Labile Hypertension Research Articles

Changes of morphofunctional state of cardiovascular system in adolescents with metabolic syndrome manifestations

The results of investigation of features of morphofunctional state of cardiovascular system in adolescents with manifestations of metabolic syndrome depending on presence of hyperuricemia are presented. In the cardiorheumatology department of the hospital, 34 adolescent patients were observed. Criteria for inclusion in the study: the presence of increased blood pressure levels, increased body mass index values. Depending on serum uric acid levels, patients were divided into two groups: group 1 patients without hyperuricemia (n = 18) and group 2 patients with hyperuricemia (n = 16). Functional diagnostic methods were used: standard 12-channel electrocardiography, transtoral echocardiography, daily Holter monitoring. The main attention was paid to the study of the parameters of the left ventricle. Students t-test was used to determine the significance of the differences, the results at p 0.05 were considered reliable. It was established that adolescents with hyperuricemia were more often diagnosed with primary and secondary arterial hypertension, less often with labile arterial hypertension and autonomic dysfunction syndrome by hypertensive type, and adolescents without hyperuricemia were equally often diagnosed with primary arterial hypertension and labile arterial hypertension, autonomic dysfunction syndrome by hypertensive type. Signs of left ventricular remodeling according to echocardiography were more often noted in boys without hyperuricemia (62.5% of cases) than in girls without hyperuricemia (10%; p 0.01) and in boys with hyperuricemia (26.7%; p 0,05). The findings indicated more significant changes in the morphofunctional state of the cardiovascular system in adolescents with hypertensive conditions and manifestations of metabolic syndrome without hyperuricemia, which requires further study.

Dynamics of resistant hypertension in the postoperative period of carotid endarterectomy with and without carotid body saving

Aim. To analyze the results of multicenter study on dynamics of resistant hypertension (RH) in patients after various types of carotid endarterectomy (CE) with and without carotid body savingMaterial and methods. During the period from January 2010 to December 2020, 1827 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RH were operated on. Depending on CE type, the two groups were selected. Group 1 (n=1135; 62,2%) consisted of patients received glomus-saving surgery: 19,2% (n=351) -conventional CE with a patch repair of reconstitution point; 13,6% (n=248) — glomus-saving CE sensu R. A. Vinogradov; 7,3% (n=133) — glomus-saving CE sensu K. A. Antsupov; 11,7% (n=214) — glomus-saving CE sensu A. N. Kazantsev; 4,6% (n=84) — Chick-Chirik CE; 5,7% (n=105) — swallow tail type patch repair sensu R. I. Izhbuldin. Group 2 (n=692; 37,8%) consisted of patients received CE without glomus saving: 18,6% (n=341) — eversion CE with carotid body cutoff; 6,3% (n=115) — CE with new bifurcation plasty; 5,85% (n=107) — autoarterial reconstruction; 7,1% (n=129) ICA autotransplantation sensu E. V. Rosseikin.Results. The mortality rate, as well as the prevalence of myocardial infarction (MI) and ischemic strokes were comparable in groups. The incidence of hemorrhagic transformation (group 1: 0%; group 2: 0,6%; p=0,04; OR=0,06; 95% CI, 0,003-1,25) and composite endpoint (death+MI+ischemic stroke+hemorrhagic transformation) (group 1: 1,06%; group 2: 3,0%; p=0,004; odds ratio (OR)=0,34; 95% CI, 0,16-0,69) significantly differs between groups. After glomus-saving CE, the number of patients with the target blood pressure (BP) level reached 51,1% (p <0,0001; OR=0,0009; 95% CI, 6,05-15,9). The number of patients with grade II (31,1%; p<0,0001; OR=12,7; 95% CI, 10,4-15,52) and III (3,6%; p<0,0001; OR=10,26; 95% CI, 6,71-15,67) hypertension significantly decreased. In the group 2, the prevalence grade III hypertension increased (48,0%; p<0,0001; OR=0,23; 95% CI, 0,18-0,3), while the number of patients with grade I (0%; p<0,0001; OR=77,0; 95% CI, 4,71-12,58) and II (52%; p<0,0001; OR=3,06; 95% CI, 2,43-3,86) hypertension decreased.Conclusion. Glomus-saving CE contributes to achieving target BP in patients with RH. Its removal increases the risks of labile hypertension, postoperative hypertensive crisis, hyperperfusion syndrome and hemorrhagic transformation.

