mmHg Increase Research Articles

Abstract P394: Initial Antihypertensive Prescribing in Relation to Blood Pressure Among Medicaid and Medicare Recipients

Introduction: Early treatment for hypertension (HTN) portends better outcomes. However, few real-world studies have assessed initial antiHTN regimens and how they differ by baseline blood pressure (BP). We sought to compare initial treatment patterns, stratified by BP, between Medicaid and Medicare recipients. Methods: We performed a cross-sectional study of adults with newly-treated HTN in the One Florida+ Consortium(2012-2020) who had linked claims-EHR data from the treatment initiation visit. Eligible patients were Floridians with Medicaid or Medicare aged ≥18 years, with diagnosed HTN, who filled ≥1 first-line antiHTN class with no evidence of anti HTN fills during the year prior (in which continuous insurance enrollment was required). Baseline BP was categorized per current HTN guidelines, and logistic regression was used to estimate age-adjusted odds of combination vs. monotherapy, per 10 mmHg increase in systolic BP (SBP) or diastolic BP (DBP). Results: We included 2,902 patients (47% Medicaid, 53% Medicare); mean age was 44 (Medicaid) and 67 yrs(Medicare); 60% (64% and 56%, respectively) were women and 42% (57% and 29%, respectively) were Black. Initial antiHTN classes were similar comparing cohorts: ACEI, ARB and thiazide initiation varied little by BP category, in contrast to CCBs and β-blockers (Figure, panels A-B). In age-adjusted analyses, use of initial combination therapy was 40% more likely (OR, 1.40; 95% CI, 1.11, 1.76) among Medicare recipients and inversely related to BP category (panels C-D) among Medicare patients, in which each 10mmHg greater SBP (OR, 0.93; 95% CI, 0.88, 0.97) and DBP (OR 0.82; 95% CI, 0.75, 0.90) had lower odds of combination therapy. Among Medicaid recipients, only SBP associated with combination therapy (OR1.11; 95% CI, 1.03, 1.20). Conclusions: We observed similar initial class patterns among Medicaid & Medicare recipients across baseline BP, but differential use of combination therapy was less likely at higher baseline BP in Medicare recipients, which contrasts current guidance.

Associations between air pollutants and blood pressure in an ethnically diverse cohort of adolescents in London, England.

Longitudinal evidence on the association between air pollution and blood pressure (BP) in adolescence is scarce. We explored this association in an ethnically diverse cohort of schoolchildren. Sex-stratified, linear random-effects modelling was used to examine how modelled residential exposure to annual average nitrogen dioxide (NO2), particulate matter (PM2.5, PM10) and ozone (O3), measures in μg/m3, associated with blood pressure. Estimates were based on 3,284 adolescents; 80% from ethnic minority groups, recruited from 51 schools, and followed up from 11-13 to 14-16 years old. Ethnic minorities were exposed to higher modelled annual average concentrations of pollution at residential postcode level than their White UK peers. A two-pollutant model (NO2 & PM2.5), adjusted for ethnicity, age, anthropometry, and pubertal status, highlighted associations with systolic, but not diastolic BP. A μg/m3 increase in NO2 was associated with a 0.30 mmHg (95% CI 0.18 to 0.40) decrease in systolic BP for girls and 0.19 mmHg (95% CI 0.07 to 0.31) decrease in systolic BP for boys. In contrast, a 1 μg/m3 increase in PM2.5 was associated with 1.34 mmHg (95% CI 0.85 to 1.82) increase in systolic BP for girls and 0.57 mmHg (95% CI 0.04 to 1.03) increase in systolic BP for boys. Associations did not vary by ethnicity, body size or socio-economic advantage. Associations were robust to adjustments for noise levels and lung function at 11-13 years. In summary, higher ambient levels of NO2 were associated with lower and PM2.5 with higher systolic BP across adolescence, with stronger associations for girls.

