Lower Arterial Pressure Research Articles

P4559Assess of angiotensin receptor blockers therapy associated to mineralocorticoid receptor antagonists or to calcium channel blockers plus hydrochlorothiazide according central haemodynamic parameters

Abstract Background Protective effect of Angiotensin-II Receptor Blockers (ARBs) on major cardiovascular events might be partly independent of the degree of blood pressure reduction. Calcium channel blockers (CCBs), lower arterial pressure by decreasing total peripheral resistance without reducing cardiac output. Hydrochlorothiazide (Hctz) is one of the most commonly prescribed antihypertensive drugs worldwide, but associated with more frequent adverse effects, such as hypokalaemia, hyponatraemia, hyperuricaemia and may increase the glycaemia, It sensitizes the endothelium to the action of angiotensin II, might act on the aldosterone release. The phenomenon of “aldosterone escape” occurs even in the presence of combination therapy with ARBs. The harmful effects of aldosterone are innumerable: induced cardiac and renal fibrosis, sodium and water retention, inflammation, oxidative stress, arrhythmias, glucose intolerance, insulin resistance, among others, that are involved in arterial and myocardium remodelling. Mineralocorticoid Receptor Antagonists (MRAs) therapy improve diastolic function, decrease plasma volume and vascular/myocardial fibrosis. Purpose This study aimed to assess the responses of two groups of therapy such as ARBs associated to MRAs or to CCBs+Hctz according to central haemodynamic parameters (CHPs) in hypertensive patients, both genders, with normal kidney function. Methods For this cross-sectional retrospective study, data were collected from 391 hypertensive patients who were assisted in the hypertension centre. Female/male 239/152, each gender divided into two groups of therapy: ARB+MRA/ARB+CCB+Hctz. Female 210/29 (average age 57/70) and male 125/27 (average age 55/61). The CHPs were measured with a SphygmoCor System PVX (AtCor-Medical Australia), a validated device employing the high-fidelity technique of applanation tonometry according to established protocols. Also, the difference of Augmentation Index (Diff-AIx) between the observed values and the expected levels was assessed according to normal range by age. No patients had cardiovascular, endocrine, renal and metabolic decompensated diseases. Results After measuring the body mass index, waist circumference and heart rate, the two therapy groups were confronted, both genders, had not found the statistically significant difference. The results of CHPs (Central Aortic Pressure, End-Systolic Pressure, Mean Arterial Pressure, Pulse Pressure, Augmentation Pressure), systolic and diastolic blood pressure during association of ARBs+MRAs therapy compared to ARBs+CCBs+Hctz, both genders, showed the lowest values with a highly statistically significant difference. In the female/male the Diff-AIx was found p=0.05/0.04. Conclusion These findings suggest that ARBs+MRAs treatment reaches the best haemodynamic conditions because improve the levels of CHPs and arterial stiffness (Diff-AIx) giving an adequate reduction of the stress to the arterial-ventricular coupling.

P1651Pulmonary artery pressure could predict closed aortic valve in patients managed by veno-arterial extracorporeal membrane oxygenation

