Higher Mean Arterial Blood Pressure Research Articles

Blood Pressure Targets for Adults with Vasodilatory Shock - An Individual Patient Data Meta-Analysis.

We sought to estimate whether a lower mean arterial blood pressure target, compared with a higher mean arterial blood pressure target, reduced 90-day all-cause mortality among critically ill adult patients with vasodilatory shock. We conducted an individual patient data meta-analysis of randomized controlled trials that evaluated the effect of distinct thresholds of mean arterial blood pressure to guide vasopressor support among critically ill adults identified in a systematic literature search. The main exposure was a lower mean arterial pressure target compared with a higher mean arterial pressure target (including usual care). The primary outcome was 90-day all-cause mortality. We used a Bayesian random effects log-binomial model to estimate risk ratios with 95% credible intervals (CrIs). Between 2010 and 2019, 3352 patients were randomly assigned in three trials (SEPSISPAM, OVATION pilot trial, and 65-Trial) across 103 hospitals from the United Kingdom, France, and Canada. When compared with a higher mean arterial blood pressure target or usual care, the risk ratio for 90-day all-cause mortality associated with a lower blood pressure target was 0.93 (95% CrI, 0.76 to 1.07; low certainty, posterior probability of benefit 87%). Results were consistent across multiple secondary and sensitivity analyses, including adjustment for prognostically important baseline covariates and alternative modeling techniques. Multiple approaches to evaluate the heterogeneity of treatment effect did not identify any subgroups that may potentially benefit from higher mean arterial blood pressure targets. Targeting a lower mean arterial blood pressure for vasopressor therapy in critically ill patients with vasodilatory shock possibly reduced 90-day all-cause mortality. However, the certainty of evidence is low, and this analysis does not exclude the possibility that lower targets may cause harm overall.

Long-term effects of sub-chronic exposure to L-NAME on reproductive system of male rats.

Nω-nitro-l-arginine methyl ester (L-NAME) has been utilized as a nitric oxide synthase antagonist for many years in both basic and clinical research settings to assess its therapeutic potential. Though a number of studies have shown the effect of L-NAME on testicular function, the information regarding the reversibility of these effects upon L-NAME withdrawal is limited. In the present study, male rats (68-80days old) divided randomly into three groups received different doses of L-NAME, i.e. 20mg/kg bw (L20) and 10mg/kg bw (L10) in drinking water, and drinking water only (control) through oral gavage daily for three weeks. The rats were monitored for and sacrificed after 60days of L-NAME treatment termination. The animals had a significantly higher (p < 0.01) mean blood pressure compared to control. Aberrant histological changes were observed in the testes of L-NAME-treated rats. A significant reduction (p < 0.05) in the sperm count and an increase in abnormal sperm morphology (p < 0.05) was observed in L-NAME treated rats. Moreover, the spermatogenic cycle was found to be altered in L-NAME treated rats. No change was observed in serum estradiol levels, while serum testosterone levels were significantly increased (p < 0.05) in L10 and L20 animals. The intra-testicular testosterone was increased significantly (p < 0.01) in L20 animals. A significant decrease (p < 0.05) in superoxide dismutase activity was observed in L20 animals. The sub-chronic exposure to L-NAME resulted in higher mean arterial blood pressure and long-term testicular tissue damage, affecting sperm quality and spermatogenesis.

Hypertension is associated with reduced resting-state medial temporal lobe dynamic network flexibility in older African Americans.

