Strict Blood Pressure Control Research Articles

Prolonged/delayed cerebral hyperperfusion in adult patients with moyamoya disease with RNF213 gene polymorphism c.14576G>A (rs112735431) after superficial temporal artery-middle cerebral artery anastomosis.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the standard surgical management for moyamoya disease (MMD), whereas cerebral hyperperfusion (CHP) is one of the potential complications of this procedure that can result in delayed intracerebral hemorrhage and/or neurological deterioration. Recent advances in perioperative management in the early postoperative period have significantly reduced the risk of CHP syndrome, but delayed intracerebral hemorrhage and prolonged/delayed CHP are still major clinical issues. The clinical implication of RNF213 gene polymorphism c.14576G>A (rs112735431), a susceptibility variant for MMD, includes early disease onset and a more severe form of MMD, but its significance in perioperative pathology is unknown. Thus, the authors investigated the role of RNF213 polymorphism in perioperative hemodynamics after STA-MCA anastomosis for MMD. Among 96 consecutive adult patients with MMD comprising 105 hemispheres who underwent serial quantitative cerebral blood flow (CBF) analysis by N-isopropyl-p-[123I]iodoamphetamine SPECT after STA-MCA anastomosis, 66 patients consented to genetic analysis of RNF213. Patients were routinely maintained under strict blood pressure control during and after surgery. The local CBF values were quantified at the vascular territory supplied by the bypass on postoperative days (PODs) 1 and 7. The authors defined the radiological CHP phenomenon as a local CBF increase of more than 150% compared with the preoperative values, and then they investigated the correlation between RNF213 polymorphism and the development of CHP. CHP at POD 1 was observed in 23 hemispheres (23/73 hemispheres [31.5%]), and its incidence was not statistically different between groups (15/41 [36.6%] in RNF213-mutant group vs 8/32 [25.0%] in RNF213-wild type (WT) group; p = 0.321). CHP on POD 7, which is a relatively late period of the CHP phenomenon in MMD, was evident in 9 patients (9/73 hemispheres [12.3%]) after STA-MCA anastomosis. This prolonged/delayed CHP was exclusively observed in the RNF213-mutant group (9/41 [22.0%] in the RNF213-mutant group vs 0/32 [0.0%] in the RNF213-WT group; p = 0.004). Multivariate analysis revealed that RNF213 polymorphism was significantly associated with CBF increase on POD 7 (OR 5.47, 95% CI 1.06-28.35; p = 0.043). Prolonged/delayed CHP after revascularization surgery was exclusively found in the RNF213-mutant group. Although the exact mechanism underlying the contribution of RNF213 polymorphism to the prolonged/delayed CBF increase in patients with MMD is unclear, the current study suggests that genetic analysis of RNF213 is useful for predicting the perioperative pathology of patients with MMD.

Day‐to‐day blood pressure variability and severity of COVID‐19: Is sympathetic overdrive a potential link?

Day‐to‐day blood pressure variability and severity of COVID‐19: Is sympathetic overdrive a potential link?

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach.

To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus.

Childhood-onset systemic lupus erythematosus (cSLE) is a prototype of a multisystemic, inflammatory, heterogeneous autoimmune condition. This disease is characterized by simultaneous or sequential organ and system involvement, with unpredictable flare and high levels of morbidity and mortality. Racial/ethnic background, socioeconomic status, cost of medications, difficulty accessing health care, and poor adherence seem to impact lupus outcomes and treatment response. In this article, the management of cSLE patients is updated. Regarding pathogenesis, a number of potential targets for drugs have been studied. However, most treatments in pediatric patients are off-label drugs with recommendations based on inadequately powered studies, therapeutic consensus guidelines, or case series. Management practices for cSLE patients include evaluations of disease activity and cumulative damage scores, routine non-live vaccinations, physical activity, and addressing mental health issues. Antimalarials and glucocorticoids are still the most common drugs used to treat cSLE, and hydroxychloroquine is recommended for nearly all cSLE patients. Disease-modifying antirheumatic drugs (DMARDs) should be standardized for each patient, based on disease flare and cSLE severity. Mycophenolate mofetil or intravenous cyclophosphamide is suggested as induction therapy for lupus nephritis classes III and IV. Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin) appear to be another good option for cSLE patients with lupus nephritis. Regarding B-cell-targeting biologic agents, rituximab may be used for refractory lupus nephritis patients in combination with another DMARD, and belimumab was recently approved by the US Food and Drug Administration for cSLE treatment in children aged > 5 years. New therapies targeting CD20, such as atacicept and telitacicept, seem to be promising drugs for SLE patients. Anti-interferon therapies (sifalimumab and anifrolumab) have shown beneficial results in phase II randomized control trials in adult SLE patients, as have some Janus kinase inhibitors, and these could be alternative treatments for pediatric patients with severe interferon-mediated inflammatory disease in the future. In addition, strict control of proteinuria and blood pressure is required in cSLE, especially with angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use.