Abstract Background Although veno-arterial extracorporeal oxygenation (VA-ECMO) is widely used as mechanical circulatory support, it reduces native left ventricular (LV) stroke volume through the cardiac preload decrease and afterload increase. Therefore some patients with severe cardiac dysfunction present persistently closed aortic valve (AV). The closed AV is considered to increase the risk of pulmonary edema or intracardiac thrombosis. However, little is known about the variables that contribute to persistently closed AV under the management of VA-ECMO. Purpose We investigated the factors that could predict persistently closed AV at the time of VA-ECMO initiation. Methods This was a retrospective chart review. We investigated the patients who received the management of VA-ECMO due to cardiogenic shock from April 2011 to December 2018, and analyzed 18 patients (43±16 years, 50% female) who presented closed AV immediately after the introduction of VA-ECMO. We obtained the hemodynamic data at the time of VA-ECMO initiation (baseline) and 24h after. The patients who presented persistently closed AV during 24h were defined as Close-group (n=8). The patients whose AV was opened within 24h were defined as Open-group (n=10). The status of AV was investigated by the echocardiogram. Results All patients were managed by concomitant use of intra-aortic balloon pumping. The etiologies were myocarditis (56%), cardiomyopathy (33%), and acute myocardial infarction (11%). Nine patients experienced in-hospital death (6 were Close-group and 3 were Open-group, p=0.15). At baseline, there were no significant differences between mean arterial blood pressure (mABP) (p=0.07), central venous pressure (CVP) (p=0.71), and left ventricular ejection fraction (p=0.44). However, Close-group had significantly lower mean pulmonary artery pressure (MPAP) and pulmonary artery pulse pressure (PAPP) than Open-group (Close-group versus Open-group; MPAP, 15±6 mmHg versus 27±11 mmHg, p=0.01; PAPP, 3±2 mmHg versus 8±3 mmHg, p=0.01). Logistic regression analyses revealed the lower MPAP and PAPP had the predictive value of closed AV within 24-h after VA-ECMO initiation [MPAP: odds ratio (OR) 0.78, 95% confidence interval (95% CI) 0.62–0.99, P=0.003; PAPP: OR 0.18, 95% CI 0.02–1.13, P<0.001]. In the following 24h, no significant change was found in MPAP and PAPP. Conclusion At the time of VA-ECMO initiation, lower MPAP and PAPP had the predictive value for persistently closed AV. LV preload derived from right heart function would have major impact on AV status.

P1856Percutaneous mitral edge-to-edge valvuloplasty in end-stage heart failure as a bridge to heart transplant: a case series from a single tertiary referral center

Abstract Background Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking. Purpose Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF. Methods Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”. Results Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause. Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons. Figure 1 Conclusions Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy. Acknowledgement/Funding None

56The SGLT2 inhibitor empagliflozin reduces mortality in experimental pulmonary hypertension

Abstract Introduction Empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, enhances urinary glucose excretion and profoundly reduces hospitalisation for heart failure and cardiovascular mortality in individuals with type 2 diabetes. While empagliflozin has been reported to reduce blood pressure, its effect on pulmonary arterial hypertension (PAH) is unknown. PAH is a serious and progressive disease that is characterised by pulmonary artery vasoconstriction, vascular remodelling, right ventricular hypertrophy, and ultimately heart failure. Purpose To investigate the impact of empagliflozin on PAH-associated mortality and the progression as well as reversal of PAH in monocrotaline (MCT)-treated Sprague-Dawley rats. Methods A total of 66 male rats (220–250 g) were randomly assigned to one of three studies. PAH was induced with a single intraperitoneal injection of MCT on day 0 and empagliflozin (10 mg/kg) was administered daily by oral gavage. Survival study: PAH was induced with 60 mg/kg MCT. Starting on day 1, rats were treated with empagliflozin (n=8) or vehicle (n=8) for 28 days and monitored for up to 45 days post-MCT injection. Prevention study: Rats were administered 60 mg/kg MCT and treated with empagliflozin (n=12) or vehicle (n=12) for 20 days from day 1 onwards. Reversal study: 21 days after being injected with 40 mg/kg MCT, rats were given empagliflozin (n=8) or vehicle (n=8) for 14 days. At the end of the treatment window, rats in the latter two studies underwent haemodynamic assessments before their tissues were harvested for histological review. Results Mortality rates between the two groups were significantly different (median survival 24 vs 33 days for vehicle vs empagliflozin; p<0.05). Compared to the MCT-vehicle-treated rats, the MCT-empagliflozin group had significantly lower mean pulmonary artery pressure (77.4±8.6 vs 51.0±4.9 mmHg [Prevention study]; 56.0±4.3 vs 43.0±3.4 mmHg [Reversal study]); higher pulmonary acceleration time (21.0±0.8 vs 27.4±1.4 ms [Prevention study] and 27.1±1.0 vs 33.4±1.3 ms [Reversal study]); and less right ventricular hypertrophy (0.52±0.01 vs 0.41±0.04 [Prevention study]). Histological assessments revealed significantly less medial wall thickening (50.8±2.2 vs 44.7±1.1 mm) and muscularisation (53.2±1.3 vs 43.6±2.1 mm) in pulmonary arterioles from the empagliflozin- vs vehicle-treated rats (p<0.001 for both). Conclusion This is the first study demonstrating that SGLT2 inhibition with empagliflozin lowers mortality in experimental pulmonary hypertension in part via reduced pulmonary vascular remodelling. Acknowledgement/Funding This study was supported by grants from the Canadian Institutes of Health Research.

Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation

The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ± 241 vs. 1273 ± 359 mm, P = 0.02 and 125 ± 11 vs. 117 ± 16%, P = 0.02), a smaller left atrial volume (54.1 ± 26 vs. 71.5 ± 20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ± 11 vs. 49 ± 12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ± 17 vs. 141 ± 23%, P = 0.014). Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure.

THE SGLT2 INHIBITOR EMPAGLIFLOZIN REDUCES MORTALITY IN EXPERIMENTAL PULMONARY HYPERTENSION

Empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, enhances urinary glucose excretion and profoundly reduces hospitalization for heart failure and cardiovascular mortality in individuals with type 2 diabetes. While empagliflozin has been reported to reduce blood pressure, its effect on pulmonary hypertension (PH) is unknown. PH is a severe and progressive disease that is characterized by pulmonary artery vasoconstriction, vascular remodeling, right ventricular hypertrophy, and ultimately heart failure. This study investigated the impact of empagliflozin on PH-associated mortality and the progression as well as the reversal of PH in monocrotaline (MCT)-treated Sprague-Dawley rats. A total of 83 male Sprague-Dawley rats (220-250 g) were randomly assigned to one of three studies. PH was induced with a single intraperitoneal injection of MCT on day 0 and empagliflozin (10 mg/kg) or vehicle (0.5% hydroxyethyl cellulose) was administered daily by oral gavage. Some rats were injected with an equal volume of saline in place of MCT. Survival study: PH was induced with 60 mg/kg MCT. Starting on day 1, rats were treated with empagliflozin (n=16) or vehicle (n=15) for 28 days and monitored for up to 45 days of post-MCT injection. Prevention study: Rats were administered 60 mg/kg MCT and treated with empagliflozin (n=12) or vehicle (n=12) for 20 days from day 1 onwards. Reversal study: 21 days after being injected with 40 mg/kg MCT, rats were given empagliflozin (n=8) or vehicle (n=8) for 14 days. At the end of the treatment window, rats in the latter two studies underwent hemodynamic assessments before key tissues were harvested for molecular and histological review. Compared to its vehicle, empagliflozin significantly improved survivability in rats with MCT-induced PAH (Figure). Furthermore, the MCT-empagliflozin group, relative to the MCT-vehicle-treated rats, had significantly lower mean pulmonary artery pressure, right ventricular systolic pressure, higher pulmonary acceleration time in both the Prevention and Reversal study groups. The decreased afterload resulted in less right ventricular hypertrophy in the empagliflozin-treated rats. Histological assessments of lung tissues revealed significantly less medial wall thickening and muscularization in pulmonary arterioles from empagliflozin-treated vs. vehicle-treated rats (Table). This is the first study demonstrating that SGLT2 inhibition with empagliflozin lowers mortality in experimental pulmonary hypertension in part via reduced pulmonary vascular remodeling.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Comparison of blood pressure measurements in the upper and lower extremities versus arterial blood pressure readings in children under general anesthesia.