Hypertension disproportionately affects African Americans and is a risk factor for Alzheimer's disease (AD). We investigated the relationship of blood pressure (BP) with medial temporal lobe (MTL) dynamic network flexibility (a novel AD biomarker) and cognitive generalization in older African Americans. In a cross-sectional study, 37 normotensive (systolic BP <130 mmHg, 82.5% F, 64.4 ± 4.9 years; 14.3 ± 2.1 years of education) versus 79 hypertensive (systolic BP ≥130 mmHg, 79.5% F, 66.8 ± 4.1 years; 14.0 ± 0.2 years of education) participants were enrolled. All participants completed a 10-min resting-state functional magnetic resonance imaging scan to assess MTL dynamic network flexibility and two generalization tasks to assess cognition. Anthropometrics and aerobic fitness (via 6-min walk test) were also determined. There was no difference in BMI (29.7 ± 6.4 vs. 31.9 ± 6.3 kg/m2, p = 0.083) or aerobic fitness (15.5 ± 2.6 vs. 15.1 ± 2.6 mL/kg/min; p = 0.445) between normotensive and hypertensive groups. However, normotensive participants had higher MTL dynamic network flexibility compared to hypertensive participants (0.42 ± 0.23 vs. 0.32 ± 0.25 mL, p = 0.040), and this was associated with higher mean arterial blood pressure (r = -0.21, p = 0.036). Therefore, hypertensive older African Americans demonstrated lower MTL dynamic network flexibility compared to their normotensive counterparts independent of BMI and aerobic fitness. Further studies are required to determine how blood pressure mediates AD risk in African Americans.

Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study.

This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, pgroup = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors (n = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (n = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, pgroup < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.

Antihypertensive effect of chicken blood peptide hydrolysate in streptozotocin-induced diabetic rats

Chicken blood peptide hydrolysate (CBH) has been reported to exert antioxidant, angiotensin 1-converting enzyme (ACE) inhibitory, and cholesterol-lowering activities. Antihypertensive effect of the CBPH was also demonstrated in spontaneously hypertensive rats. This study aimed to assess the anti-diabetic and antihypertensive effect of the CBH in streptozotocin (STZ)-induced diabetic rats. CBH was prepared from fresh chicken blood collected from an industrial slaughterhouse in Nakhon Ratchasima, Thailand. Adult male Wistar rats were randomly divided into 2 main groups: normal and STZ-induced diabetes mellitus (DM) groups. Five subgroups of each main group were given distilled water, metformin (200 mg/kg), and CBH (300, 600, 1200 mg/kg) by oral gavage for 28 days (n=10 per each group). Fasting blood sugar level and OGTT were evaluated before and at the end of experiment. Each rat underwent monitoring of blood pressure using femoral artery. STZ-induced diabetic rats showed higher fasting blood glucose concentration and area under curve from OGTT than normal rats, which was not reduced by all treatments. STZ-induced diabetic rats showed higher mean arterial blood pressure than normal rats, which was significantly reduced by metformin and CBH (300 and 1200 mg/kg) (p&lt;0.05). The blood pressure-lowering effect of CBH suggested the potential for the application of CBH in the management of diabetic hypertension. However, attention must be paid to concerns about bird flu in certain places and prohibition of the use of blood product. This work was supported by Suranaree University of Technology (SUT), Thailand Science Research and Innovation (TSRI), and National Science Research and Innovation Fund (NSRF) (FF1-111-65-12-30(08)). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Antidiabetic activity of egg white protein hydrolysate in streptozotocin-induced diabetic rats

Egg white protein hydrolysate (EWH) has been reported to work as a cardiovascular protective agent. EWH exert antioxidant, vascular relaxing, anti-inflammatory properties and antihypertensive properties. This study aimed to assess the anti-diabetic and antihypertensive effect of the EWH in streptozotocin (STZ)-induced diabetic rats. Adult male Wistar rats were randomly divided into 2 main groups: normal and STZ-induced diabetes mellitus (DM) groups. Five subgroups of each main group were given distilled water, metformin (200 mg/kg), and EWH (300, 600, 1200 mg/kg) by oral gavage for 28 days (n=10 per each group). Fasting blood sugar level and OGTT were evaluated before and at the end of experiment. Each rat underwent monitoring of blood pressure using femoral artery. STZ-induced diabetic rats showed higher fasting blood glucose concentration and area under curve from OGTT than normal rats, which was significantly reduced by 600 mg/kg of EWH (p&lt;0.05). STZ-induced diabetic rats showed higher mean arterial blood pressure than normal rats, which was significantly reduced by metformin (p&lt;0.05). A decrease in hypertension in STZ-induced diabetic rats following EWH, but without significant difference, was observed. EWH may be useful in controlling the blood glucose level in diabetes mellitus and is therefore recommended for further studies. This work was supported by Suranaree University of Technology (SUT), Thailand Science Research and Innovation (TSRI), and National Science Research and Innovation Fund. (NSRF) (FF1-111-65-12-30(08)). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Factors that mediate change in creatinine and acute kidney injury after the Norwood operation: insights from high-fidelity haemodynamic monitoring data.