The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques.

The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.

First case of an invasive Bacteroides dorei infection detected in a patient with a mycotic aortic aneurysm\u2014raising a rebellion of major indigenous bacteria in humans: a case report and review

BackgroundBacteroides dorei is an anaerobic gram-negative bacterium first described in 2006. Because of the high similarity in mass spectra between B. dorei and Bacteroides vulgatus, discriminating between these species is arduous in clinical practice. In recent decades, 16S rRNA gene sequencing has been a complementary method for distinguishing taxonomically close bacteria, including B. dorei and B. vulgatus, at the genus and species levels. Consequently, B. dorei has been shown to contribute to some diseases, including type 1 autoimmune diabetes mellitus and atherosclerotic diseases. However, there are no reports on invasive infectious diseases caused by B. dorei. This report describes the first case of direct invasion and colonisation of human tissue by B. dorei, thus providing a warning regarding the previously proposed application of B. dorei as a live biotherapeutic for atherosclerotic diseases.Case presentationA 78-year-old Japanese man complained of intermittent chest/back pain and was diagnosed with a mycotic thoracic aortic aneurysm by enhanced computed tomography on admission. Despite strict blood pressure control and empirical antibiotic therapy, the patient’s condition worsened. To prevent aneurysmal rupture and eliminate infectious foci, the patient underwent surgical treatment. The resected specimen was subjected to tissue culture and 16S rRNA gene sequencing analysis to identify pathogenic bacteria. A few days after the surgery, culture and sequencing results revealed that the pathogen was B. dorei/B. vulgatus and B. dorei, respectively. The patient was successfully treated with appropriate antibacterial therapy and after improvement, was transferred to another hospital for rehabilitation on postoperative day 34. There was no recurrence of infection or aneurysm after the patient transfer.ConclusionsThis report describes the first case of invasive infectious disease caused by B. dorei, casting a shadow over its utilisation as a probiotic for atherosclerotic diseases.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy.

Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy. A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed. One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values. Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Association between longitudinal blood pressure and prognosis after treatment of cerebral aneurysm: A nationwide population-based cohort study.

High blood pressure is a major risk factor for the development and rupture of cerebral aneurysm. Endovascular coil embolization and surgical clipping are established procedures to treat cerebral aneurysm. However, longitudinal data of blood pressure after the treatment of cerebral aneurysm and its impact on long-term prognosis are not well known. This retrospective cohort study included 1275 patients who underwent endovascular coil embolization (n = 558) or surgical clipping (n = 717) of cerebral aneurysm in 2002-2015 using the nationwide health screening database of Korea. Systolic and diastolic blood pressure of patients were repeatedly obtained from the nationwide health screening program. We performed a multivariate time-dependent Cox regression analysis of the primary composite outcome of stroke, myocardial infarction, and all-cause death. During the mean follow-up period of 6.13 ± 3.41 years, 89 patients suffered the primary outcome. Among the total 3546 times of blood pressure measurement, uncontrolled high blood pressure (systolic ≥140 mmHg or diastolic ≥90 mmHg) was 22.9%. There was a significantly increased risk of primary outcome with high systolic (adjusted HR [95% CI] per 10 mmHg, 1.16 [1.01-1.35]) and diastolic (adjusted HR [95% CI] per 10 mmHg, 1.32 [1.06-1.64]) blood pressure. High blood pressure is prevalent even in patients who received treatment for cerebral aneurysm, which is significantly associated with poor outcome. Strict control of high blood pressure may further improve the prognosis of patients with cerebral aneurysm.