PurposeTo compare invasive blood pressure (IBP) readings obtained from an arterial cannula with non-invasive blood pressure (NIBP) measurements from oscillometric cuffs on the upper and lower extremities of infants and children under general anesthesia.Patients and methodsPatients under 10 years of age were enrolled in our study if they were to receive general anesthesia with planned placement of a radial arterial cannula. At 5 mins intervals, IBP was measured using a fluid-coupled pressure transducer and NIBP was measured with two oscillometers with appropriately sized cuffs placed on the upper arm and lower leg, for 10 readings per patient.ResultsThe study enrolled 18 boys and 12 girls, ranging in age from 0 to 8 years. Across 300 data points, the absolute difference between the arm and invasive mean arterial pressure (MAP) measurements was 7±7 mmHg (range: 0–52 mmHg). The absolute difference between the leg and invasive MAP measurements was 8±8 mmHg (range: 0–52 mmHg). Although both non-invasive measurement sites demonstrated frequent deviation from invasive measurement, large deviations were more common when BP was measured at the leg (81 of 298 observations (27%) deviating by >10 mmHg) compared to the arm (60 of 300 observations (20%) deviating by >10 mmHg).ConclusionThe frequency of clinically significant NIBP deviation in children under general anesthesia supports the importance of IBP monitoring when hemodynamic fluctuations are likely and would be particularly detrimental. NIBP measured at the lower leg is more likely to result in clinically significant deviation from invasively measured MAP than NIBP values obtained from an upper arm.

Effect of SGLT2 Inhibitors on the Sympathetic Nervous System and Blood Pressure.

Hyperactivity of sympathetic nervous system (SNS) plays a role in the development of arterial hypertension and heart failure, two co-morbidities frequently associated with type 2 diabetes (T2DM). This review aims at analyzing the effects of sodium-glucose cotransporter type 2 inhibitors (SGLT2is) on blood pressure and more especially on SNS activity in patients with T2DM. By enhancing glucosuria, natriuresis, and osmotic diuresis, SGLT2is improve glucose control, promote weight loss, lower arterial blood pressure, and reduce the risk of major cardiovascular events and hospitalization for heart failure. No rise of heart rate is detected despite reductions in blood pressure and plasma volume, which may suggest a dampening of SNS activity. Indeed, increasing experimental and clinical data demonstrated a reduction in SNS activity, including in key target organs such as the heart and the kidneys. Of potential major interest, a better understanding of the mechanisms linking SGLT2 and SNS deserves further investigation.

Therapeutic effects of soluble guanylate cyclase stimulation on pulmonary hemodynamics and emphysema development in guinea pigs chronically exposed to cigarette smoke.

We have analyzed the effect of the soluble guanylate cyclase (sGC) stimulator BAY 41-2272 in a therapeutic intervention in guinea pigs chronically exposed to cigarette smoke (CS). The effects of sGC stimulation on respiratory function, pulmonary hemodynamics, airspace size, vessel remodeling, and inflammatory cell recruitment to the lungs were evaluated in animals that had been exposed to CS for 3 mo. CS exposure was continued for an additional 3 mo in half of the animals and withdrawn in the other half. Animals that stopped CS exposure had slightly lower pulmonary artery pressure (PAP) and right ventricle (RV) hypertrophy than those who continued CS exposure, but they did not recover from the emphysema and the inflammatory cell infiltrate. Conversely, oral BAY 41-2272 administration stopped progression or even reversed the CS-induced emphysema in both current and former smokers, respectively. Furthermore, BAY 41-2272 produced a reduction in the RV hypertrophy, which correlated with a decrease in the PAP values. By contrast, the degree of vessel remodeling induced by CS remained unchanged in the treated animals. Functional network analysis suggested perforin/granzyme pathway downregulation as an action mechanism capable of stopping the progression of emphysema after sGC stimulation. The pathway analysis also showed normalization of the expression of cGMP-dependent serine/kinases. In conclusion, in guinea pigs chronically exposed to CS, sGC stimulation exerts beneficial effects on the lung parenchyma and the pulmonary vasculature, suggesting that sGC stimulators might be a potential alternative for chronic obstructive pulmonary disease treatment that deserves further evaluation.