Pulmonary Hypertension and Operative Risk in Mitral Valve and Coronary Surgery

IntroductionPulmonary hypertension (PHT) is a known risk factor for coronary artery bypass grafting (CABG), though less well understood for valve operations. We hypothesized PHT is associated with lower risk during mitral valve operations compared to CABG. MethodsPatients undergoing isolated mitral valve or CABG operations (2011-2019) in a regional Society of Thoracic Surgeons (STS) database were stratified by pulmonary artery systolic pressure (PASP). The association of PASP by procedure type was assessed by hierarchical regression modeling, adjusting for STS predicted risk scores. ResultsOf the 2542 mitral and 11,059 CABG patients, the mitral population had higher mean STS risk of mortality (3.6% versus 2.4%, P < 0.0001) and median PASP (42 mmHg versus 32 mmHg, P < 0.0001). PASP was independently associated with operative mortality and major morbidity in both mitral and CABG patients. However, for mitral patients a 10-mmHg increase in PASP was associated with lower odds of morbidity (odds ratio: 1.06 versus 1.13), mortality (odds ratio: 1.11 versus 1.18) and intensive care unit time (4.3 versus 7.6 h) compared with CABG patients (interaction terms P < 0.0001). Among mitral patients, median PASP was higher in stenotic versus regurgitant disease (57 mmHg versus 40 mmHg, P < 0.0001). However, there was no differential association of PASP on morbidity or mortality (interaction terms P > 0.05). ConclusionsAlthough mitral surgery patients tend to have higher preoperative pulmonary artery pressures, PHT was associated with a lower risk for mitral outcomes compared with CABG. Further research on the management and optimization of patients with PHT perioperatively is needed to improve care for these patients.

Abstract TP199: Association Of Blood Pressure Parameters In Unsecured Aneurysmal Subarachnoid Hemorrhage And Outcomes

Background: Elevated systolic blood pressure (SBP) has been linked to pre-procedural rebleeding risk and poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the relationship between blood pressure parameters including mean arterial pressure (MAP) with rebleeding both prior to and during aneurysm securement remains unclear. This study seeks to determine the association between BP parameters and rebleeding events and outcomes in patients with aSAH. Design/Methods: We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic center between July 2016 and March 2021. All BP parameters, which were recorded on an hourly basis from admission, were reviewed. Per our institutional protocol, the SBP target is &lt;140 mmHg for all unsecured aSAH patients. Rebleeding was defined as radiographic worsening of hemorrhage prior to or immediately following aneurysm securement, as seen on imaging and determined by a radiologist. Binary regression analysis was used to determine association between maximum recorded BP parameters and outcomes including rebleeding and poor functional outcome defined as modified Rankin Scale 4-6 at 3 months post-discharge. Results: The cohort included 295 patients (mean age 57 years [SD 13.4], 61% female, 87% received endovascular treatments, 13% surgical clipping). Two or more consecutive SBP values &gt;140 were seen in 41% and &gt;160 in 15% of patients. Rebleeding prior or during securing aneurysms including intra-procedural bleeding occurred in 53 patients (18%). There was no association between either maximum recorded SBP (169.7 mmHg [36.2] vs. 166.9 [32.7], p=0.57) or MAP (121 mmHg [22.9] vs. 117.8 [22.9], p=0.42) and rebleeding. However, maximum recorded MAP was associated with poor outcome (OR 1.01 for 1 mmHg increase in MAP, 95% CI: 1.006-1.02, p=0.039). Conclusions: Elevated MAP peri-securement of a ruptured cerebral aneurysm can be associated with poor outcome. Multicenter prospective studies should further examine the association between MAP cut offs and outcomes to be considered in guidelines.

Sex-specific associations between systolic, diastolic and pulse pressure and hemostatic parameters in the population-based KORA-Fit study: a cross-sectional study

BackgroundSeveral prior studies postulated an effect of hypertension on coagulation factors. However, population-based studies investigating the sex-specific associations between hypertension and hemostatic parameters are scarce. Therefore, we investigated the relationship between blood pressure and parameters of coagulation, namely activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, factor VIII, antithrombin III, protein C, protein S, and D-dimer in men and women from the general population.MethodsBased on 803 participants (376 men, 427 women) from the KORA-Fit Study the sex-specific relationship between systolic, diastolic, and pulse pressure and commonly measured coagulation factors were investigated using multivariable-adjusted linear regression models.ResultsHypertensive males had significantly higher median fibrinogen levels and factor VIII activity in comparison to normotensive males. There was a statistically significant difference between females with and without hypertension regarding the parameter fibrinogen, D-dimers, Protein S activity, and factor VIII activity. In multivariable linear regression analyses no significant association between systolic blood pressure, diastolic blood pressure, as well as pulse pressure and the investigated hemostatic parameters was found in men. In women, a significant positive association could be observed between systolic blood pressure and D-dimer level [β-estimate per mmHg increase 3.37 (95% CI 0.935–5.804; p = 0.007)] and between pulse pressure and D-dimer level [β-estimate per mmHg increase 5.351 (95% CI 1.772–8.930; p = 0.003)].ConclusionsIt appears that sex differences exist in the association between blood pressure parameters and commonly measured coagulation markers in the general population. Further studies are needed to identify the underlying causes.