May Measurement Month 2019: an analysis of blood pressure screening results from Korea.

Hypertension is the biggest contributing risk factor to cerebrovascular disease and is associated with increased risk of coronary artery disease. The May Measurement Month (MMM) campaign is a global initiative aimed at raising awareness of hypertension and acting as a temporary solution to the lack of screening programs worldwide. An opportunistic cross-sectional survey of participants aged ≥18 was carried out during May 2019 in Korea. Over 10 000 participants were recruited in the MMM campaign in Korea, with a slogan of ‘A simple measure to save lives—#checkyourpressure’. A total of 9975 participants with valid clinical and blood pressure (BP) data were used for analysis. All participants were Korean in ethnicity, mean age was 57.2 (SD ± 21.2) years, 57.7% were females, and the mean body mass index was 23.4 kg/m2 (SD ± 3.3). In total, 37.7% of the participants reported a previous diagnosis of hypertension, and 91.3% of those diagnosed were on antihypertensive medications. For other comorbidities, 11.6% reported having diabetes mellitus, 2.0% had previous stroke, and 1.0% had previous myocardial infarction. Mean BP was 130.0/81.0 mmHg in the overall population. After multiple imputation, 47.6% of participants were classified as hypertensive (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or on treatment for raised BP). Among all hypertensive participants, the awareness rate, the treatment rate, and the control rate (systolic BP <140 mmHg and diastolic BP <90 mmHg) were 76.2%, 74.0%, and 50.5%, respectively. Of those on antihypertensive medication, the control rate was 68.2%. While awareness and treatment rates were relatively high in the MMM19 campaign, the BP control rate of the total hypertensive population was still only ∼50%, which demands more emphasis on strict BP control.

Predictors of fatal outcomes among hospitalized COVID-19 patients with pre-existing hypertension in China.

BackgroundCoronavirus disease 2019 (COVID‐19) is an emerging, rapidly evolving pandemic, hypertension is one of the most common co‐existing chronic conditions and a risk factor for mortality. Nearly one‐third of the adult population is hypertensive worldwide, it is urgent to identify the factors that determine the clinical course and outcomes of COVID‐19 patients with hypertension.Methods and results148 COVID‐19 patients with pre‐existing hypertension with clarified outcomes (discharge or deceased) from a national cohort in China were included in this study, of whom 103 were discharged and 45 died in hospital. Multivariate regression showed higher odds of in‐hospital death associated with high‐sensitivity cardiac troponin (hs‐cTn) > 28 pg/ml (hazard ratio [HR]: 3.27, 95% confidence interval [CI]: 1.55–6.91) and interleukin‐6 (IL‐6) > 7 pg/ml (HR: 3.63, 95% CI:1.54–8.55) at admission. Patients with uncontrolled blood pressure (BP) (n = 52) which were defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg for more than once (≥2 times) during hospitalization, were more likely to have ICU admission (p = 0.037), invasive mechanical ventilation (p = 0.028), and renal injury (p = 0.005). A stricter BP control with the threshold of 130/80 mm Hg was associated with lower mortality. Treatment with renin‐angiotensin‐aldosterone system (RAAS) suppressors, including angiotensin‐converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and spironolactone, was associated with a lower rate of ICU admission compared to other types of anti‐hypertensive medications (8 (22.9%) vs. 25 (43.1%), p = 0.048).ConclusionAmong COVID‐19 patients with pre‐existing hypertension, elevated hs‐cTn and IL‐6 could help clinicians to identify patients with fatal outcomes at an early stage, blood pressure control is associated with better clinical outcomes, and RAAS suppressors do not increase mortality and may decrease the need for ICU admission.

The Role of Cell Division Autoantigen 1 (CDA1) in Renal Fibrosis of Diabetic Nephropathy.

