevention and control of hypertension. Nepal has been participating in this campaign since 2017. We present the results of MMM2023 in Nepal.

Methods:
Opportunistic BP screening was conducted among adults aged ≥ 18 years from May-August 2023 in Nepal. Participants, selected with convenient sampling, were administered a questionnaire developed by the May Measure Month. Three BP measurements were taken by trained volunteers using digital or manual BP devices. Hypertension is defined using both definitions: 1) BP ≥140/90 mm Hg or currently under antihypertensive medication 2) ≥130/80 mm Hg or currently under antihypertensive medication. Multivariate logistic regression analysis was used to identify factors associated with hypertension.

Results:
A total of 7,573 adults participated. The mean (SD) systolic BP (SBP) and diastolic BP (DBP) were 119.0 (15.9) and 79.8 (10.6) mm Hg, respectively. 22.3% and 50.1% participants were hypertensive using thresholds of 140/90 mmHg and 130/80 mmHg, respectively. Proportion of hypertension, overweight (BMI≥ 25 kg/m2), tobacco use, e-cigarette use, alcohol use, diabetes, and mean SBP/DBP were statistically significantly higher among males than females. Among hypertensive individuals, 48.9% were aware of their condition, and 42.1% were receiving pharmacological treatment. Among those under treatment, 60.1% had BP under control (<140/90 mm Hg). Factors associated with hypertension were age ≥40 years (OR 4.91, [95%CI 4.28-5.64]), history of cardiovascular diseases (2.15 [1.30-3.56]), diabetes (1.83 [1.52-2.21]), male sex (1.61 [41.41-1.84]), and overweight (1.60 [1.42-1.80].

Conclusions:
The MMM 2023 underscored the ongoing challenge of hypertension management in Nepal, reaffirming the strong association of hypertension with risk factors including age, male sex, history of CVDs, diabetes, and overweight. Despite higher proportion of hypertension among males, their awareness, treatment, and control levels were significantly lower than in females. This study highlights the need to strengthen community-based programs to enhance the continuum of hypertension management.
P087 ASSOCIATION OF INTRACRANIAL ARTERIAL STENOSIS WITH LEVEL AND VARIABILITY OF THE HOME BLOOD PRESSURE
Authors: Zhang Dong-Yan , An Dewei , Chen Hui , Xu Jie , Wang Ying , Cheng Yibang , Guo Qianhui , Huang Qifang , Huang Jianfeng , Sheng Changsheng , Wang Jiguang , Staessen Jan A , Li Yan 
Published: September 2024

Background and Objective:
Given the close relation between intracranial arterial stenosis (ICAS) and systolic blood pressure (SBP), this study assessed whether blood pressure variability (BPV) refines risk stratification for ICAS over and beyond SBP using various BPV indexes derived from home blood pressure (BP) monitoring.

Methods:
In consecutively referred outpatients, all untreated for hypertension, ICAS was assessed by transcranial Doppler ultrasonography. SBP and BPV were determined from 7-day home BP recordings with triplicate readings in the morning and evening. BPV indexes included the standard deviation (SD), the coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV). ICAS probability was assessed with multivariable logistic models and model performance from the area under the curve (AUC).

Results:
Based on all home readings in 1510 patients, SBP, SD, CV, VIM, and ARV averaged 130.1 mm Hg, 8.36 mm Hg, 6.42%, 8.36, and 6.41 mm Hg. ICAS compared to non-ICAS patients had a similar CV and VIM (P≥0.09), but higher (P≤0.007) SBP, SD, and ARV by 3.9 mmHg, 0.66 mmHg, and 0.54 mmHg, respectively. ICAS was associated with SBP (P<0.001) irrespective of the time of day and with the BPV indexes independent of SBP in all morning readings (P≤0.050), but not in evening readings (P≥0.16). However, the AUC increment only reached significance for ARV in all readings and for CV, VIM, and ARV in morning readings.

Conclusions:
BPV derived from all-day and morning home BP readings was associated with ICAS independent of SBP but does not substantially refine ICAS risk assessment.
P098 CARDIAC REMODELING IN MICE TREATED WITH SODIUM OXALATE AND AORTIC STENOSIS
Authors: De Almeida Silva Amanda , Marques Juliana Romeu , Nascimento-Carvalho Bruno , de Souza Leandro Eziquiel , da Silva Maikon Barbosa , Juocys Dias Moreira Nathalia , Veras Mariana Matera , Waked Dunia , Caldini Elia Garcia , Irigoyen Maria Cláudia 
Published: September 2024

Background:
Cardiovascular Diseases are one of the main global public health problems, with increasing mortality due to population aging and Hypertension (HTN). HTN is a risk factor for other diseases, such as aortic stenosis, renal dysfunction, and cardiac hypertrophy (CH). The hemodynamic overload caused by HTN affects the heart and kidneys, but the exact mechanisms of these alterations are not fully understood. Experimental models help study these mechanisms; however, a well-established model of CH with cardiorenal dysfunction does not yet exist.