Acute kidney injury is a common postoperative complication of paediatric cardiac surgery associated with increased morbidity and mortality. The purpose of this study is to characterise associations between haemodynamic parameters, clinical parameters, and medical interventions, on acute kidney injury. Nine patients with univentricular physiology undergoing the Norwood procedure from a single-centre tertiary care paediatric cardiac ICU were included (September 2022 to March 2023). Patients were monitored with the T3 software. Data were analysed using a Fisher exact test, Mann-Whitney-U test, LASSO-based machine learning techniques, and receiver operator curve analyses. Over 27,000 datapoints were included. Acute kidney injury occurred in 2 patients (22%) during this period. Net fluid balance and renal oxygen extraction were independently associated with acute kidney injury, while commonly used metrics of pressure (systolic, diastolic, or mean arterial blood pressure) were not. The resulting acute kidney injury risk score was (4.1 × fluid balance) + (1.9 × renal oxygen extraction). The risk score was significantly higher in acute kidney injury with a score of 32.9 compared to 7.9 (p < 0.01). Optimal cut-offs for fluid balance (7 mL/hr) and renal oxygen extraction (29%) were identified. Higher serum creatinine:baseline creatinine ratio was associated with a higher mean airway pressure, higher renal oxygen extraction, higher mean arterial blood pressure, higher vasoactive inotropic score, and fluid balance. Among patients with univentricular physiology undergoing the Norwood procedure, renal oxygen extraction and a higher net fluid balance are independently associated with increased risk of acute kidney injury. Renal perfusion pressure is not significantly associated with acute kidney injury.

Assessment of macular choroidal and retinal thickness: a cohort study in Tibetan healthy children

This research investigates the distribution, progressive changes, and contributing factors of macular choroidal and retinal thickness in Tibetan children utilizing swept-source optical coherence tomography (SS-OCT). The Lhasa childhood study recruited 1632 students from seven primary schools in Lhasa. These participants underwent OCT and ophthalmological evaluations, encompassing retinal and choroidal thickness measurements, refractive error, axial length (AL), and systemic examinations. The median age of the scholars was 8.57 ± 0.50 years with a median spherical equivalent (SE) of 0.19 ± 1.28D. Multivariate regression analysis revealed that thinner macular choroid thickness was correlated with lower value of SE, worse best-corrected visual acuity, higher mean arterial blood pressure (MABP) and boys, while retinal thickness was associated with better image quality and lower value of SE. The choroid and retina were significantly thinner in myopic children. SE was positively related to the thickness of all choroidal and full retinal subregions. In comparison to baseline data from 20 months prior, most regions of the full retina had significantly thinned. Choroidal thickness of Tibetan children is thinner than that of same-age children from other regions. Thinning of retina, the outer-sector GCC and GCIPL may be specified as a follow-up and prognostic indicator for myopia.

Sex differences in outcome after targeting mean arterial blood-pressures and oxygenation in comatose patients after out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Background Previous studies have found lower survival rate and neurological outcomes for female patients with out-of-hospital cardiac arrest (OHCA) compared to males. Recently, the effect of liberal or restrictive oxygenation and lower or higher mean arterial blood-pressures (MAP) on outcome in comatose OHCA patients were investigated; showing no differences between the target groups. Evidence concerning sex differences in outcome after appropriate oxygenation and different MAP levels in comatose OHCA patients is limited. Purpose The aim of this study was to investigate whether female sex was associated with higher rates of unfavourable outcome after treatment with oxygenation and MAP in comatose patients after OHCA related to outcome. Methods Adult comatose OHCA patients (age ≥18 years) of presumed cardiac cause were included in a dual-center, double-blind, randomized trial with a 2-by-2 factorial design. Patients were allocated by a 1:1:1:1 ratio into a MAP target of 63 mm Hg or 77 mm Hg and arterial oxygen concentration during mechanical ventilation of 9–10 kPa (restrictive) or 13–14 kPa (liberal). The primary outcome was a composite of all causes of death within a year or hospital discharge with a cerebral performance category (CPC) of 3 or 4. Results Of the 789 included comatose OHCA patients, 152 (19%) were women. Mean age of women and men were similar, 61±14 years and 63±13 years, respectively. Comorbidities and characteristics of the cardiac arrest were comparable between sexes except for ischemic heart disease, which was more frequent in men (12% women, 24% men) and pulseless electrical activity, which was more frequent in women (8% women, 4% men). CPC 3 or 4 occurred equally in women and men (both 3%). Women had a higher, but non-significant one-year all-cause mortality (women: 42%, men: 35%), Figure 1. In a univariate Cox regression model, the difference in all-cause mortality was not significant (HR: 1.25, CI: 0.95-1.63), but showed significance after adjustment for age (HR: 1.31, CI: 1.004-1.72). Conclusion Men and women in comatose after OHCA had similar unfavourable outcome when treated in the same manner with oxygenation and MAP.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Angiotensin AT2 Receptor Activation during Ischemic Injury Protects against High Salt‐Induced Hypertension and Proteinuria in the Long‐term: Role of IL‐17A Cells