The common kidney disease diabetic nephropathy (DN) accounts for significant morbidity and mortality in patients with diabetes, and its effective diagnosis in incipient stages is still lacking. Renal fibrosis is the main pathological feature of DN. Cell division autoantigen 1 (CDA1), a phosphorylated protein encoded by TSPYL2 on the X chromosome, plays a fibrogenic role by modulating the transforming growth factor-β (TGF-β) signaling, but the exact mechanism remains unclear. TGF-β signaling has been recognized as the key factor in promoting the development and progression of DN. At present, strict control of blood sugar and blood pressure can significantly lower the development and progression of DN in the early stages, and many studies have shown that blocking TGF-β signaling can delay the progress of DN. However, TGF-β is a multifunctional cytokine. Its direct intervention may result in increased side effects. Therefore, the targeted intervention of CDA1 not only can block the TGF-β signaling pathway but also can reduce these side effects. In this article, we review the main physiological roles of CDA1, with particular attention to its effect and potential mechanism in the renal fibrosis of DN.

ANALYSIS OF FACTORS RELATING TO DAY-TO-DAY HOME BLOOD PRESSURE VARIATION IN HYPERTENSIVE PATIENTS

Objective: In order to prevent cardiovascular events and organ injuries in hypertensive patients, strict blood pressure (BP) control over 24 hours is of primary importance. In addition to the BP level, it has been indicated that the variabilities of blood pressure during a day or between visits also influence the risk of cardiovascular disorders. This study aimed to delineate the factors relating to the variations of office and home BPs throughout a year in hypertensive outpatients under antihypertensive therapy. Design and method: The subjects enrolled in this study were 83 hypertensive out-patients who recorded home blood pressure measurements. Office BP and the home BP records within 7 days before each visit were collected for the analyses calculating the coefficient of variation (CV). In addition to the physical findings such as blood pressure and body mass index, laboratory data of blood and urine samples were collected. Results: The office BP value (131/77mmHg) was comparable to the morning home BP (130/76) and higher than the evening home BP (126/73), however, the CV values were comparable between the office and the morning and evening home BPs. Correlations of BP and CV were stronger between the morning and the evening home BPs than between the office and the home BPs. The CV of systolic office BP was greater in patients with diabetes mellitus than patients without diabetes (7.8 vs 6.1%). In patients with chronic kidney disease, the CVs of diastolic office BP and diastolic evening home BP were greater than patients without chronic kidney disease (8.0 vs 6.2% and 8.1 vs 6.7%, respectively). In addition, The CVs of diastolic morning and evening home BP were positively correlated with serum creatinine and negatively correlated with estimated glomerular filtration rate. Patients with cardiovascular diseases such as stroke and coronary artery disease showed greater CV of diastolic morning home BP than patients without cardiovascular diseases (8.2 vs 6.6%). Conclusions: These results suggest that the home BP exhibits different variability from the office BP and the BP variability is increased in high-risk hypertensive patients with diabetes mellitus, chronic kidney disease and cardiovascular diseases.