Objective:
to evaluate whether the combination of cardiac hypertrophy, induced by transverse aortic constriction (TAC), and renal injury, induced by soluble sodium oxalate (OXA), can be a new model of CH with cardiorenal dysfunction.

Methods:
Male C57BL mice were randomized as follows: SHAM, receiving saline or OXA solution, and TAC, receiving saline or OXA solution. Echocardiography, direct blood pressure (BP) recording, metabolic cage, histology were performed to evaluate cardiac and renal function, hemodynamics, autonomic modulation, and baroreflex.

Results:
The TAC+OXA group showed the highest systolic BP(SBP) (SBP: SHAM: 122±5.24 vs. TAC+OXA: 160±5.24 mmHg, p<0.01), increased double product (DP) (DP: SHAM: 64.65±4.76 mmHg/bpm vs. TAC: 89.53±5.85 mmHg/bpm, p=0.02), significant reduction in autonomic modulation (RMSSD: OXA: 12.5±1.8 vs. TAC+OXA: 2.8±0.2 ms, p<0.01) and reflex tachycardia, eccentric hypertrophy, and worse renal function. The TAC group showed eccentric hypertrophy, increased BP variability (SD-SBP: SHAM: 2.97±0.07 mmHg vs. TAC: 5.63±0.57 mmHg, p≤0.01), diastolic dysfunction, and dilated left ventricle in diastole. The OXA group showed increased autonomic modulation and heart rate variability, renal damage characterized by inflammation, proximal tubule damage, and interstitial fibrosis when associated with TAC. All treated groups showed a significant reduction in reflex tachycardia.

Conclusion:
Transverse aortic constriction combined with OXA gavage is a model of CH with renal dysfunction, as the combination caused more significant renal damage, systemic hypertension, decreased autonomic modulation and baroreflex sensitivity, and eccentric hypertrophy with subsequent LV diastolic dysfunction.
P103 EFFICACY AND SAFETY OF TRIPLE VERSUS DUAL COMBINATIONS OF ANTIHYPERTENSIVE DRUGS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF DOUBLE-BLIND RANDOMIZED CLINICAL TRIALS
Authors: Dhurjati Rupasvi , Satheesh Gautam , Pant Rashmi , Rodgers Anthony , Haghdoost Faraidoon , Salam Abdul 
Published: September 2024

Background:
Some patients taking two blood pressure (BP) lowering drugs do not achieve and maintain BP <140/90mmHg on two drugs and substantially more do not reach <130/80 mmHg targets that are increasingly recommended by guidelines.

Objective:
To evaluate, among adults with hypertension, triple combination of antihypertensive drugs (AHTDs) compared to dual combinations of AHTDs for BP-lowering efficacy and safety.

Methods:
We searched multiple databases and the USFDA website until December 2023 for randomized, double-blind trials involving adults with hypertension, that compared triple versus dual combinations of AHTDs from five major classes (angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, calcium channel blockers, beta-blockers, and diuretics) over a minimum of 4 weeks. Drugs and doses were categorized by standard daily doses based on WHO daily defined dose. Primary outcomes were reduction in BP and treatment withdrawals due to adverse events (WDAE). Meta-analyses were conducted using random-effects model.

Results:
Twenty-four trials (15,533 participants) were included. Overall, triple compared with dual combination reduced BP by 5.1/3.7 mmHg (95% CI 4.3-5.9/3.0-4.4, p<0.001 for both), improved BP control by 69% versus 54% (relative risk [RR] 1.35 [95% CI: 1.25%-1.45%], p=<0.001). Incidence of WDAE was 4.2% versus 2.9% (RR 1.9 [95% CI: 1.3-2.4], P=0.004). Addition of a third drug to dual combinations at 0.5, 1, 1.5 and 2 standard doses resulted in additional SBP reduction of 3.4 (95% CI: 2.2-4.6), 6.1 (95% CI: 4.8-7.0), 4.5 (95% CI: 1.7-7.6) and 7.5 (95% CI: 6.2-8.8) mmHg, respectively with no significant difference in incidence of WDAEs [RR 1.63 (95% CI: 0.84-3.18) vs 1.58 (95% CI: 1.14-2.19) vs 0.94 (95% CI: 0.44-1.98)].