Short time renal ischemia/reperfusion (I/R) causes reversible acute kidney injury (AKI) that often recovers within 5‐7 days. However, a single event of AKI predisposes and makes kidneys susceptible to develop chronic kidney disease (CKD) in conditions such as obesity and hypertension. Recently we have shown that angiotensin type 2 receptor (AT2R) activation by the agonist compound C21 (C21) protects against I/R‐induced AKI in the early injury phase in terms of suppressing pro‐inflammatory cytokines and improving functional injury markers such as reducing proteinuria and blood urea nitrogen (BUN). The late recovery phase (day 5) in the I/R and I/R treated with C21 remained same i.e., the C21 treated and un‐treated animals fully recovered functionally to the same extent but with higher anti‐inflammatory IL‐10 producing and protective Treg cell (FoxP3+) in I/R+C21 compared I/R groups. However, the long‐term protective effect of the AT2R agonist C21 on these recovered kidneys against chronic injury is unknown. To address this question, male Sprague‐Dawley (SD) rats were administered C21 (0.3 mg/kg, i.p.) prior to 30‐minute bilateral renal ischemia and allowed to recover for 5 days, with daily C21 treatment (I/R+ C21), without treatment (I/R) and sham control. On 7th day, all the three groups were placed on high salt (1% NaCl) in drinking water for two weeks but without C21 treatment. On day 6 (prior to initiating high salt treatment), week 1 and 2 of the high salt treatment, renal function parameters (proteinuria), and T cells were quantitated in the blood and kidney (only at 2 weeks). On 6th day, all the three groups showed similar level of proteinuria, suggesting same renal function. However, at week 1 and 2, I/R group had significantly greater proteinuria, suggesting a function injury. Similarly, I/R group showed higher mean arterial blood pressure at two weeks compared with the I/R+C21 and sham control. Consistent to the higher proteinuria and blood pressure in I/R group, there were higher infiltrating proinflammatory (IL‐17A) cells in the kidney in I/R group compared with sham control and I/R+C21 groups. Also, kidney infiltrating CD45 cells, T cells and CD4 T cells were found to be similar among all the groups. Overall, the data indicate that I/R pre‐disposes the kidneys to high salt‐induced chronic injury which is completely prevented by AT2R agonist treatment during AKI phase. Moreover, AT2R’s protective effect could be related to preventing the T cell modulation into proinflammatory IL‐17A cells.

Normothermic Regional Perfusion of Circulatory Dead Donor Hearts: Quick and Dirty or Slow and Steady?