ANTIHYPERTENSIVE EFFECTS AND SAFETY OF ESAXERENONE IN HYPERTENSIVE PATIENTS WITH MODERATE KIDNEY DYSFUNCTION

Objective: Mineralocorticoid receptor blockers (MRB) adding to renin–angiotensin system (RAS) inhibitors should be an effective treatment option for the strict blood pressure (BP) control of the hypertensive patients with moderate kidney dysfunction. Esaxerenone is a novel, first non-steroidal MRB with a dose-dependent antihypertensive effect and renal protective potential. We investigated the efficacy and safety of esaxerenone in Japanese hypertensive patients with moderate kidney dysfunction. Design and method: Two multicenter, open-label, non-randomized, dose-escalation studies were conducted to assess the efficacy and safety of esaxerenone monotherapy and add-on therapy to RAS inhibitor. Esaxerenone therapy started from 1.25 mg/day, titrated to 5 mg/day and continued until 12 weeks. Primary endpoint was change from baseline in sitting BP. Safety, pharmacokinetics, and urinary albumin-to-creatinine ratios were also evaluated. Results: Of 91 patients, 33 received monotherapy and 58 received add-on therapy; mean baseline estimated glomerular filtration rates were 52 and 51 mL/min/1.73m2, respectively. The esaxerenone dose was increased to 2.5 mg/day and above in 100% (n = 33) and 93% (n = 54) of patients receiving monotherapy and add-on therapy, respectively. After the initiation of treatment, significant reduction in sitting SBP/DBP at the end of treatment was observed in both studies (monotherapy: 19/9 mmHg; add-on therapy: 18/8 mmHg; both P &lt; 0.001); 64% and 48% of patients achieved target blood pressure (&lt;140/90 mmHg). The antihypertensive effects were consistent across patient subgroups by age, BMI, and eGFR. The UACR decreased significantly from baseline to Week 12: by 26% in the monotherapy study (P &lt; 0.01) and 29% in the add-on therapy study (P &lt; 0.001). An increased serum K+ level of 5.5 mEq/L and above occurred in 7 patients (12%) receiving add-on therapy, but in none receiving monotherapy. All increases in serum K+ were transient and no patient met predefined serum K+ level criteria for dose reduction or therapy discontinuation. No patient discontinued treatment due to kidney function decline. Conclusions: Esaxerenone demonstrated sufficient antihypertensive effects and was well tolerated in hypertensive patients with moderate kidney dysfunction, both as monotherapy and add-on therapy to a RAS inhibitor.

Blood–Brain Barrier Disturbances and Potential Complications of Endovascular Management in Stroke—Technical Note with Limited Review

AbstractContrast enhancement (CE), contrast extravasation (CX), hemorrhagic transformation (HT), and cerebral hyperperfusion syndrome (CHS) in patients who have suffered ischemic stroke and have undergone revascularization. There are a handful of articles addressing these pathologies separately. But there is scant literature available combining them together, as the underlying pathophysiology involves disturbances of blood–brain barrier (BBB). We have reviewed literature and proposed a common mechanism for these events. We systematically searched PubMed, LibGen, Cochrane, and Sci-Hub databases for the studies published online regarding CE, CX, HT, and CHS after endovascular treatment for stroke. This review was conducted based on the PRISMA guidelines. The following medical search terms were used for the online search: contrast enhancement, contrast extravasation, hemorrhagic transformation, cerebral hyperperfusion syndrome, endovascular treatment, contrast staining, postprocedural attenuation, carotid stenting, intra-arterial thrombolysis, and stroke. We did a limited review of literature by analyzing the relevant articles and research papers published to date. We have randomly included prototype cases of CE, CX, HT, and CHS which we have encountered in our Interventional Department from our own database. In compliance with PRISMA guidelines, we screened 33 articles dealing with CE, 32 with CX, 26 articles that addressed CE and CX both, 53 articles dealing with HT, and 42 articles dealing with CHS. Overall, 88 articles were filtered on studying the abstract. Further, 15 more had to be excluded as reasoned in the flowchart, and finally 71 articles were included in our study, as again shown in the flowchart. We studied and discussed these articles and research papers in relation to pathophysiology, predisposing factors, preventive measures, and current treatment protocols. BBB disruption is the primary event in CE, CX, HT, and CHS with varying severity. Minimizing dose of contrast, optimum timing of revascularization and dose of thrombolytic, judicious selection of mechanical thrombectomy cases, and strict control of blood pressure in postrevascularization period are recommended preventive measures. High-index of clinical suspicion, early imaging to detect, and following-up the same on sequential imaging are key to avoid severe forms of HT and CHS.