Conclusion:
Triple combinations of AHTDs reduce BP significantly, compared to dual combinations. Adding a third AHTD to dual combination, at 0.5 or 1 standard dose appear to produce most BP reduction and can avoid dose-related adverse effects.
P104 MEDICAL TREATMENT IN PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION HOSPITALIZED AT RESEARCH INSTITUTE OF CARDIOLOGY DURING 1 YEAR (FROM SEPTEMBER 2022 TO SEPTEMBER 2023)
Authors: Gasımov Zaur , Rahmanov Zahir , Dadashova Gulnaz , Javadova Tarana , Hajiyev Azad 
Published: September 2024

Objective:
Patients with heart failure remain most challenging group of patients with cardiovascular diseases. Hospital period of these patients is important period of their life. Therefore evaluation of the level of in- hospital care and treatment options represents valuable information.
Design and method: 477 patients (pts), 13% female,87% male with HFrEF hospitalized at Research Institute of Cardiology during 1 year (September 2022 – September 2023) represented study population. Consecutive patients’ data was extracted from the archive of Institute and evaluated.

Results:
Majority of pts had NYHA III-IV and mean ejection fraction (EF) of 35% (26-43%).Atrial fibrillation (AF) observed in 17,8% out of 477 pts. Myocardial infarction (MI) in anamnesis was in 82%. Systolic Blood Pressure (SBP) – mean 137 mm.Hg(min 80-max 240),Diastolic Blood Pressure(DBP) – mean 84 mm.Hg(min 50 – max 140).Arterial Hypertension(AH) had 61,4%. Type 2 Diabetes (T2D) – 51%.Chronic Kidney Disease had 22,9%.Pulmonary artery hypertension – 33%.Hb<12 g/l had 22,4%.ACE inhibitors or ARB mainly in form of fix combination with thiazide diuretics received 34% out of 477pts. ARNI were used in 27,7% of pts.B-blockers-55%. MRA – 89%. SGLT2 inh – 17,4%.Loop diuretics-86,2%.Digoxin-28,8%.Amiodarone – 22,9%.Ivabradine – 6%. Lab, tests: К+ mean 4,4 (2,9-6,2). Na+, mean 140,4 (133- 155). NT-proBNP, mean 2246.39 pg/ml (10.0-30000.0).

Conclusion:
In significant number of patients with HFrEF hospitalized to Research Institute of Cardiology during the period from September 2022- September 2023 medical therapy was almost adequately adherent to modern international guidelines on management of heart failure. In some cases’ limitations for indication because of low blood pressure, low eGFR and high serum kalium level took place.
P108 DIFFERENCES IN BLOOD PRESSURE CONTROL BASED ON HYPERTENSION SUBTYPE IN PATIENTS WITH A DE NOVO DIAGNOSIS: A RETROSPECTIVE COHORT STUDY
Authors: Rivera-Martínez Wilfredo Antonio , Casanova-Valderrama María Eugenia , Figueroa-Torregroza Lunévar , Ocampo-Chaparro José Mauricio , Salazar-Solarte Aura María , Zambrano Jose Leonel , Gallo-Villegas Jaime , Aristizábal-Ocampo Dagnóvar 
Published: September 2024

Background and Objective:
Currently, the selection of antihypertensive pharmacological treatment is carried out without considering whether only systolic or diastolic hypertension is present or both pressures are elevated. It is unknown whether the selection of individualized pharmacological treatment according to arterial hypertension (AH) subtype leads to greater blood pressure (BP) control. Therefore, this study aims to evaluate the association between the selection of pharmacological treatment based on AH subtype and BP control.

Methods:
This was a real-world cohort study that included 1,397 Latin American subjects with a de novo diagnosis of AH who received antihypertensive pharmacological treatment following current guidelines. Retrospectively, patients were classified by AH subtype according to the pattern of systolic or diastolic predominance of AH. Also, appropriateness of the pharmacological treatment was assessed based on AH subtype and the underlying hemodynamics of each subtype. BP control at the follow-up, within the first 12 weeks after diagnosis, was defined as <140/90 mmHg.