Natural History of Afferent Baroreflex Failure in Adults.

To describe the natural history of afferent baroreflex failure (ABF) based on systematic review of clinical and laboratory data in patients with a diagnosis of ABF at Mayo Clinic Rochester. We performed a retrospective chart review of all patients who underwent standardized autonomic reflex testing between 2000 and 2020 and had confirmation of the diagnosis of ABF by an autonomic disorders specialist. Patients were identified using a data repository of medical records. Variables included demographic, all-cause mortality, medications, ABF manifestations, comorbidities, and laboratory (autonomic testing, blood pressure monitoring, echocardiogram, brain imaging, plasma catecholamines, serum sodium level, and kidney function tests). A total of 104 patients with ABF were identified. Head and neck radiation was the most common etiology (86.5%), followed by neck surgery (5.8%) and other causes (7.7%). The most common findings were hypertension (87.5%), fluctuating blood pressure (78.8%), orthostatic hypotension (91.3%), syncope (58.6%), headache (22.1%), and tachycardia (20.2%). Patients commonly received antihypertensives (66.3%), pressor agents (41.3%), or a combination of both (19.2%). The median latency from completion of radiation to ABF was longer compared to the latency in the surgery group (p < 0.0001). Comorbidities, including complications from neck radiation, were frequently seen and all-cause mortality was 39.4% over a 20-year period. ABF should be suspected in patients with prior head and neck cancer treated by radiation or surgery who present with labile hypertension and orthostatic hypotension. Management may require both antihypertensive and pressor medications. The morbidity and mortality in ABF are high.

Large Invasive Adrenal Cortical Carcinoma in a Patient With Neurofibromatosis Type I

Background: Adrenal cortical carcinoma is a rare neoplasm. Adrenal cortical carcinoma has previously been reported in less than 10 cases of patients with Neurofibromatosis Type I. Clinical Case: A 44-year-old Hispanic man with Neurofibromatosis Type I (NF1) presented with progressive hypoxia, tachypnea and abdominal pain. Intubation was required with 100% FiO2. CT angiogram of the chest and abdomen showed a 9.5 cm left adrenal mass with tumor thrombus in the left adrenal vein, distal left renal vein, IVC extending into the right atrium, suggestive of an adrenocortical carcinoma. Café-au-spots, neurofibromas and Lisch nodules were seen on physical exam but no signs suggestive of a functional adrenal cortical carcinoma. Transthoracic echocardiogram demonstrated a large well circumscribed echo-dense mass filling the right atrial cavity. Hemodynamically he was unstable with labile blood pressures due to right atrium thrombus burden. He was supported pending pheochromocytoma investigation. Biochemical work up revealed an elevated 24-hour free cortisol concentration of 95.9 ug/d (<=60ug/d) with a normal 24-hour urine metanephrine and normetanephrine [140ug/d (55-320ug/d) and 448 ug/d (114-865ug/d]. Plasma free metanephrine level was normal 0.43 (0.00-0.49nmol/L) and the normetanephrine levels was increased at 2.7 (0.00-0.89nmol/L) consistent with stress response. Serum aldosterone level and renin activity with potassium and DHEA-S levels were normal. Once pheochromocytoma was ruled out, he successfully underwent a left nephrectomy, left adrenalectomy, IVC thrombectomy, right atrium thrombectomy under a multidisciplinary team of surgeons. Surgery was well tolerated and he was discharged home 11 days later. Pathology confirmed adrenal cortical carcinoma, stage 4, with involvement of endocardium and left renal vein with mitotic count greater than 20/50 high-power fields, consistent with a high-grade tumor. Summary: Patients with NF1 have a higher predilection to develop tumors including pheochromocytoma, paraganglioma, gastrointestinal stromal tumor, and pancreatic neuroendocrine tumor. NF1 association with adrenal tumors is well known, most commonly pheochromocytomas which occur in 0.1–5.7% of patients with NF1. However, based on a literature search there have been less than 10 case reports which postulate an association between NF1 and ACC. Genetic analysis of these reported cases suggest a loss of heterozygosity at the NF1 locus as a possible explanation of development of ACC in patients with NF1. Conclusion: Adrenal cortical carcinoma is rare but should be considered in a patient with NF1 and adrenal mass when plasma/urine metanephrines are not suggestive of pheochromocytoma.