Is first pregnancy age associated with hypertension in the Chinese rural women population?

The purpose of this study was to investigate the relationship between first pregnancy age and hypertension later in the life of women from Chinese rural areas. In total, 13,493 women were enrolled in the Henan Rural Cohort study. Logistic regression and linear regression were used to evaluate the association between first pregnancy age and hypertension and blood pressure indicators [including systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP)]. The restricted cubic spline was used to examine the dose-response relationship between the first pregnancy age and hypertension or blood pressure indicators. After adjusting for potential confounders, each 1-year increase in first pregnancy age was associated with a 0.221 mmHg increase in SBP values, a 0.153 mmHg increase in DBP values, and a 0.176 mmHg decrease in MAP values (all P < 0.05). The β of SBP, DBP, and MAP showed a trend of first increasing and then decreasing with increasing first pregnancy age and there was no statistical significance after first pregnancy age beyond 33 years on SBP, DBP, and MAP, respectively. A 1-year increment in first pregnancy age was associated with a 2.9% [OR (95% CI): 1.029 (1.010, 1.048)] higher odds of prevalent hypertension. The odds of hypertension increased sharply and then eventually leveled off with an increment of first pregnancy age after adjusting for potential confounders. First pregnancy age might increase the risk of hypertension later in life and might be an independent risk factor for hypertension in women.

PS-P01-9: RELATIONSHIP BETWEEN BLOOD PRESSURE AND FRAILTY IN ELDERLY PATIENTS WITH ANY CARDIOMETABOLIC RISK FACTORS

Background: High blood pressure in mid-life was associated with frailty in elderly patients; however, frail patients have reduced quality of life (QOL) causing blood pressure decline. We thought to evaluated relationship between the blood pressure and frailty. Methods: We registered 691 elderly patients who had any cardiometabolic risk factors (hypertension, diabetes, dyslipidemia, atrial fibrillation, and heart failure) between Sep. 2015 and April 2022, and follow up for 1 year (N = 363). Clinic blood pressure (CBP) was taken twice in a seated position, using semi-automatic upper arm device, without doctors or nurses present. Frailty was evaluated using modified Japanese Cardiovascular Health Study score (J-CHS) that included appendicular skeletal muscle index, hand grip strength, and walk speed, and Kihon check list (KCL) that included QOL associated with frailty. Results: Mean age was 79.2 ± 6.3 years (male 35.6%). There were 30.4 % of patients with frailty by J-CHS criteria and 38.0 % by KCL criteria. In the multivariate-adjusted logistic regression analysis, frailty by J-CHS criteria was significantly associated with lower clinic DBP (OR = 0.901 per 5 mmHg increase, 95%CI, 0.829–0.978, P = 0.013); frailty by KCL criteria was with lower clinic SBP (OR = 0.843 per 10 mmHg increase, 95%CI 0.761–0.933, P = 0.001). In patients with antihypertensive medication, frailty with KCL was associated with clinic SBP (OR = 0.815 per 10 mmHg increase, 95%CI 0.703–0.944, P = 0.006). In frail patients by J-CHS criteria at baseline, low clinic DBP at baseline (OR = 0.937 per 1 mmHg increase, 95%CI 0.883–0.994, P = 0.031) and change in clinic DBP (OR = 0.921 per 1 mmHg change, 95%CI 0.861–0.986, P = 0.018) were associated with sustained frailty at 1 year later. In patients with preserved walk speed (&gt; 1.0m/sec) at baseline, change in clinic DBP was associated with development of reduced walk speed (&lt; 1.0m/s) at 1 year later (OR = 0.945, 95%CI 0.893–0.999, P = 0.046). Conclusion: Frailty was associated with lower clinic systolic or diastolic blood pressure, and change in clinic DBP in elderly patients with cardiometabolic risk factors.