Cerebral Venous Sinus Thrombosis in an Immunocompetent HIV Patient

Cerebral venous sinus thrombosis (CVST) is an uncommon manifestation in patients with the human immunodeficiency virus (HIV) due to the virus’s prothrombotic state. Our case involves a 41-year-old Hispanic male with a past medical history of HIV on bictegravir/emtricitabine/tenofovir/alafenamide (Biktarvy), hyperlipidemia, post-traumatic stress disorder, hypogonadism with the cessation of testosterone injections one month prior, and generalized anxiety disorder who presented with retro-orbital headache, intermittent bilateral blurry vision, and flashing lights in the lower lateral left eye for one week. Vitals signs and laboratory studies were within normal limits aside from new iron deficiency anemia. Neurological exam was unremarkable. Computed tomography (CT) of the head showed evidence of a subacute cerebral infarct with hemorrhagic transformation in the right superior parietal lobe. Magnetic resonance imaging (MRI) of the brain with contrast revealed a small thrombosed cortical vein with surrounding hemorrhage and edema in the same location, in addition to a partial thrombosis of the adjacent superior sagittal sinus, which was confirmed by magnetic resonance venogram (MRV). Although cerebral angiography was performed, no intervention was attempted for the partially occluded sagittal sinus. HIV viral load was undetectable with a robust cluster of differentiation (CD) 4 count on therapy. The patient was treated with strict blood pressure control, a statin, and a heparin drip. He remained stable and was discharged on enoxaparin injections with bridging to warfarin. In summary, appropriate lab testing, imaging, and high clinical suspicion are required for proper diagnosis and treatment of venous thromboembolism (VTE) or CVST in an HIV-positive patient.

Impact of blood pressure on the outcomes of inpatients with Subarachnoid hemorrhage: A retrospective cross-sectional study.

It is unclear whether antihypertensive treatment should be indicated after subarachnoid hemorrhage (SAH). Hence, we investigated the impact of blood pressure on inpatient outcomes after SAH rehabilitation.This retrospective cross-sectional study analyzed data of SAH inpatients, as obtained from the Japan Association of Rehabilitation Database for inpatients undergoing SAH rehabilitation. Inpatients admitted to a conventional ward with a diagnosis of cerebrovascular disease were voluntarily registered in this database between January 2006 and December 2013 from hospitals in Japan. Patients were categorized into hypertensive and non-hypertensive populations and assessed using the Barthel Index (BI) and the total BI score at hospital discharge. We compared the independent population (patients with the highest score for each activity) with its non-independent counterpart. Data on the patients’ age, BI score on admission, total BI score, BI score increase, daily BI score increase, hospitalization duration, BI activities, patients’ sex, and Brunnstrom recovery stage were compared.Eighty-eight patients with SAH were analyzed; 43 were hypertensive and 45 non-hypertensive. Hypertension was associated with increased non-independence levels (hypertensive versus non-hypertensive patients, transfers [bed to chair and back]: 15 versus 24, P = .03, odds ratio (OR) = 2.532 (95% confidence interval [CI], 1.065–6.024); toilet use: 15 versus 24, P = .03, OR = 2.532 (95% CI, 1.065–6.024); bathing: 23 versus 34, P = .0061, OR = 3.623 (95% CI, 1.414–9.259); stair climbing: 22 versus 31, P = .03, OR = 2.703 (95% CI, 1.114–6.579); and bladder control: 14 versus 24, P = .02, OR = 2.801 (95% CI, 1.170–6.711)). The total BI score of the hypertensive inpatients at discharge was lower than that of their non-hypertensive counterparts (0–75 versus 80–100, 30 versus 19, P = .03). Moreover, the BI score increase per day was significantly lower in the hypertensive group than in the non-hypertensive group (.67 versus 1.8, P = .02). The hypertensive group also had a significantly longer duration of hospitalization than the hypertensive group (52 versus 30 days, P = .02).Hypertension was associated with longer hospitalization and poorer outcomes post-discharge, suggesting the importance of strict blood pressure control in patients who have experienced SAH.

Staying Connected: Transcriptomics in the Search for Novel Diabetic Kidney Disease Treatments.