Synchronous Malignant Pheochromocytoma With Renal Cell Carcinoma: A Case Report

Introduction: In the US, Pheochromocytoma/paraganglioma incidence is estimated to be 2–8 per 1 million people each year with around 100–200 of these cases being malignant. Malignant pheochromocytoma is defined by documented presence of metastases or evidence of extensive local invasion. There are certain genetic syndromes which are also associated with renal cell carcinoma, including SDHB mutations type 4, VHL disease and familial pheochromocytoma. These syndromes are important to recognize as they may signify a worse prognosis. Here, we describe a case of co-occurrence of malignant PC with renal cell carcinoma.Case Report: A 53-year-old Hispanic male with history of HTN and recently diagnosed metastatic pheochromocytoma was admitted for surgical debulking of the left retroperitoneal/adrenal and renal masses. Symptoms began five months prior after he presented with an ischemic stroke in the setting of labile hypertension. He was diagnosed with a 6.3 x 4.6 x 6.8 cm incidental left retroperitoneal mass and suspicious left renal mass on CT imaging but also noted several lytic bony lesions concerning for bone metastasis. A spinal biopsy was obtained which was consistent with a well-differentiated metastatic neuroendocrine tumor. Laboratory evaluation was notable for Chromogranin A level of 6959ng/mL (25–140). He was started on Lanreotide. Given persistently difficult to control HTN he underwent work up for secondary hypertension. Hormonal evaluation was notable for plasma free metanephrine of 534pg/mL (<57pg/mL), normetanephrine 6155pg/mL(<148pg/mL), and total metanephrine of 6689pg/mL (205pg/mL) consistent with metastatic Pheochromocytoma. After appropriate alpha blockade he underwent left adrenalectomy, nephrectomy and liver tumor microwave ablation. Pathology was consistent with an 8.7cm pheochromocytoma with extensive retroperitoneal soft tissue invasion and PASS score of 9 as well as a 3.6 cm renal cell (clear cell-papillary type) carcinoma. On follow up, Plasma metanephrine decreased significantly postoperatively to a free metanephrine of 28pg/ml, normetanephrine 1153pg/ml, and total metanephrine of 1181pg/mL. He was referred for genetic testing but unfortunately, he was readmitted one month later with cerebral hemorrhage and expired.Conclusion: Advancements in genetics have led to improved understanding of the molecular etiologies of pheochromocytomas. A number of genetic defects are associated with PC and RCC, including SDHB mutations type 4, VHL and familial pheochromocytoma. Our case underscores the high morbidity and mortality in patients with metastatic PC with RCC and perhaps the catastrophic outcomes in such patients. Assessing patient’s genetics in these cases is now the standard of care, however further research studies are warranted to better understand the significance of tumor genetics on prognosis and management.

Intensive Care Management of Severe Tetanus.

Tetanus is caused by an exotoxin, tetanospasmin, produced by Clostridium tetani, an anaerobic gram-positive bacillus.Tetanospasmin prevents the release of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the spinal cord, brainstem motor nuclei, and the brain, producing muscle rigidity and tonic spasms.Trismus (lockjaw), dysphagia, laryngeal spasms, rigidity of limbs and paraspinal muscles, and opisthotonic posture are common.Frequent severe spasms triggered by touch, pain, bright light, or sounds may produce apnea and rhabdomyolysis.Autonomic overactivity occurs in severe tetanus causing labile hypertension, tachycardia, increased secretions, sweating, and urinary retention. Dysautonomia is difficult to manage and is a common cause of mortality; magnesium sulfate infusion is often used.Antibiotics (penicillin or metronidazole) and wound care reduce toxin production and human tetanus immune globulin neutralizes the circulating toxin.Nasogastric tube placement for feeding and medications is needed.Early elective tracheostomy is performed in moderate or severe tetanus to prevent aspiration and laryngeal stridor.Benzodiazepines help reduce rigidity, spasms, and autonomic dysfunction. Large doses of diazepam (0.2–1 mg/kg/h) are administered via nasogastric tube.Neuromuscular blocking agents and mechanical ventilation are used for refractory spasms.Mortality ranges from 5% to 50%. How to cite this article: Karnad DR, Gupta V. Intensive Care Management of Severe Tetanus. Indian J Crit Care Med 2021; 25(Suppl 2):S155–S160.

Endothelin B receptors impair baroreflex function and increase blood pressure variability during high salt diet.