Results:
Among the subjects included in the study (n=1,397), the mean age was 52.4±13.2, and body mass index 28.8±4.9 kg/m2; 56.7% were women and 50.6% achieved BP control. The median time to the follow-up after diagnosis was 55 days (IQR 32-89 days). Regarding hemodynamic variables, the mean heart rate was 76.1±7.4 beats per minute, systolic blood pressure 147±13.9 mmHg, diastolic blood pressure 86.4±11.2, mean arterial pressure 108.0±9.5 mmHg, and pulse pressure 61.1±16.1 mmHg. The most frequent AH subtype was isolated systolic hypertension (47.3%). Initiation of appropriate antihypertensive pharmacological treatment was associated with greater BP control (OR 2.17; 95% CI 1.49 to 3.15; P value <0.001) (Figure). The patients who did not reach BP control presented a higher frequency of divergent systolic-diastolic hypertension subtype, and greater hemodynamic alterations.

Conclusions:
Appropriate selection of pharmacological treatment based on AH subtype is associated with better BP control in patients with newly diagnosed AH.
P112 SUPPRESSION OF PROTEIN KINASE RNA-LIKE ENDOPLASMIC RETICULUM KINASE BY PROBIOTICS CIRCUMVENTS CARDIOVASCULAR RISK PROFILE IN EXPERIMENTALLY-INDUCED PCOS MODEL
Authors: Areloegbe Stephanie Esosa Joy , Olaniyi Kehinde 
Published: September 2024

Background and Objective:
The global cause of death attributable to cardiovascular diseases (CVD). including in women of reproductive age is alarming. Individuals with PCOS usually present CVD as a long-term life-threatening effect of PCOS. Protein kinase RNA-like endoplasmic reticulum kinase (PERK) has been implicated in cardiomyopathy. However, its role in PCOS-induced CVD risk has not been established. Studies have shown that probiotics improves metabolic-related disorders. The present study was designed to investigate the role of PERK in CVD risk associated with PCOS in experimental rat model, and the therapeutic benefits of probiotics.

Methods:
Eight-week-old female Wistar rats were assigned into four groups (n=6). Polycystic ovarian syndrome was induced by uninterrupted administration of letrozole (1 mg/kg) for 21 days, thereafter, probiotics (2 x 107 CFU) was administered for 6 weeks. Gene expression, biochemical parameters and histological evaluations were performed with Western blot, ELISA, and H&E staining techniques

Results:
The present findings revealed that animals with PCOS were characterized with phenotypic features such as hyperandrogenemia and multiple cysts in the ovaries. In addition, PCOS rats manifested insulin resistance and increase in glucose regulatory protein (GRP78), together with increased levels of circulating corticosterone, cardiac triglyceride, inflammatory mediators (NF- kappaB/TNF-alpha), TGF-beta1, Caspase-6, and HDAC2, while a decrease in HIF-1alpha and NrF2 was observed when compared with control animals. These were accompanied by elevated expression of PERK. However, treatment with probiotics reversed these systemic, endocrine, metabolic and cardiac anomalies.

Conclusion:
The present study suggests that probiotics attenuates CVD risk profile in experimental PCOS rat model by suppression of PERK/HDAC2-dependent pathway.
P118 EFFECT OF A FIXED COMBINATION THERAPY WITH PERINDOPRIL/AMLODIPINE AND ROSUVASTATIN TO PATIENTS WITH HIGH AND VERY HIGH RISK HYPERTENSION AND DYSLIPEDEMIA
Authors: Fayzullayeva Shakhlo Sodiqjon Qizi , Xamidullaeva Gulnoza Abdusattarovna , Abdullaeva Guzal Djaloliddinovna 
Published: September 2024

Purpose:
Assess achievement target level blood pressure, LDL cholesterol, non-HDL cholesterol, Triglyceride, patients with high, very high risk AH during 6-month therapy with fixed combination perindopril/amlodipine addition rosuvastatin.

Material, methods:
Study included 43 patients hypertension I-II degrees (ESC/ESH, 2018), All patients assessed for cardiovascular risk using the SCORE2scale, high risk identified n=34 (80%) patients, very high n=9 (20%) patients. Average age patients 58.23±9.82 years, the average duration hypertension 13.07±8.53 years. SBP 159.46±10.52 mmHg, DBP 91.69±8.60 mmHg. All patients underwent: determination level blood lipids, glucose, ALT, AST, CPK, creatinine, uric acid in the blood and microalbuminuria. All patients with AHT and hypolipidemic purposes prescribed fixed combination drug perindopril/amlodipine and rosuvastatin. Drug dose titrated every 2 weeks until target values of BP and LDL cholesterol (<100-70 mg/dl), non-HDL cholesterol (<100-85 mg/dl), TG (<150 mg/dl) achieved. Average drug doses were perindopril at dose 4 to 8 mg/day, amlodipine dose 5 to 10 mg/day, initial dose orosuvastatin10 mg/day. All types analysis, p values <0.05 were considered statistically significant (Wilcoxontest).