PS-C12-4: OPEN-ANGLE GLAUCOMATOUS OPTIC DAMAGE ASSOCIATED WITH DAYTIME AND NOCTURNAL DIPS IN BLOOD PRESSURE

Background: Impaired ocular perfusion pressure via systemic hypoperfusion plays a pivotal role in the pathogenesis of open-angle glaucoma (OAG). Extreme dips in mean arterial pressure (MAP) during 24-h are associated with OAG, however, whether this is driven by diurnal or nocturnal dips remains undocumented. We aimed this study to investigate the association of OAG damage with daytime and nocturnal dips in MAP. Methods: We conducted a retrospective longitudinal study that included 110 primary OAG patients who underwent 24-h ambulatory blood pressure monitoring. OAG damage was defined as changes in mean deviation (MD) of visual field tests during follow-up. MAP variability independent of the mean (VIMmap) was computed for daytime and nighttime. Dips were the five daytime and three nighttime lowest drops in MAP. We also calculated the night-to-day ratio and defined low diurnal and nocturnal MAP levels. We applied mixed models to evaluate changes in MD (expressed as decibels [dB]) during follow-up in relation to diurnal and nocturnal variability and dips in MAP. Results: The mean age was 64.0y (53% women). The median follow-up was nine years. In adjusted mixed models, every + 3 mmHg increase in daytime VIMmap was associated with a -2.57 dB longitudinal change in MD (P &lt; 0.001). The longitudinal changes in MD associated with daytime dip measures ranged from -2.56 dB (95% confidence interval [CI], -3.61 to -1.51; P &lt; 0.001) to -3.19 dB (95% CI, -4.53 to -1.84; P &lt; 0.001). For nighttime measures, the MD changed -0.71 dB (CI, -1.24 to -0.17; P = 0.009) per every -5 decrease in the nighttime MAP level. Nocturnal MAP level &lt; 74 mmHg and every 0.05 decrease in the night-to-day ratio were related to -7.23 (P = 0.003) and -0.96 (P = 0.011) changes in MD. Nighttime VIMmapP and nocturnal dips were not associated with changes in MD (P &gt; 0.097). Conclusions: Extreme daytime dips in MAP relate to OAG damage independently of the MAP level. Whereas, the association between OAG damage and nocturnal measures is driven by the nocturnal MAP level rather than variability or dips in MAP. The assessment of diurnal patterns in MAP might offer an opportunity to understand the pathogenesis of OAG. This is also critical as the perfusion pressure to the eyes is physiological 30% lower than at the brachial level in the standing or sitting positions. Therefore, a physiological lower perfusion pressure combined with extreme diurnal dips in MAP would exacerbate the hypoperfusion state in the optic nerve, leading to further glaucoma damage.

PS-BPC03-5: OFFICE AND HOME BLOOD PRESSURE AND CARDIOVASCULAR DISEASE IN PATIENTS WITH DIABETES, PREDIABETES AND NORMAL GLUCOSE METABOLISM