Baroreflex function is an integral component maintaining consistent blood pressure. Hypertension is often associated with baroreflex dysfunction, and environmental risk factors such as high salt diet exacerbate hypertension in subjects with baroreflex dysfunction. However, the interactions between high salt diet, baroreflex dysfunction, and hypertension are incompletely understood. The endothelin system is another potent mediator of blood pressure control especially in response to a high salt diet. We hypothesized that the endothelin B (ETB) receptor activation on adrenergic nerves decreases baroreflex sensitivity. We utilized male ETB receptor deficient (ETB-def) rats that express functional ETB receptors only on adrenergic nerves and transgenic (TG) controls to evaluate baroreflex function during normal (0.49% NaCl) and high (4.0% NaCl) salt diets. In conscious rats equipped with telemetry, ETB-def rats had an increased lability of systolic blood pressure (SBP) compared to TG controls as indicated by higher standard deviation (SD) of SBP under both normal (10.2±0.6 vs. 12.4±0.9mmHg, respectively, p=0.0001) and high (11.7±0.6 vs. 16.1±1.0mmHg, p=0.0001) salt diets. In anesthetized preparations, ETB-def rats displayed reduced heart rate (p genotype=0.0167) and renal sympathetic nerve (p genotype=0.0022) baroreflex sensitivity. We then gave male Sprague-Dawley rats the selective ETB receptor antagonist, A-192621 (10mg/kg/day), to block ETB receptors. Following ETB receptor antagonism, even though SBP increased (131±7 before vs. 152±8mmHg after, p<0.0001), the lability (standard deviation) of SBP decreased (9.3±2.0 vs. 7.1±1.1mmHg, p=0.0155). These data support our hypothesis that ETB receptors on adrenergic nerves contribute to baroreflex dysfunction.

Elderly Patient with Hypertension in General Practice: Clinical Features and Antihypertensive Therapy

The prevalence of arterial hypertension (AH) increases with age: among people over 60 years old this index is more than 2 times higher in the general population, 2/3 of people over 65 years old suffer from hypertension. Among patients 65–89 years old with hypertension, 2/3 patients have isolated systolic hypertension (ISAG). Features of hypertension in the elderly patients are: lability of blood pressure (BP), increasing frequency of pseudohypertension, high frequency of «white coat hypertension», decreased sensitivity of pressor factors for antihypertensive drugs, high frequency of resistant to treatment of hypertension. The new recommendations of the European Society of Cardiology for the diagnosis and treatment of hypertension emphasize 2 groups of elderly patients: 65–79 years old and ≥80 years old, which described the epidemiological features, the prevalence of risk factors for cardiovascular events, blood pressure levels for antihypertensive therapy and target blood pressure, and the recommended principles of drug therapy that are different from young and middle-aged patients. For most patients, fixed combinations are indicated as starting AGT, but monotherapy is recommended for the treatment of hypertension in very elderly patients (over 80 years old) and elderly patients over 65 years old with senile asthenia. The decreasing of blood pressure should be gradual, taking into consideration the increased risk of orthostatic reactions at this age. European and American experts recommend os first-line drugs low doses of thiazide diuretics and calcium channel antagonists (mainly dihydropyridine), which are especially indicated in isolated systolic arterial hypertension to effectively reduce the frequency of cardiovascular complications in the treatment of elderly patients with hypertension.

Further evidence against the role renal medullary perfusion in short-term control of arterial pressure in normotensive and mildly or overtly hypertensive rats

Earlier evidence from studies of rat hypertension models undermines the widespread view that the rate of renal medullary blood flow (MBF) is critical in control of arterial pressure (MAP). Here, we examined the role of MBF in rats that were normotensive, with modest short-lasting pressure elevation, or with overt established hypertension. The groups studied were anaesthetised Sprague-Dawley rats: (1) normotensive, (2) with acute i.v. norepinephrine-induced MAP elevation, and (3) with hypertension induced by unilateral nephrectomy followed by administration of deoxycorticosterone-acetate (DOCA) and 1% NaCl drinking fluid for 3 weeks. MBF was measured (laser-Doppler probe) and selectively increased using 4-h renal medullary infusion of bradykinin. MAP, renal excretion parameters and post-experiment medullary tissue osmolality and sodium concentration were determined. In the three experimental groups, baseline MAP was 117, 151 and 171 mmHg, respectively. Intramedullary bradykinin increased MBF by 45%, 65% and 70%, respectively, but this was not associated with a change in MAP. In normotensive rats a significant decrease in medullary tissue sodium was seen. The intramedullary bradykinin specifically increased renal excretion of water, sodium and total solutes in norepinephrine-treated rats but not in the two other groups. As previously shown in models of rat hypertension, in the normotensive rats and those with acute mild pressure elevation (resembling labile borderline human hypertension), 4-h renal medullary hyperperfusion failed to decrease MAP. Nor did it decrease in DOCA-salt model mimicking low-renin human hypertension. Evidently, within the 4-h observation, medullary perfusion was not a critical determinant of MAP in normotensive and hypertensive rats.