<h3>Purpose</h3> We sought to compare two strategies for cardiac reanimation in normothermic regional perfusion (NRP) in a clinically relevant porcine model of donation after circulatory death (DCD). To this day, many different protocols for NRP have been described. <h3>Methods</h3> For NRP-strategy 1(30mProp), pigs (n=16) were anaesthetized with intravenous Propofol (3.5 mg/kg/h) and subjected to hypoxic circulatory arrest (CA) by halting mechanical ventilation. After an 8-minute warm ischemia period, donor hearts were reanimated by a 30-minute NRP-period with Propofol suspended. For NRP-strategy 2(60mSevo), pigs (n=10) were anaesthetized with inhaled Sevoflurane (3.5%) before institution of hypoxia induced CA. A 10-minute warm ischemia followed before 60 minutes NRP with Sevoflurane continued. Both groups were reperfused via central cannulation with the aortic arch vessels and infrarenal aorta occluded. NRP flow, oxygenation, and weaning were standardized between groups. We assessed hemodynamic function with invasive blood pressure and bi-ventricular pressure-volume recordings 30 minutes post-NRP. <h3>Results</h3> All hearts were successfully reanimated during NRP in both groups. During NRP, a significantly higher mean arterial blood pressure and a minor need for pressor support with norepinephrine were observed in the 60mSevo group compared to the 30mProp group. Cardiac output remained on baseline levels in both groups post-NRP. Arterial lactate was significantly lower in the 60mSevo group post-NRP compared to the 30-minProp group. Left ventricular end-systole elastance as a measure of contractility increased significantly from baseline to post-NRP by 0.5 mmHg/mL (95%CI 0.09 : 1.0) in the 60-minSevo group and increased non-significantly by 0.3 mmHg/mL (95%CI -0.04 : 0.7) in the 30minProp group, while right ventricular contractility increased non-significantly in both groups. <h3>Conclusion</h3> Hearts reperfused for 60 minutes combined with inhaled Sevoflurane showed superior contractile function compared to hearts subjected to 30-minute NRP and Propofol anaesthesia. The results indicate that longer NRP is beneficial in DCD heart donation.

Effects of norepinephrine infusion on cerebral energy metabolism during experimental haemorrhagic shock

BackgroundThe use of norepinephrine in the case of life-threatening haemorrhagic shock is well established but widely discussed. The present study was designed to compare the effects of early norepinephrine treatment vs. no treatment on cerebral energy metabolism during haemorrhagic shock.MethodsTwelve pigs were subjected to haemorrhagic shock, 4 in the control group and 8 in the norepinephrine (NE) group. Following a 60 min baseline period haemorrhagic shock was achieved by bleeding all animals to a pre-defined mean arterial blood pressure (MAP) of approximately 40 mm Hg. When mean arterial pressure had decreased to 40 mmHg NE infusion started in the treatment group. After 90 min, NE infusion stopped, and all pigs were resuscitated with autologous blood and observed for 2.5 h. During the experiment cerebral tissue oxygenation (PbtO2) was monitored continuously and variables reflecting cerebral energy metabolism (glucose, lactate, pyruvate, glutamate, glycerol) were measured by utilizing intracerebral microdialysis.ResultsAll 12 pigs completed the protocol. NE infusion resulted in significantly higher MAP (p < 0.001). During the shock period lactate/pyruvate (LP) ratio group increased from 20 (15–29) to 66 (38–82) (median (IQR)) in the control group but remained within normal limits in the NE group. The significant increase in LP ratio in the control group remained after resuscitation. After induction of shock PbtO2 decreased markedly in the control group and was significantly lower than in the NE group during the resuscitation phase.ConclusionNE infusion during haemorrhagic shock improved cerebral energy metabolism compared with no treatment.

Gastroesophageal resuscitative occlusion of the aorta prolongs survival in a lethal liver laceration model.