On detection of spontaneous pulse by photoplethysmography in cardiopulmonary resuscitation

ObjectiveThis work investigates the potential of photoplethysmography (PPG) to detect a spontaneous pulse from the finger, nose or ear in order to support pulse checks during cardiopulmonary resuscitation (CPR). MethodsIn a prospective single-center cross-sectional study, PPG signals were acquired from cardiac arrest victims who underwent CPR. The PPG signals were analyzed and compared to arterial blood pressure (ABP) signals as a reference during three distranaisco; Date: 2/2/2020; Time:18:44:23inct phases of CPR: compression pauses, on-going compressions and at very low arterial blood pressure. Data analysis was based on a qualitative subjective visual description of similarities of the frequency content of PPG and ABP waveform. ResultsIn 9 patients PPG waveforms corresponded to ABP waveforms during normal blood pressures. During ABP in the clinically challenging range of 60 to 90 mmHg and during chest compressions and pauses, PPG continued to resemble ABP, as both signals showed similar frequency components as a result of chest compressions as well as cardiac activity. Altogether 1199 s of PPG data in compression pauses were expected to show a spontaneous pulse, of which 732 s (61%) of data were artifact-free and showed the spontaneous pulse as visible in the ABP. ConclusionsPPG signals at all investigated sites can indicate pulse presence at the moment the heart resumes beating as verified via the ABP signal. Therefore, PPG may provide decision support during CPR, especially related to preventing and shortening interruptions for unnecessary pulse checks. This could have impact on CPR outcome and should further be investigated.

Therapeutic Monoclonal Antibody Antagonizing Endothelin Receptor A for Pulmonary Arterial Hypertension.

Endothelin receptor A (ETA) is a G protein-coupled receptor and a major therapeutic target for pulmonary arterial hypertension (PAH). We took a novel approach and developed an antagonistic monoclonal antibody, getagozumab, specifically against ETA. Getagozumab displayed a K d value of 8.7 nM and an IC50 value of 37.9 nM in the cell-based assays. Getagozumab could significantly lower pulmonary arterial pressure in both hypoxia-induced and monocrotaline (MCT)-induced PAH monkey models and further attenuate the pulmonary arterial and right ventricular hypertrophy in MCT-induced PAH monkeys. The preclinical studies demonstrated that getagozumab is safe, long lasting, and efficacious. Getagozumab may provide a new and effective treatment for PAH patients.

Comparison of Ketamine-Propofol and Ketamine-Thiopental on Bispectral Index Values during Monitored Anesthesia Care (MAC) in Minor Traumatic Orthopedic Surgery; A Randomized, Double-Blind, Clinical Trial.

Objective:To compare the effects of ketamine-propofol and ketamine-thiopental on bispectral index values during monitored anesthesia care in minor orthopedic surgeries.Methods:This randomized double-blind clinical trial was performed on 90 patients undergoing minor orthopedic surgeries. Participants were randomly allocated to either groups of propofol or thiopental. Bispectral index (BIS), non-invasive arterial blood pressure, SpO2, and electrocardiogram were monitored every 5 minutes. Patients in propofol group received a bolus dose of 0.5 mg/kg ketamine, plus 0.5 mg/kg propofol. In thiopental group, patients received a bolus dose of 0.5 mg/kg ketamine, plus 50-75 mg thiopental. After the surgery, recovery duration, patients’ pain score (VAS) and any intra-operative recall or awareness were recorded. Statistical analysis was performed using SPSS version 19.0 Results:BIS was lower in ketamin-propofol group (p< 0.001). Mean arterial blood pressure, heart rate and O2 saturation showed a significant difference between two groups (p< 0.001), which were lower in ketamin–propofol group. VAS score was higher in ketamin-thiopental group (p< 0.001). Both groups were similar in intra-operative recall/awareness.Conclusion:Ketamine-propofol combination deliver a better control over monitored anesthesia during surgery, providing lower BIS, higher O2 saturation and lower heart rate and arterial blood pressure in patients undergoing minor traumatic orthopedic surgeries.Clinical trial registration:IRCT6N 2016032320258

Transthoracic Pulmonary Artery Denervation for Pulmonary Arterial Hypertension.