Brief report: Musical improvisation skills can combat labile hypertension

• Our data supports the conclusion that musical improvising has the potential to both blunt emotional distress (i.e. through mindfulness) and impact negative thoughts and emotions in ways that can help labile hypertension. This may additionally help patients better anticipate and react to seen and unforeseen stressors in daily life. Notably, patients who participated in this study not only learned a new technique to address labile hypertension, but indicated they are also more likely to practice mindfulness and exercise techniques to benefit their health. All of these pathways can potentially lessen the impact of labile hypertension and give patients an engaging option to treat this condition that is common in so many patients. Patients with labile hypertension experience transient but substantial increases in blood pressure, usually surrounding episodes of emotional distress and anxiety. Difficulties with or inability to express negative emotions may play a role. We hypothesize that therapy involving musical improvisation may blunt emotional response but may also decrease brain activity associated with negative thoughts and emotions. Unlike relaxation techniques that involve music, musical improvisation includes listening and creating music in a heightened state of awareness, listening and spontaneous interaction with music, and involves decreased activity in brain structures associated with negative thoughts and emotions. Improvisation experiences allow improvisers to predict and to anticipate what might occur in the moment, actively engaging in any unexpected “stress” that may come their way. (Palatini et al., 1998 Jul) To create and to improvise, musicians move past the anxiety of failure of being able to interact with unexpected stimuli, and we postulated that with a similar educational approach, patients may be able to better manage their labile hypertension.

A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension

To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH). The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE. In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.

Abstract 17500: A Crisis of the Heart

A 59 year old female with past medical history of metastatic neuroendocrine tumor without cardiac involvement was admitted for transarterial catheter embolization (TACE) procedure of liver lesions. During the TACE procedure, she developed hypertensive urgency treated with intravenous beta blocker therapy and continuous octreotide for carcinoid reaction. The following day she developed acute pulmonary edema and labile blood pressures requiring low dose norepinephrine. Octreotide infusion was up-titrated to 500 mcg/hour with concern for carcinoid crisis. On physical exam, she was tachycardic and regular without notable murmurs or extra cardiac sounds, no elevated jugular venous distension, and no lower extremity edema. She had bilateral crackles on pulmonary exam and was diaphoretic and delirious. There were sub-millimeter lateral ST- segment elevations on her electrocardiogram but her troponin levels were elevated to 14 ng/dL. Point of care cardiac ultrasound demonstrated severely impaired left ventricular systolic function without regional wall motion abnormalities. Coronary angiogram revealed diffuse coronary vasospasm and elevated left ventricular end-diastolic pressure. On right heart catheterization, she had elevated filling pressures, pulmonary arterial oxygen saturation of 25%, and cardiac index of 1.42 L/min/m2. Our patient was diagnosed with cardiogenic shock secondary to octreotide mediated coronary vasospasm causing diffuse myocardial injury. Continued multidisciplinary discussions were needed to determine appropriate vasopressor and inotropic agent use to support cardiac function without triggering further hormonal dysregulation during carcinoid crisis. Her cardiac function eventually improved with left ventricular Impella support and gradual down-titration of octreotide dose. Norepinephrine, epinephrine, and phenylephrine were avoided in favor of vasopressin, and dobutamine was switched to milrinone to prevent further sympathetic activation. She was able to wean off Impella and pressor support and had improvement of her left ventricular function on repeat echocardiography one month later. She has not had recurrence of heart failure symptoms and continues to follow up with oncology via tele-visits.