Noncompressible torso hemorrhage management remains a challenge especially in the prehospital setting. We evaluated a device designed to occlude the aorta from the stomach (gastroesophageal resuscitative occlusion of the aorta [GROA]) for its ability to stop hemorrhage and improve survival in a swine model of lethal liver laceration and compared its performance to resuscitative endovascular balloon occlusion of the aorta (REBOA) and controls. Swine (n = 24) were surgically instrumented and a 30% controlled arterial hemorrhage over 20 minutes was followed by liver laceration. Animals received either GROA, REBOA, or control (no treatment) for 60 minutes. Following intervention, devices were deactivated, and animals received whole blood and crystalloid resuscitation. Animals were monitored for an additional 4 hours. The liver laceration resulted in the onset of class IV shock. Mean arterial blood pressure (MAP) (standard deviation) decreased from 84.5 mm Hg (11.69 mm Hg) to 27.1 mm Hg (5.65 mm Hg) at the start of the intervention. Seven of eight control animals died from injury prior to the end of the intervention period with a median survival (interquartile) time of 10.5 minutes (12 minutes). All GROA and REBOA animals survived the duration of the intervention period (60 minutes) with median survival times of 86 minutes (232 minutes) and 79 minutes (199 minutes) after resuscitation, respectively. The GROA and REBOA animals experienced a significant improvement in survival compared with controls (p = 0.01). Resuscitative endovascular balloon occlusion of the aorta resulted in higher MAP at the end of intervention 114.6 mm Hg (22.9 mm Hg) compared with GROA 88.2 mm Hg (18.72 mm Hg) (p = 0.024), as well as increased lactate compared with GROA 13.2 meq·L-1 (1.56 meq·L-1) versus 10.5 meq·L-1 (1.89 meq·L-1) (p = 0.028). Histological examination of the gastric mucosa in surviving animals revealed mild ischemic injury from both GROA and REBOA. The GROA and REBOA devices were both effective at temporarily stanching lethal noncompressible torso hemorrhage of the abdomen and prolonging survival.

The impact of courteous and discourteous drivers on physiological stress

Prior studies into road safety have concentrated largely on studying unsafe forms of driving behaviour such as aggressive, stressed, and risky driving. Little attention has been given to ‘positive’ driving behaviour, such as how pro-social driving may help to promote cooperation with other road users and decrease incidences of aggressive and stressful driving. This study aimed to compare the impact of courteous and discourteous driving on the immediate physical health of other drivers (blood pressure, heart rate, and markers of stress) whilst controlling for other recognized factors responsible for driver stress such as road infrastructure (e.g. roadworks, traffic lights, freeways) and driving maneuvers (e.g. merging, tail-gaiting, navigating roundabouts). Using actors in a deception study, a naturalistic driving scenario was created in a lab-based simulation. All participants (n = 10; 39 ± 14.5 years) drove the same route in a simulator and engaged with the same driving behaviours and other virtual road users on two separate occasions separated by 7 days. The difference between conditions was whether the participant interacted with other drivers who displayed: a) courteous or b) discourteous behaviours. Blood pressure, heart rate variability and salivary hormone concentrations (cortisol and alpha amylase) were measured before and immediately after each simulated drive. After interacting with the discourteous drivers, participants experienced significantly higher mean arterial blood pressure, systolic and diastolic pressure, central systolic and diastolic pressure, and heart rate, and lower heart rate variability (indicative of acute stress) compared to interacting with the courteous drivers. Conversely, these markers of stress were reduced after interacting with the courteous drivers. The results support courtesy on the road to provide short-term benefits for the recipient of the action, while also increasing road safety more generally.

Cannabis Exposure Decreases Need for Blood Pressure Support During General Anesthesia in Orthopedic Trauma Surgery.

Introduction:As cannabis use continues to increase in popularity, it is important to investigate how it impacts public health in all sectors of the population, including patients undergoing anesthetic management. This retrospective study focuses on the orthopedic trauma population presenting through an emergency department (ED) and receiving a urine drug screen (UDS) with subsequent urgent surgical intervention. We aimed to evaluate differences in response to general anesthesia in patients with exposure to THC, a major cannabinoid, compared to controls that screened negative for THC.Materials and Methods:All ED visits at UC Irvine, a level 1 trauma center between November 4, 2017 and January 7, 2020, were evaluated in this study. Only adult patients who received a UDS and underwent urgent orthopedic trauma surgery within 48 h of ED visit were included in this study. Additional inclusion criteria required an anesthesia time greater than 1 h as well as anesthesia induction and intubation while in the operating room. Overall, we analyzed a total of 221 adult patients.Discussion:When adjusting for demographic variability, there were statistically significant differences in response to general anesthesia between these two groups. The THC-positive (THC(+)) group was less likely to receive intraoperative vasopressors, had higher mean arterial blood pressure and mean diastolic blood pressure, needed less total fluid input and had a lower overall fluid balance. Chronic exposure to THC has been shown to downregulate cannabinoid 1 receptors and cause alterations in endocannabinoid tone. These are two potential mechanisms by which the THC(+) group in our study may have become more resistant to the typically observed hypotensive effects of general anesthesia.Conclusion:The present study suggests that prior use of cannabis, objectively assessed by urinalysis, results in a decreased need for blood pressure support during general anesthesia. The physiological basis for this phenomenon is unclear, but possible causes might include the downregulation of vascular cannabinoid receptor 1 and/or altered endocannabinoid levels after exposure to cannabis.