Objective: Few studies have investigated whether the association between home blood pressure (BP) and cardiovascular disease (CVD) events is different according to prediabetes and diabetes populations. The main purpose of this study is to clarify the impact of home BP and office BP on CVD events in prediabetes and diabetes. Design and method: We used the database of the J-HOP (Japan Morning Surge-Home Blood Pressure) study, which enrolled 4,310 patients having at least one cardiovascular risk. We classified the patients with a self-reported clinical history of a physician's diagnosis, using of medication of diabetes mellitus, a fasting plasma glucose greater than or equal to 126 mg/dL, a casual plasma glucose level greater than or equal to 200 mg/dL or hemoglobin A1c (HbA1c;NGSP) greater than or equal to 6.5 % as diabetes (n = 1,034), those with HbA1c 5.7–6.4 % as prediabetes (n = 1,167), and the remaining patients as the patients with normal glucose metabolism (NGM) (n = 2,024). Outcome was measured against composite CVD outcome (first occurrence of coronary artery disease, stroke and heart failure). Results: During a median 6.2 ± 3.8 year follow-up, 259 CVD events occurred. Prediabetes was a risk of CVD events (Unadjusted Hazard ratios [uHR],1.43; 95% confidence interval [CI], 1.05–1.95) and this association was followed by diabetes (uHR, 2.13; 95%CI, 1.59–2.85) compared to NGM. In NGM group, the adjusted HR expressing the risk of composite CVD events, were 1.15 (95%CI, 1.01–1.31) and 1.18 (95%CI, 1.03–1.36), 1.01(95%CI, 0.88–1.15) per 10 mmHg increase of morning and evening home systolic BP (SBP), office SBP, respectively. In diabetes, increased home SBP as a risk of composite CVD events had similar tendency and office SBP was also associated with a risk of CVD (adjusted HR, 1.16; 95%CI, 1.02–1.31). In prediabetes group, only morning home SBP was associated with a risk of CVD events (uHR, 1.15; 95%CI, 1.00–1.31), but was not in adjusted model. Conclusion: Prediabetes was a risk for CVD events as well as diabetes. Increased home BP contributes to CVD risk in diabetes, albeit weakly in prediabetes.

S-46-6: COMPARING OFFICE, CENTRAL, HOME AND AMBULATORY BLOOD PRESSURE IN PREDICTING LEFT VENTRICULAR MASS

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m2 (95% CI; 3.7–27, P = .01, adjR2 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m2 (95% CI 0.76–3.9, P &lt; .01, adjR2 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.

Prehospital Cardiovascular Autoregulatory Disturbances Correlate With the Functional Neuroanatomy of Acute Spinal Cord Injury.

Retrospective study. The importance of attenuating the cardiovascular autoregulatory disturbances accompanying acute spinal cord injury (SCI) has long been recognized. This report assembles SCI emergency service data and correlates cardiovascular parameters to preserved functional neuroanatomy. The nascent nature of evidence-based reporting of prehospital cardiovascular autoregulatory disturbances in SCI indicates the need to assemble more information. SCI data for <24 hours were extracted from ambulance and hospital records. The mean arterial pressure (MAP) was calculated. The International Standard for Neurological Classification of SCI (ISNCSCI) evaluates the primary outcome of motor incomplete injury (grades C/D) at acute presentation. Logistic regression was adjusted for multiple confounders that were expected to influence the odds of grade C/D. A cohort of 99 acute SCI cases was retained; mean (SD) age 40.7±20.5 years, 88 male, 84 tetraplegic, 65 grades A/B (motor complete injury), triage time 2±1.6 hours. The lowest recorded prehospital MAP [mean (SD): 77.9±19, range: 45-145mmHg] approached the nadir for adequate organ perfusion. Thirty-four (52%) grade A/B and 10 (30%) C/D cases had MAP readings <85mmHg. In data adjusted for age, injury level, and triage time a 5mmHg increase in the lowest MAP value was associated with a 34% increase in the odds of having motor incomplete injury at acute presentation (adjusted odds ratio=1.34; 95% CI: 1.11-1.61; P =0.002). An important observation with implications for timely and selective cardiovascular resuscitation during SCI prehospital care involves significant negative associations between the depth of systemic hypotension and preserved functional neuroanatomy. Regardless of the mechanism, our confounder-adjusted logistic regression model extends in-hospital evidence and provides a conceptual bedside-bench framework for future investigations.

High pulse pressure is associated with an increased risk of diabetes in females but not in males: a retrospective cohort study

ObjectiveAccumulating evidence suggests a close relationship between metabolic disturbance and increased arterial stiffness. However, whether there is an association between pulse pressure (PP) and diabetes and how this association might be impacted by sex is not clear.MethodsA total of 209,635 adult Chinese individuals > 20 years old across 32 sites and 11 cities in China (Shanghai, Beijing, Nanjing, Suzhou, Shenzhen, Changzhou, Chengdu, Guangzhou, Hefei, Wuhan, Nantong) were included in the study; participants were free of diabetes at baseline. In the present study, we analyzed the relationship between PP at baseline and incident diabetes using the Cox proportional hazard model.ResultsDuring a median follow-up of 2.99 years, a total of 3971 participants (2885 men and 1086 women) developed diabetes, and the incidence was 6.3 per 1000 person-years. With each 10 mmHg increase in PP, the multivariable adjusted hazard ratio (HR) (95% confidence interval) for incident diabetes was 1.117 (1.061, 1.176) in females and 0.981 (0.951, 1.012) in males. Using the lowest quartile of PP as the reference category, the hazard ratio (HR) (95% CI) of the highest quartile of PP for incident diabetes was 1.494 (1.225, 1.822) in females and 0.939 (0.843, 1.045) in males. Smooth plots revealed a significant difference between males and females in the HRs for new-onset diabetes according to PP.ConclusionHigher PP was related to future diabetes development in females but not in males and further research is needed to explore the mechanism.

Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke

We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0–2 (absent-to-moderate) versus 3–4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.

The effect of positive end-expiratory pressure on intracranial pressure in obese and non-obese severe brain injury patients: a retrospective observational study

BackgroundThe effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) had never been studied in obese patients with severe brain injury (SBI). The main aim was to evaluate the effect of PEEP on ICP in SBI patients with mechanical ventilation according to obesity status.MethodsSBI patients admitted to the ICU with mechanical ventilation between 2014 and 2015 were included. Demographic, hemodynamic, arterial blood gas, and ventilator data at the time of the paired PEEP and ICP observations were recorded and compared between obese (body mass index ≥ 30 kg/m2) and non-obese SBI patients. Generalized estimating equation (GEE) model was used to assess the relationship between PEEP and ICP in obese and non-obese SBI patients, respectively.ResultsSix hundred twenty-seven SBI patients were included, 407 (65%) non-obese and 220 (35%) obese patients. A total of 30,415 paired PEEP and ICP observations were recorded in these patients, 19,566 (64.3%) for non-obese and 10,849 (35.7%) for obese. In the multivariable analysis, a statistically significant relationship between PEEP and ICP was found in obese SBI patients, but not in non-obese ones. For every cmH2O increase in PEEP, there was a 0.19 mmHg increase in ICP (95% CI [0.05, 0.33], P = 0.007) and a 0.15 mmHg decrease in CPP (95% CI [-0.29, -0.01], P = 0.036) in obese SBI patients after adjusting for confounders.ConclusionsThe results suggested that, contrary to non-obese SBI patients, the application of PEEP may produce an increase in ICP in obese SBI patients. However, the effect was modest and may be clinically inconsequential.

Relationship between Diurnal Variation in Intraocular Pressure and Central Corneal Power.

Relationship between intraocular pressure (IOP) change and central corneal curvature is complicated by measurement techniques and corneal biomechanical parameters. Findings from this study indicate that it is worthwhile to observe the association between diurnal change in IOP and corneal power. This study aimed to investigate the relationship between the diurnal change in IOP and central corneal power among eyes with and without myopia. Sixty healthy eyes of 24 emmetropes and 36 myopes were recruited for this cross-sectional study. Both anterior and posterior central corneal powers of the steep (Ks), flat (Kf), mean meridian (Km), best-fit spheres, and central corneal thickness were recorded followed by the IOP (Goldmann-correlated IOP [IOPg] and corneal-compensated IOP) and corneal biomechanics (corneal hysteresis and corneal resistance factor). Measurements were obtained every 3 hours from 9.30 am to 6.30 pm . Linear-mixed model was used to determine the relationship between the change in IOP and the associated change in corneal measurements (adjusted for age, sex, refractive error, central corneal thickness, and biomechanics) among the myopic and nonmyopic eyes. Group mean, amplitude of change, and the diurnal change in IOPg were (mean ± standard deviation) 15.14 ± 2.50, 3.33 ± 1.44, and 1.81 ± 1.25 mmHg, respectively. Overall, an IOP increase was associated with a decrease in the adjusted anterior corneal powers. Myopic eyes were associated with a decrease of 0.04 D (95% confidence interval [CI], 0.07 to 0.01 D; P = .02) in Ks and 0.03 D (95% CI, 0.06 to 0.001 D; P = .047) in Kf per mmHg increase in IOP, whereas for emmetropes, per mmHg increase in IOP only flattened the Kf by 0.03 D (95% CI, 0.06 to 0.004 D; P = .02). Change in anterior corneal power was inversely related to the change in IOPg, with myopic and nonmyopic eyes reporting a significant but differential impact of IOP. Clinicians must keep in mind the impact of large IOP fluctuation on the anterior corneal power.