Abstract 12938: An Unusual Case of Malignant Hypertension and Stress Cardiomyopathy Originating From the Urinary Bladder

A 39-year-old man with hypertension presented for an elective knee surgery. Within 15 minutes of induction of anesthesia, he developed malignant hypertension and acute hypoxia. Surgery wasaborted and he was subsequently transferred to our facility. High-sensitivity troponin was elevated. Chest X-ray demonstrated bilateral hilar opacities, consistent with pulmonary edema.Transthoracic echocardiography demonstrated mildly depressed left ventricular function with hypokinesis of the septum and inferolateral wall. Cardiac catheterization showed normal filling pressures and no coronary artery disease. Initial work up for secondary hypertension, including Duplex Doppler ultrasonography of renal artery and serum aldosterone level were unrevealing. Because of high index of suspicion, additional workup was pursued for adrenal hypertension. Hewas found to have severely elevated plasma normetanephrine level (36 nmol/L) and 24-hrurinary normetanephrine of 8,990 mcg while plasma metanephrine and epinephrine levels were within normal limits. Computed tomography of abdomen showed no adrenal mass but revealed contrast-enhancing mass in the bladder wall with surrounding lymphadenopathy, suggestive of metastatic paraganglioma. He underwent genetic evaluation which identified a heterozy gouspathogenic variant in the succinate dehydrogenase subunit B (SDHB) gene. He was treated withalpha- and beta-blockade and underwent partial cystectomy with lymph node dissection. Follow-up Gallium-68 DOTATATE scan was positive for uptake in several lymph nodes withsubsequent successful lymph node dissection. He is now asymptomatic. Discussion: This case illustrates the importance of a complete history in the evaluation of hypertension inyoung people. The presence of labile hypertension and acute cardiomyopathy which isprecipitated by stress or noncardiac surgery should prompt an evaluation of pheochromocytoma.The isolated elevation in plasma and urinary normetanephrine with normal plasma/urinarymetanephrine level is consistent with extra-adrenal production of catecholamines, which iscommon in the presence of SDHB mutation.

Chronic pain in children with oncopathology: ways of solving the problem

Objective. Pain is one of the complications in children with acute leukemia, which requires timely and effective analgesic therapy. We decided to determine the effectiveness and tolerability of analgesia in children with acute leukemia depending on the method of analgesia.&#x0D; Materials and methods. There was a survey of 60 children (3 groups of 20 children each). In group 1 conducted morphine analgesia, in group 2 – morphine in combination with gabapentin, in group 3 – paracetamol with gabapentin. Investigated performance of the cardiovascular system, gastrointestinal tract. The questionnaire “Feeling. Activity. Mood” was used to determine psycho-emotional disorders, visual-analogue scale and face scale was used to determine the intensity of pain.&#x0D; Results and discussion. In group 1, all children had dysfunction of the gastrointestinal tract and lability of blood pressure. In group 2, only 11 children had disorders of the digestive system, there were no cardiovascular complications. In group 3, only 5 children had lability of blood pressure. Averages activity in all three groups are almost identical and reflect favorable condition. The average health indicators are the lowest in the 1st group – 3.78±0.11 (p&lt;0.05), in the 2nd group – 3.84±0.06 (p&lt;0.05), and in the 3rd group – 4.01±0.09 (p&lt;0.05). Mood indicators in groups 2 and 3 are almost the same – 4.04±0.12 (p&lt;0.05) and 4.42±0.04 (p&lt;0.05), respectively, and the worst in 1st group – 3.94±0.07 (p&lt;0.05). The pain intensity according to visual-analogue scale on day 30 was in the 1st group ≤5 points, in the 2nd group ≤4 points and in the 3rd group ≤3 points. On day 78, the intensity of pain in group 1 was ≤5 points, in 2nd and 3rd groups – ≤3 points. Severe asthenia was observed only in 6 children (10 %) of the group 1, moderate asthenia – in 45 children (75 %) and the fatigue reaction – in 9 children (25 %).&#x0D; Conclusions. The best tolerability of analgesia in children, receiving paracetamol with gabapentin, the worst – in children receiving only opiates. Children who combined opiates with gabapentin had better health and significantly fewer complications than children who received opiates alone.

Blood pressure lability is associated with subcortical atrophy in early Parkinson's disease

Background: Cardiovascular dysautonomia is commonly found in PD, even before the diagnosis. Increased cerebral white matter intensities relevant to blood pressure lability were observed in previous studies. However, cardiovascular dysautonomia such as orthostatic hypotension (OH) and blood pressure (BP) variability has seldom been associated with cerebral deep gray matter structures in early PD. The aim of this study was to evaluate the associations between blood pressure lability and subcortical structures.