Diabetic kidney disease (DKD) is the most common cause of end-stage renal disease in the U.S. Nephrologists and primary care providers are quite familiar with this diagnosis and the standard of care for slowing its long-term progression. Current treatment is highly reliant on nonspecific measures such as strict blood pressure and glycemic control. Until recent promising data showing benefits of sodium–glucose cotransporter 2 inhibitors (1), it had been more than two decades since specific pharmacological therapy with angiotensin-converting enzyme inhibitors or AT1 receptor blockers had been shown to be effective (2,3) in slowing progression of this disease. Morbidity and mortality remain high, and despite recent successes in the field, our current therapeutic armamentarium remains vastly inadequate to combat a disease of this magnitude. There remains a great need for discovery of further novel treatments. In this issue of Diabetes , Zhang et al. (4) use an innovative approach to identify new therapeutics for DKD. Rather than initiating their study with a targeted hypothesis focused on the role of a single signaling pathway, they used data from several publicly available gene expression data sets to perform an in silico screen of potential therapeutic agents. They conducted a transcriptome-wide search to define DKD “gene signatures” based …

Factors Associated with Antihypertensive Medication Adherence among Diabetic Patients with Coexisting Hypertension in a Tertiary Care Centre from a Low Middle Income South Asian Country

Introduction: Poor medication adherence is a known preventable factor which can adversely affect desired achievable blood pressure (BP) target. Strict control of blood pressure is essential among patients who have diabetes and hypertension (HT) in order to prevent complications. This is the first study conducted among 371diabetic patients with co-existing HT to examine the antihypertensive medication adherence in Sri Lanka to date. Materials and Methods: This cross-sectional study was done in the general medical clinics of Jaffna Teaching Hospital from October 2019 to November 2019. Results: The majority (66.6%) of the patients were female. Mean age of the participants was 60.93 ± 9.77. The total mean score for modified MASES (Medication Adherence Self Efficacy Scale) was 48.1 ± 3.81. A negative correlation was noted between MASES scores and systolic (r= -0.033) and diastolic (r=- 0.083) blood pressure. Median score 49 was used to classify the patients into optimal or suboptimal adherence to antihypertensive medication. A significant percentage (43.4%CI: 38.4-48.5) of research participants were sub optimally adhered to antihypertensive medication. Among the associated factors explored, gender (P-0.007), low-income (P-0.002) and employed people (P-0.046) showed significant association with poor adherence. However, the number of co-morbidities (P-0.335), number of medications (P-0.454), duration of hypertension (P-0.440), and frequency of clinical visits (P-0.373) were not significantly associated with anti-hypertensive medication adherence. Conclusion: This finding has an implication in clinical practice to improve the quality of care. Professionals should give consideration to above socio-demographic factors (gender, income, and occupation) before prescribing appropriate medication and its dosing schedule for hypertension.

Characteristic Pattern of the Cerebral Hemodynamic Changes in the Acute Stage After Combined Revascularization Surgery for Adult Moyamoya Disease: N-isopropyl-p-[123I] iodoamphetamine Single-Photon Emission Computed Tomography Study.

Surgical revascularization for moyamoya disease (MMD) prevents cerebral ischemic attack by improving cerebral blood flow (CBF) and could also reduce the risk of re-bleeding in hemorrhagic-onset patients. We sought to clarify the cerebral hemodynamic changes in the acute stage after revascularization surgery for adult MMD. The present study includes 54 consecutive adult patients with MMD (21-76years old, 43.1 average), undergoing superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis on 65 affected hemispheres. We prospectively performed single-photon emission computed tomography (SPECT) at postoperative day (POD) 1 and 7 of 65 surgeries. Perioperative management was conducted with strict blood pressure control (100-130mmHg) and minocycline hydrochloride administration. The outcome of 65 surgeries was favorable except for one (1.5%), which manifested as delayed intracerebral hemorrhage due to local hyperperfusion. The postoperative SPECT revealed the characteristic CBF improvement pattern with transient local hyperperfusion (POD1) and subsequent distribution of CBF in wider vascular territory (POD7) on 37 hemispheres (56.9%, 37/65). The revascularization surgery is a safe and effective treatment for adult MMD, while transient local hyperperfusion should be strictly managed by intensive perioperative care.

Severity of hypertension as a predictor of initiation of dialysis among study participants with and without diabetes mellitus

To determine associations between severity of hypertension and risk of starting dialysis in the presence or absence of diabetes mellitus (DM). A nationwide database with claims data on 258 874...