Objective- Pulmonary arterial hypertension is characterized by progressive pulmonary vascular remodeling and persistently elevated mean pulmonary artery pressures and pulmonary vascular resistance. We aimed to investigate whether transthoracic pulmonary artery denervation (TPADN) attenuated pulmonary artery (PA) remodeling, improved right ventricular (RV) function, and affected underlying mechanisms. We also explored the distributions of sympathetic nerves (SNs) around human PAs for clinical translation. Approach and Results- We identified numerous SNs in adipose and connective tissues around the main PA trunks and bifurcations in male Sprague Dawley rats, which were verified in samples from human heart transplant patients. Pulmonary arterial hypertensive rats were randomized into TPADN and sham groups. In the TPADN group, SNs around the PA trunk and bifurcation were completely and accurately removed under direct visualization. The sham group underwent thoracotomy. Hemodynamics, RV function, and pathological changes in PA and RV tissues were measured via right heart catheterization, cardiac magnetic resonance imaging, and pathological staining, respectively. Compared with the sham group, the TPADN group had lower mean pulmonary arterial pressures, less PA and RV remodeling, and improved RV function. Furthermore, TPADN inhibited neurohormonal overactivation of the sympathetic nervous system and renin-angiotensin-aldosterone system and regulated abnormal expressions and signaling of neurohormone receptors in local tissues. Conclusions- There are numerous SNs around the rat and human main PA trunks and bifurcations. TPADN completely and accurately removed the main SNs around PAs and attenuated pulmonary arterial hypertensive progression by inhibiting excessive activation of the sympathetic nervous system and renin-angiotensin-aldosterone system neurohormone-receptor axes.

THE COMPARATIVE ASSESSMENT OF THE EFFECTIVENESS OF THE THERAPEUTIC DIET

In order to evaluate the effectiveness of therapeutic diet depending on background diet, eating behavior and occupational exposure, authors assessed food intake, nutritional adequacy of the daily food consumption in 2000 workers of similar social and economic background, working in similar conditions. Therapeutic diets No. 2 and No. 3 used at 6 metallurgical facilities were analyzed. The effectiveness of therapeutic diets developed by the authors was evaluated in workers of relevant occupations at two enterprise-based prevention and rehabilitation centers. The authors assessed the nutritional status and health of the workers with unbalanced background diet but on-the-job therapeutic diet and the workers who are on a balanced background diet and on-the-job therapeutic diet. The results show workers with unbalanced diet in terms of fat, carbohydrate, vitamin and trace element consumption as well as ill-conceived therapeutic diet to have impaired fat and carbohydrate metabolism, obesity of various degrees, premorbidities that exacerbate the effects of occupational exposure and increase the likelihood of occupational and work-related diseases. The comprehensive preventive approach, that involves reducing occupational exposure and improving the daily diet including the therapeutic diet, yields the most effective results. The use of therapeutic diets in workers maintaining a balanced background diet results in significant health gain compared to those who are treated in the same enterprise-based prevention and rehabilitation centers but whose background diet is unbalanced. They exhibit weight loss, lower arterial blood pressure, improved carbohydrate and fat metabolism, antioxidant status and functional indicators as well as reduced metal levels in biological media.

Effects of vatinoxan on cardiorespiratory function and gastrointestinal motility during constant-rate medetomidine infusion in standing horses.