S2567 Hepatic Manifestations of Disseminated Histoplasmosis

INTRODUCTION: Disseminated histoplasmosis is a fungal infection that can be severe in gastroenterology patients with weakened immune systems such as solid organ transplant patients and those on immunosuppression – corticosteroids or TNF-inhibitors. Treatment includes anti-fungal medication such as Itraconazole and amphotericin B. Here we present two patients with history of liver disease and disseminated histoplasmosis. CASE DESCRIPTION/METHODS: We have a 59-year-old male who presented with donor-derived disseminated histoplasmosis one month following simultaneous liver kidney transplant, after BAL cultures confirmed that donor’s lungs were positive for histoplasmosis. Patient had urine histoplasma antigen (Histo Ag) greater than 19 ng/mL. He was started on Itraconazole, recommended for a 12-month course; however, patient discontinued use after 4 months, at which point Histo Ag was 10.6 ng/mL. Two months after discontinuation, patient presented with a neck mass, positive for fungal yeast consistent with histoplasmosis. He was started on Isavuconazole. Histo Ag levels are decreasing steadily over 2.5-year period from 5.4 to less than 0.4 ng/mL. We have a 42-year-old male with history of ulcerative colitis (UC) who presented with disseminated histoplasmosis. For UC management, patient had received three infusions of Entyvio prior to discontinuation due to pruritus and blood pressure lability; and was subsequently started on methylprednisolone. After two weeks, patient presented with disseminated histoplasmosis, confirmed with liver biopsy showing lobular granulomas with intracellular budding yeast and Histo Ag of 5.9 ng/mL. He had positive serum 1,3-beta-d glucan and elevated alkaline phosphatase. Methylprednisolone was discontinued. Following 8 infusions of amphotericin B, he was transitioned to Itraconazole for 12 months. DISCUSSION: There is an increased risk of disseminated histoplasmosis in immunosuppressed patients – following a solid organ transplant or with corticosteroid medication, as seen in our two patients. Such patients are more susceptible to developing progressive forms of the infection, which can be severe and sometimes fatal if not treated. As these cases show, it is important to detect disseminated histoplasmosis early and to continue to monitor Histo Ag levels throughout treatment course to ensure infection is not progressing. Further studies may show how disseminated histoplasmosis can progress based on cause of infection and treatment course.

Abstract P181: Musical Improvisation In Labile Hypertension

Background: Patients with labile hypertension experience transient but substantial increases in blood pressure, usually surrounding episodes of emotional distress and anxiety. Inability to express negative emotions may also play a substantial role. Most psychological interventions are aimed at blunting the stress response to anxiety or distress (i.e. mindfulness techniques). We hypothesize that musical improvisation therapy may blunt emotional response but may also decrease brain activity associated with negative thinking and emotions. Materials/methods: We surveyed 20 individuals with labile hypertension. Subjects completed a pre- and post-intervention and also had their blood pressure checked pre- and post-intervention. The intervention involved subjects actively engaging in a roughly one hour-long interactive musical improvisation simulation delivered via electronic media. Results: Nine out of 20 participants had a positive responsive to the exercise (SBP drop &gt; 10mmHg). Fifty-eight percent of all subjects and 63% of positive responders felt the exercise made them feel less self-conscious and self-critical. Sixty-seven percent of all subjects who endorsed struggling with mindfulness felt that this exercise would help them practice mindfulness more regularly. Discussion: One of the most difficult judgments to make is whether a patient’s office hypertension is due to isolated “white coat spike” or whether the elevated readings represent a potentially physically damaging recurring hyperadrenergic response to life stressors. Most efforts of combating labile hypertension, such as yoga and relaxation techniques, aim at blunting the stress response, but results are variable. Yet, labile hypertension may well additionally be linked to inhibition of the expression of negative emotions. The neural complexes involved in musical improvisation appear to not only increase pleasure but also decrease activity in brain structures associated with negative thoughts and emotions. Conclusion: Our data supports the conclusion that musical improvising has the potential to both blunt emotional distress (i.e. through mindfulness) and decrease negative thoughts and emotions. Both pathways can potentially lessen the impact of labile hypertension.