Long-term peridialytic blood pressure changes are related to mortality.

In chronic haemodialysis (HD) patients, the relationship between long-term peridialytic blood pressure (BP) changes and mortality has not been investigated. To evaluate whether long-term changes in peridialytic BP are related to mortality and whether treatment with HD or haemodiafiltration (HDF) differs in this respect, the combined individual participant data of three randomized controlled trials comparing HD with HDF were used. Time-varying Cox regression and joint models were applied. During a median follow-up of 2.94years, 609 of 2011 patients died. As for pre-dialytic systolic BP (pre-SBP), a severe decline (≥21mmHg) in the preceding 6months was independently related to increased mortality [hazard ratio (HR) 1.61, P=.01] when compared with a moderate increase. Likewise, a severe decline in post-dialytic diastolic BP (DBP) was associated with increased mortality (adjusted HR 1.96, P<.0005). In contrast, joint models showed that every 5-mmHg increase in pre-SBP and post-DBP during total follow-up was related to reduced mortality (adjusted HR 0.97, P=.01 and 0.94, P=.03, respectively). No interaction was observed between BP changes and treatment modality. Severe declines in pre-SBP and post-DBP in the preceding 6months were independently related to mortality. Therefore peridialytic BP values should be interpreted in the context of their changes and not solely as an absolute value.

In utero exposure to per-/polyfluoroalkyl substances (PFASs): Preeclampsia in pregnancy and low birth weight for neonates

Per-/polyfluoroalkyl substances (PFASs) have been linked to preeclampsia with inconsistent directions for outcomes. However, information regarding the joint effects of PFASs mixtures on preeclampsia as well as their associations with the low birth weight (LBW) and small for gestational age (SGA) is nascent. The present study included 82 women with preeclampsia and 169 healthy participants from Hangzhou, China. Fifteen PFASs were analyzed in maternal serum before delivery. PFOA and 6:2Cl-PFESA were associated with higher incidence of preeclampsia both linearly and by tertile. Each log-unit increase in serum PFOA (OR:5.29, 95% CI: 1.05, 26.7, p = 0.044) and 6:2 Cl-PFESA (OR:1.02, 95%CI: 1.00, 1.48, p = 0.045) concentrations were associated with increased risks of preeclampsia. These effects were more profound among primiparous women carrying female fetuses. Both PFOA and PFUnDA concentrations were significantly associated with higher odds of early-onset preeclampsia, but the associations tended to be null for late-onset. In addition, each logarithmic increment in PFOA concentrations were significantly associated with a 0.262 and 0.224 mmHg increase in systolic (95% CI: 0.147, 0.377) and diastolic (95% CI: 0.133, 0.314) blood pressures. Using Bayesian kernel machine regressions (BKMR), the overall effects of PFASs mixture concentrations on preeclampsia showed an increasing trend, with PFOA being the largest contributor. With regard to birth weight, the Cox proportional hazards model indicated that significantly higher risks of the LBW were associated with preeclampsia than normal pregnancy (OR: 4.56, 95% CI: 2.44, 6.68, p = 0.000). Increased LBW risks were found for the higher PFOA exposure both linearly and by tertile. Besides, serum PFOA and PFUnDA concentrations were significantly associated with higher odds of SGA development. Nevertheless 4:2 FTS and ADONA were inversely associated with LBW and SGA incidences. Further adverse birth outcomes should be explored to elucidate the health implications of PFASs exposure and preeclampsia development.

Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units

BackgroundCOVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented. MethodsPatients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined. Main findings3388 patients were analysed (63 [55–70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5–9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09–1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10–1.67]), PaO2/FiO2 ratio at intubation (HR 0.99 [0.98–0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76–0.998]), and corticosteroids (HR 1.27 [1.09–1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16–1.55]), predominantly due to late VAP (HR 1.51 [1.26–1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar. ConclusionVAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

Geographic Information System Mapping of Social Risk Factors and Patient Outcomes of Pediatric Glaucoma

This study aimed to use Geographic Information System (GIS) mapping to present the geospatialdistribution of visual outcomes and sociodemographic risk factors of a cohort of pediatric glaucoma patients. Retrospective cohort study. 233 eyes of 177 pediatric glaucoma patients treated at UC Davis Medical Center. We reviewed the medical records of pediatric patients (aged less than 18 years) with the diagnosis of pediatric glaucoma or any adult with a prior history of pediatric glaucoma at UC Davis Medical Center from 2001 to 2019. Patient sociodemographic information and ocular health data were recorded. Patients were mapped to their residential home 3-digit zip code prefix using ArcGIS software to generate geographic representations of the pediatric glaucoma database. Statistical analyses were performed to identify significant risk factors to poor visual outcome. The primary outcome was the patient's final visual acuity (VA), defined as a binary variable based on the World Health Organization's criteria: good VA (better than 20/200) or poor VA (worse than 20/200). The secondary outcome was final intraocular pressure (IOP) at patients' final follow-ups. Risk factors for poor vision and higher IOP were assessed. At final follow-up, 65 eyes (27.9%) had poor vision and 168 eyes (72.1%) had good vision. In the multivariate analysis, the odds ratio of good VA decreased by 4% for every 1 mmHg increase in initial IOP (P= 0.03), and the odds of good VA decreased by 6% for every year increase in age (P= 0.04). Patients with private insurance had a 3.5 mmHg lower final IOP than those with Medicaid (P= 0.004). Travel distance was not associated with a poorer visual outcome. Private insurance patients had lower final IOP than Medicaid patients. Age and initial IOP were significant negative predictors of VA. Despite travel distance appearing to be associated with poorer visual outcomes by GIS mapping, it was not statistically significant. Geographic information system mapping of patient outcomes is an innovative way to visualize patient demographics and risk factors. Geographic information system may prove particularly useful in larger nationwide disease and surgical registries, especially for rare disorders like pediatric glaucoma. Proprietary or commercial disclosure may be found after the references.

Progression of functional and structural glaucomatous damage in relation to diurnal and nocturnal dips in mean arterial pressure.

Systemic hypoperfusion plays a pivotal role in the pathogenesis of primary open-angle glaucoma (POAG). Extreme dips in mean arterial pressure (MAP) due to high 24-h variability are associated with POAG, however, whether this is driven by diurnal or nocturnal dips remains undocumented. We aimed this study to investigate the association of POAG damage with variability and dips in the diurnal and nocturnal MAP. We conducted a retrospective longitudinal study that included 110 POAG patients who underwent 24-h ambulatory blood pressure monitoring. Our outcomes included (i) functional [visual field defects expressed as mean deviation (MD)] and (ii) structural (optic disc cupping obtained from cup-to-disc ratio) glaucoma damage. MAP variability independent of the mean (VIMmap) was computed for diurnal and nocturnal MAP. Dips were the five diurnal and three nocturnal lowest drops in MAP. We also calculated the night-to-day ratio. We applied mixed models to evaluate the progression of visual field defects and optic disc cupping in relation to diurnal and nocturnal MAP measures. The mean age was 64.0 y (53% women). The median follow-up was 9 years. In adjusted mixed models, functional progression of glaucoma damage was associated with VIMmap (-2.57 dB change in MD per every 3 mmHg increase in VIMmap; P < 0.001) and diurnal MAP dips (changes in the MD ranged from -2.56 to -3.19 dB; P < 0.001). Every 5 mmHg decrease in the nocturnal MAP level was associated with -1.14 dB changes in MD [95% confidence interval (CI), -1.90 to -0.40] and 0.01 larger optic disc cupping (95% CI, 0.01-0.02). Lower night-to-day ratio was also related to both outcomes (P ≤ 0.012). Functional glaucoma damage worsened if nocturnal hypotension was combined with high variability or extreme dips in the diurnal MAP (P ≤ 0.022). Progression of glaucoma damage in POAG associates with high variability and extreme dips in the diurnal MAP. Structural glaucoma damage seems more vulnerable to nocturnal hypotension. Ambulatory blood pressure monitoring allows the assessment of sporadic diurnal and persistent nocturnal hypotension episodes. These phenotypes might offer an opportunity to improve the risk-stratification of open-angle glaucoma (OAG).