SummaryBackgroundMedetomidine suppresses cardiovascular function and reduces gastrointestinal motility in horses mainly through peripheral α2‐adrenoceptors. Vatinoxan, a peripheral α2‐antagonist, has been shown experimentally to alleviate the adverse effects of some α2‐agonists in horses. However, vatinoxan has not been investigated during constant‐rate infusion (CRI) of medetomidine in standing horses.ObjectivesTo evaluate effects of vatinoxan on cardiovascular function, gastrointestinal motility and on sedation level during CRI of medetomidine.Study designExperimental, randomised, blinded, cross‐over study.MethodsSix healthy horses were given medetomidine hydrochloride, 7 μg/kg i.v., without (MED) and with (MED+V) vatinoxan hydrochloride, 140 μg/kg i.v., followed by CRI of medetomidine at 3.5 μg/kg/h for 60 min. Cardiorespiratory variables were recorded and borborygmi and sedation levels were scored for 120 min. Plasma drug concentrations were measured. The data were analysed using repeated measures ANCOVA and paired t‐tests as appropriate.ResultsInitially heart rate (HR) was significantly lower and mean arterial blood pressure (MAP) significantly higher with MED compared with MED+V. For example at 10 min HR (mean ± s.d.) was 26 ± 2 and 31 ± 5 beats/minute (P = 0.04) and MAP 129 ± 15 and 103 ± 13 mmHg (P<0.001) respectively. At 10 min, cardiac index was lower (P = 0.02) and systemic vascular resistance higher (P = 0.001) with MED than with MED+V. Borborygmi were reduced after MED; this effect was attenuated by vatinoxan (P<0.001). All horses were sedated with medetomidine, but the mean sedation scores were reduced with MED+V until 20 min (6.8 ± 0.8 and 4.5 ± 1.5 with MED and MED+V, respectively, at 10 min, P = 0.001). Plasma concentration of dexmedetomidine was significantly lower in the presence of vatinoxan (P = 0.01).Main limitationsExperimental study with healthy, unstimulated animals.ConclusionsVatinoxan administered i.v. with a loading dose of medetomidine improved cardiovascular function and gastrointestinal motility during medetomidine CRI in healthy horses. Sedation was slightly yet significantly reduced during the first 20 min.. The Summary is available in Portuguese – see Supporting Information

Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery

BackgroundA multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk. MethodsA modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines. ResultsSignificant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events. ConclusionsFuture research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.

Spontaneous bacterial peritonitis among adult patients with ascites attending Korle-Bu Teaching Hospital.

Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of ascites, mostly in patients with cirrhotic ascites and children with nephrotic syndrome. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. It is therefore important to determine the prevalence of SBP among in-patients with ascites attending our facility and to determine the clinical characteristics associated with SBP among these patients. A cross-sectional study was conducted involving 140 patients with ascites irrespective of the underlying cause from 25th March 2016 to 25th November 2016. Demographic information and clinical data were collected using a standardized questionnaire. Ascitic fluid culture, the gold standard for SBP diagnosis and ascitic fluid cell count was done. Positive ascitic fluid culture and/ or ascitic polymorpho nuclear leukocyte ≥250cells/mm3 were diagnostic for SBP. Of the 140 patients with ascites the mean age was 44.7±13.2 years. There were seventy six (76) male and sixty four (64) female patients. The prevalence of SBP was 21.43% (30/140). Majority, (41.7%) of the bacteria isolated from ascitic fluid with SBP was Escherichia coli. History of jaundice, low arterial blood pressure on admission and encephalopathy were found to be independent predictors of SBP. SBP is common among patients with ascites admitted at the Korle-Bu Teaching Hospital. Jaundice, encephalopathy and low blood pressure are highly suggestive of SBP and diagnostic paracentesis should be done immediately on admission to confirm the diagnosis. None.

Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review.