Nebulized Magnesium Sulfate for Treatment of Persistent Pulmonary Hypertension of Newborn: A Pilot Randomized Controlled Trial.

ObjectivesTo investigate the effectiveness of nebulized magnesium sulfate in treating persistent pulmonary hypertension of newborn (PPHN).MethodsTwenty-eight mechanically ventilated term neonates with severe PPHN were randomized into two groups: NebMag group (n = 14), who receiving nebulized isotonic magnesium (1024 mg/h), and IVMag group (n = 14), who received intravenous magnesium (200 mg/kg over 30 min, followed by 50 mg/kg/h). The study time frame was 24 h. Outcome measures were the changes in oxygenation index (OI), mean arterial blood pressure (MABP), vasoactive inotropic score (VIS), and serum magnesium level.ResultsBaseline demographic, ventilatory, and hemodynamic characteristics were comparable between the two groups. At the end of the study, the OI decreased by 44.3% in the NebMag group compared with 35.3% in the IVMag group (mean difference −3.14; 95%CI −5.08, −1.19; p 0.003). The NebMag group had a higher MABP (mean difference 2.29 mmHg; 95% CI 1.80, 2.77; p 0.000) and lower VIS (mean difference −14.64; 95% CI −16.52, −12.77; p 0.000) at the 24-h study time point. The increase in serum magnesium level, measured at 12-h study time point, was lower in the NebMag group (mean difference −2.26 mmol/L; 95% CI −2.58, −1.96; p 0.000).ConclusionNebulized magnesium sulfate may be an effective therapeutic modality for neonates with severe PPHN on mechanical ventilation, but this should be confirmed by larger studies.Retrospectively registered at www.clinicaltrials.gov (identifier: NCT04328636).

Mortality and predictors of survival in patients with recent ventricular septal rupture.

Ventricular septal rupture (VSR) is a rare but fatal complication after acute myocardial infarction (AMI). However, the mortality in patients with recent VSR and appropriate timing of surgical repair have not been clarified. To examine the background characteristics and mortality of VSR patients as well as the usefulness and appropriate timing of surgery in this patient cohort. Among 3,947 consecutive patients with AMI at our hospital, 39 patients diagnosed with VSR from 2002 to 2020 were included in the analysis. All patients underwent transthoracic echocardiography to confirm VSR on admission. Coronary angiography (CAG) and measurement of pulmonary-systemic flow ratio were performed before emergent surgery. The use of mechanical support devices before or after procedures was considered for all patients who underwent CAG. Basically, we performed emergent or urgent operations to patients who were in a shock state or who needed mechanical support. The final decision of the timing of the operation was made by the cardiac team. Patients' mean age was 76.3years, and 33.3% of them were males. Most culprit lesions were located in the left anterior ascending artery (81.3%). The mean pulmonary-systemic flow ratio after VSR onset was 3.07 ± 1.98. On admission, 48.7% of patients were in a shock state. Surgical repair was possible in 28 patients at a median of 1day after admission, with a mortality rate of 25%. Among all patients, the mortality rate was 43.6%. Survivors were significantly younger (71.3 ± 11.3 vs. 82.7 ± 6.2years, p < 0.01), had higher mean arterial blood pressure (75.6 ± 14.4 vs. 62.8 ± 16.2mmHg, p = 0.0496) and lower ejection fraction (44.3 ± 11.7% vs. 54.8 ± 7.9%, p = 0.04), and underwent surgical repair more frequently (95.5% vs. 41.2%, p < 0.01) than the non-survivors. In multivariate analysis, younger age (odds ratio [OR] 1.18 95% confidence interval [CI] 1.01-1.38, p = 0.04) and surgical repair (OR 0.04, 95% CI 0.00-0.73, p = 0.03) were significant predictors of survival. In surgical repair cases, time from admission to operation did not differ significantly between survivors and non-survivors. Surgical repair and younger age are predictors of survival in patients with recent VSR, but the timing of surgery was not.