Results:
In general, 6-month combination therapy with perindopril/amlodipine, rosuvastatin showed high lipotensive effectiveness. There was significant decrease in scores SCORE2scale, LDL cholesterol, non-HDL cholesterol, TG, SBP, DBP, blood pressure. The degree of scores SCORE2scale: initially 20.92±8.05 dynamics 14.92±9.66 points (p<0.001); LDL cholesterol 146.53±35.90,dynamics 114.86±36.43 mg/dl (p<0.003); Non-HDL cholesterol 185.61±35.90 mg/dl, dynamics 143.25±37.01 mg/dl (p<0.079); TG 181.23±108.47 dynamics 143.90±64.47 mg/dl (p<0.006); SBP 159.84±9 mmHg, dynamics 131.65±5.93 mmHg (p<0.000); DBP 91.69±8.60 mmHg, dynamics 82.55±4.17 mmHg(p<0.000); BPmean 115.48±7.22 mmHg, dynamics 99.96±3.75 mmHg. (p<0.000). In addition SBP decreased by -16.86±4.70%, DBP by -8.16±6.99%. The target level LDL cholesterol reached by39% patients, non-HDL cholesterol by 18%, Triglycerides by 55%, the target level SBP reached 88%, DBP 81% patients, SBP and DBP simultaneously 81% patients.

Conclusion:
Analysis effectiveness of combination therapy with drug perindopril/amlodipine, rosuvastatin showed significant decrease in level of indicators SCORE2 scores, LDL cholesterol, non-HDL cholesterol, TG, SBP, DBP, blood pressure. In patients with high, very high risk hypertension.
P119 COMPARISON BETWEEN MACRONUTRIENT DISTRIBUTION AND ANTHROPOMETRIC MEASURES IN POSTMENOPAUSAL WOMEN WITH AND WITHOUT HYPERTENSION
Authors: Ávila Mariana Ouriques , Dalmazo Aline , Santetti Daniele , Irigoyen Maria Cláudia , Fetter Claudia 
Published: September 2024

Introduction:
The hormonal changes of menopause have a deleterious effect on metabolism and on blood pressure regulation, since 50% of women have metabolic syndrome. At this stage, there is an increased risk for some chronic non-communicable diseases, especially hypertension. Anthropometric data are established indicators for the risk of heart disease and, associated with the food consumption of post-menopausal women and hypertension, represent a gap to be elucidated.

Objective:
To compare the relationships between anthropometric measures and macronutrient distribution in the diet of postmenopausal women with and without hypertension.

Methods:
The study recruited 45 women between 45 and 65 years old, with and without hypertension and a minimum of one year of amenorrhea. Participants answered a food recall and had their weight, height, waist circumference, abdomen and hips collected. Distribution of macronutrients in the diet, waist/hip ratio and waist/height were calculated. Data by T-test considering significant differences between groups for p <0.05.

Results:
There was a statistical difference between normotensive and hypertensive women for BMI (24.87±4.05 kg/m2 vs. 32.03±4.20 kg/m2; p<0.001) Waist Circumference (80.91±9.96 cm vs. 102.08±9.27 cm, p<0.001); Hips circumference (101.43±8.15 cm vs. 111.23±8.93 cm; p<0.001); Waist-to-height ratio (0.43±0.06 cm vs. 0.64±0.06 cm, p<0.001); and Waist-to-hips ratio (0.79±0.05 cm vs. 0.91±0.04 cm, p<0.001) In food consumption, there was an important disparity in intake of carbohydrates (172.66±88.67 g vs. 250.32 ± 92.95 g, p=0.007) and lipids (55.69±26.23 g vs. 82.07±51.12 g, p=0.037) with no difference in protein consumption (62.80±23.32 g vs. 77.60±39.67 g, p=0.139).

Conclusion:
The study suggests that there are significant differences in anthropometric and food consumption variables among the participants, which may, therefore, be related to the development of hypertension.