Cardiovascular evaluation of female rats with 6-OHDA-induced parkinsonism: Possible protection by ovarian hormones and participation of nitric oxide

AimsParkinson's disease (PD) is a neurological disorder caused by environmental and genetic factors, characterized by the death of dopaminergic neurons of the substantia nigra pars compacta (SNpc), leading to a decrease of dopamine in the striatum. In addition to motor symptoms, PD has several abnormalities, among which are cardiovascular changes, such as orthostatic and postprandial hypotension, and blood pressure lability. Studies demonstrate gender differences in PD pathogenesis, indicating that female hormones have a protective role against disease development. However, no studies examining cardiovascular changes in a female rat model of parkinsonism exist. Main methodsWistar female rats were subjected to ovariectomy (OVX) or sham surgery. After seven days, these animals were subjected to bilateral infusion of 6-hydroxydopamine (6-OHDA) or vehicle solution in their SNpc. On the 14th experimental day, a femoral artery catheterization was performed to record cardiovascular parameters after 24 h in conscious state. Analyses of cardiovascular variability and spontaneous baroreflex were performed. The nitrite (NO) concentration in the heart, thoracic aorta, abdominal aorta, and plasma was measured. Key findingsThe sham-6-OHDA group had no decrease in the mean arterial pressure compared to sham-saline group, whereas the OVX-6-OHDA group presented a baseline decrease in comparison to sham-6-OHDA. The OVX-6-OHDA group showed an NO increase in the heart and abdominal aorta, whereas the sham-6-OHDA group did not. The very low frequency variability component decreased in the sham-6-OHDA but not in the OVX-6-OHDA group. SignificanceWe suggest a cardiovascular protection by ovarian hormones in PD with a possible NO involvement.

Minimising haemodynamic lability during changeover of syringes infusing norepinephrine in adult critical care patients: a multicentre randomised controlled trial

BackgroundArterial pressure lability is common during the process of replacing syringes used for norepinephrine infusions in critically ill patients. It is unclear if there is an optimal approach to minimise arterial pressure instability during this procedures. We investigated whether ‘double pumping’ changeover (DPC) or automated changeover (AC) reduced blood pressure lability in critically ill adults compared with quick syringe changeover (QC). MethodsPatients requiring a norepinephrine infusion syringe change were randomised in a non-blinded trial undertaken in six ICUs. Randomisation was minimised by norepinephrine flow rate at inclusion and centre. The primary outcome was the frequency of increased/decreased mean arterial pressure (defined by </>15 mm Hg from baseline measurements) within 15 min of switching the syringe compared with QC. ResultsPatients (mean age: 64 (range:18–88)) yr were randomly assigned to QC (n=95), DPC (n=95), or AC (n=96). Increased MAP was the commonest consequence of syringe changeovers. MAP variability was most frequent after DPC (89/224 changeovers; 39.7%) compared with 57/223 (25.6%) changeovers after quick syringe switch and 46/181 (25.4%) in patients randomised to receive automated changeover (P=0.001). Fewer events occurred with QC compared with DPC (P=0.002). Sensitivity analysis based on mixed models showed that performing several changeovers on a single patient had no impact. Both type of changeover and norepinephrine dose before syringe changeover were independently associated with MAP variations >15 mm Hg. ConclusionsQuick changeover of norepinephrine syringes was associated with less blood pressure lability compared with DPC. The prevalence of MAP variations was the same between AC and QC. Clinical trial registrationNCT02304939.

Blood pressure lability is associated with subcortical atrophy in early Parkinson's disease.

Increased cerebral white matter intensities associated with blood pressure (BP) lability were reported in patients with Parkinson's disease. However, this type of cardiovascular dysautonomia has seldom been associated with disruptions in deep gray matter structures in Parkinson's disease. In the present study, the associations between BP lability and subcortical deep gray matter structures in early Parkinson's disease were evaluated. The present study included 98 early nondemented Parkinson's disease patients. Supine and orthostatic BPs were measured using head-up tilt tests. BP variabilities, measured as standard deviations of 24-h daytime and nighttime BPs, were assessed using 24-h ambulatory BP monitoring. Every patient underwent brain MRI and measurement of deep gray matter volumes. The associations between BP lability and deep gray matter structures were analyzed. Parkinson's disease patients with orthostatic hypotension had smaller volumes of striatum, particularly caudate, than patients without OH after adjusting for covariates of age, sex, disease duration, and Mini-Mental Status Examination score. Nocturnal BP variability was inversely associated with thalamus, hippocampus, and globus pallidus volumes. The results from the present study showed that BP lability was adversely associated with structural changes in early Parkinson's disease. Different forms of BP fluctuations influenced distinct deep gray matter structures.