Predictors of Postthrombolysis Outcome and Symptomatic Postthrombolysis Hemorrhage following Intravenous Thrombolysis with Alteplase for Acute Ischemic Stroke.

Background Thrombolysis improves the outcome in acute ischemic stroke (AIS), albeit with an increased risk of symptomatic intracranial hemorrhage (sICH). Biomarkers to find patients at risk of sICH, and guide treatment and prognosis would be valuable. Methods Consecutive patients of AIS thrombolysed between February 2017 and September 2019 at Calcutta National Medical College were studied prospectively for sICH and outcome at 6-month follow-up. We identified the independent risk factors for unfavorable outcomes, mortality, and sICH using multivariate analysis. Prethrombolysis and 24-hour postthrombolysis fibrinogen levels were estimated to evaluate its biomarker role. Results Out of 180 AIS patients admitted during the study period, 60 patients were thrombolysed. Door to needle time was <3 hours among 24 patients and 3 to 4.5 hours among 36 patients. Favorable outcomes occurred among 76.67% and sICH occurred among 13.33% patients. Upper tertile of National Institute of Health Stroke Scale (NIHSS) had the highest adjusted odds for sICH (17.5 [95% confidence intervals=1.7–178.44]). Total anterior circulation stroke had the highest adjusted odds for unfavorable outcome (19.11 [3.9–92.6]). Following thrombolysis, the mean (standard deviation) fibrinogen level of 449.27 (32.87) decreased 7% to postthrombolysis level of 420 (20.5; p< 0.0001). Higher tertiles of fibrinogen levels had progressively increasing odds for morbidity and sICH. Conclusion Congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (double weight), i.e., CHADS2 score >2, low ejection fraction, the occurrence of total anterior circulation stroke and higher mean arterial blood pressure, blood glucose level, NIHSS score, and fibrinogen at admission were the common risk factors significantly predicting postthrombolysis sICH and morbidity. Antiplatelet and anticoagulant therapy, lower ASPECT (Alberta Stroke Program Early CT Score), and higher SEDAN scores also predicted sICH . Fibrinogen levels were significantly higher among those developing sICH and having unfavorable outcome. The performance of thrombolysis within 3 hours or between 3 and 4.5 hours after symptom onset did not affect morbidity, mortality, or the occurrence of sICH.

Renal transplant biopsy complications: assessment of risk factors and potential of desmopressin to decrease risk of hemorrhage.

Renal transplant biopsies are essential in nephrology; however, they are invasive and complications can occur. To explore the risk of transplant kidney biopsy (TxB) complications in relation to possible preventive effects of desmopressin prophylaxis. A total of 515 consecutive TxB (375 patients, median age 53 years) were analyzed. In 252 TxB, the Resistive Index (RI) was measured right before the biopsy. A total of 282 patients had serum creatinine >150 µmol/L. In one of the six hospitals 39/282 patients consecutively received desmopressin (dose 0.3 µg/kg subcutaneously) as prophylaxis within 1 h before the biopsy. Fisher's exact and χ2 test were used (odds ratio [OR], 95% confidence interval [CI]). Univariate and multiple binary logistic regression analyses were performed. A two-sided P value <0.05 was considered significant. RI ≥ 0.8 was a risk factor for major TxB complications (OR 4.2, 95% CI 1.13-15.76). The risk for minor complications decreased with mean arterial blood pressure (MAP) (97.9 vs. 89.5 mmHg, OR 0.97, 95% CI 0.95-0.997). In a multiple regression analysis for overall biopsy complications, the risk remained increased for patients with RI ≥ 0.8 (OR 4.45, 95% CI 1.32-15.04). No patients (0/39) with desmopressin prophylaxis had a major complication versus 8/243 in the other group. In patients with serum creatinine >150 µmol/L, those with a higher MAP had more overall TxB complications (104.5 vs. 98.2 mmHg, OR 1.05, 95% CI 1.004-1.1). RI ≥ 0.8 was a risk factor for major and overall complications and a lower MAP for minor biopsy complications. Desmopressin prophylaxis showed yet no verified benefit as prophylaxis in TxB.