BackgroundUse of a high-flow nasal cannula (HFNC) reduced postextubation respiratory failure (PERF) and reintubation rate compared to use of a low-flow oxygen system (LFOS) in low-risk patients. However, no obvious conclusion was reached for high-risk patients. Here, we sought to present the current status of HFNC use as adjunctive oxygen therapy in a clinical setting and to elucidate the nature of the protective effect following extubation.MethodsThe medical records of 855 patients who were admitted to the intensive care unit of single university hospital during a period of 5.5 years were analyzed retrospectively, with only 118 patients ultimately included in the present research. The baseline characteristics of these patients and the occurrence of PERF and reintubation along with physiologic changes were analyzed.ResultsEighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of high-risk features including old age, neurologic disease, moderate to severe chronic obstructive pulmonary disease, a long duration of mechanical ventilation, low baseline arterial partial pressure of oxygen to fraction of inspired oxygen ratio, and a high baseline alveolar–arterial oxygen difference. The reintubation rate at 72 hours after extubation was not different (9.5% vs. 8.8%; P=1.000). Hypoxic respiratory failure was slightly higher in the nonreintubation group than in the reintubation group (31.9% vs. 6.7%; P=0.058). Regarding physiologic effects, heart rate was only stabilized after 24 hours of extubation in the HFNC group.ConclusionsNo difference was found in the occurrence of PERF and reintubation between both groups. It is worth noting that similar PERF and reintubation ratios were shown in the HFNC group in those with certain exacerbating risk factors versus not. Caution is needed regarding delayed reintubation in the HFNC group.

Early nasal high-flow versus Venturi mask oxygen therapy after lung resection: a randomized trial

BackgroundData on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO2). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy.MethodsIn this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO2 (PaO2/FiO2) lower than 300 mmHg) within four postoperative days.ResultsBetween September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41–3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60–3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51–3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11–4.18]). Post hoc analyses revealed that PaO2/FiO2 during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5–3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06–0.54], p = 0.002).ConclusionsWhen compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance.Trial registrationClinicalTrials.gov, NCT02544477. Registered 9 September 2015.

Vascular access outcome with a dedicated vascular team based approach

The objective of this study is to determine the impact of a dedicated vascular team in the early detection of complications and improvement of vascular access patency. A dedicated vascular access team comprised four dialysis nurses, a vascular access coordinator and led by a physician. They were assigned for the surveillance and care of all vascular accesses. The team presented problematic cases in the regular quality meeting with documentation of access blood flow, dynamic venous pressure, findings of hematoma, prolonged bleeding, swelling, low arterial pressures, steal syndrome, recirculation studies and dialysis adequacy. In case of failed recirculation or persistently elevated dynamic venous pressure, further evaluation was done either a fistulogram or review by a vascular surgeon. A total of 226 problematic vascular access cases were detected during the study (January 2014 to October 2017). The majority were in 41-70 years age group. A total of 248 referrals were given. Two hundred cases were referred for fistulogram, but it was performed in 188 patients. Vascular access stenosis was detected in 153 patients (81.3%) and angioplasty was performed in 137 (89.5%) of these patients. Fifteen (9.8%) patients were managed conservatively and one patient refused angioplasty. The 15 cases managed conservatively continued to work normally. One patient who refused to angioplasty later clotted his fistula during the follow-up period. Out of 41 cases who were totally noncompliant to referral, nine (22%) clotted their fistula during the follow-up period. In 12 cases in whom fistulogram was requested, but the request was declined by the primary hospital, five patients (41.6%) clotted their fistulas. Subgroup analysis showed that in patients who had both failed recirculation and high venous pressure, the prevalence of stenosis was 90% and angioplasty was performed in 94.4%. In patients who had failed recirculation and low arterial pressure, stenosis was detected in 85.7% and angioplasty was performed in 100% of cases. A dedicated vascular team approach for the care of dialysis vascular access helps in early identification of complications and improve vascular access outcome.