P57262018 ESC/ESH guideline-recommended age categories and intensive blood pressure management in high-risk adults: insights from SPRINT

Background

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for arterial hypertension propose different intensities of blood pressure (BP) lowering in patients <65 years, 65–79 years, and ≥80 years of age. However, it is unclear whether intensive BP management is well-tolerated and modifies risk uniformly across this age spectrum.

Purpose

To assess the relationship between age, treatment response to intensive BP lowering, and cardiovascular (CV) outcomes.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events (SAE). We examined the prognostic implications of age, using Cox proportional-hazards regression models adjusted for demographic, clinical, and laboratory variables. Whether a linear association was present between age and clinical endpoints was evaluated using restricted cubic splines. We further explored the effects of intensive BP lowering across the age spectrum using interaction analyses.

Results

Age was noted for all individuals, and 3,805 (41%), 4,390 (47%), and 1,166 (12%) were <65 years, 65–79 years, and ≥80 years, respectively. Mean age was similar between the two study groups (intensive group 67.9 years vs. standard group 67.9 years; P=0.94). Median follow-up was 3.3 years (range 0–4.8), with 562 primary efficacy events (6%) and 3,529 primary safety events (38%) recorded during the study period. Age was linearly associated with the risk of stroke (test for overall trend, P<0.001) and non-linearly associated with the risk of primary efficacy events, death from CV causes, death from any cause, heart failure, and SAE (test for non-linearity, P<0.05; test for overall trend, P<0.001). Age remained significantly associated with all tested endpoints after multivariable adjustment (P<0.001). Furthermore, the risk of primary events increased over guideline-recommended age-categories (65–79 years vs. <65 years; adj. HR 1.65, 95% CI 1.34–2.04; P<0.001 and ≥80 years vs. 65–79 years; adj. HR 1.92, 95% CI 1.54–2.40; P<0.001), as did the risk of SAE (P<0.001). The safety and efficacy of intensive BP lowering was not modified by age whether tested continuously or categorically (P>0.05). The Figure shows similar treatment effects (hazard ratios) across the spectrum of age. P-values are for the interaction between age and treatment effect for each endpoint.

Figure 1

Conclusions

In SPRINT, higher age was associated with a greater risk of both CV events and SAE. However, intensive BP lowering appeared to be associated with similar risks and benefits across the age spectrum.

Abstract P3018: Sirt3 Depletion in Human Essential Hypertension is Linked to Vascular Inflammation and Oxidative Stress While Endothelial Specific Sirt3 Depletion in Mice Promotes Vascular Dysfunction and Increases Hypertension

Hypertension represents a major risk factor for stroke, myocardial infarction, and heart failure and affects 30% of adult population. Vascular dysfunction is crucial in hypertension pathophysiology and exhibits bidirectional relationship. Metabolic disorders and oxidative stress contribute to vascular dysfunction, and mitochondrial deacetylase Sirt3 is critical in the regulation of metabolic and antioxidant functions. We hypothesized that reduced Sirt3 expression contributes to vascular dysfunction and essential hypertension. We studied Sirt3 in arterioles from human mediastinal fat in patients with essential hypertension compared with normotensive subjects. Pathophysiological role of vascular Sirt3 depletion was studied in mice with tamoxifen-inducible endothelial specific Sirt3 depletion (Ec Sirt3KO ). For the first time, we showed a 40% decrease in vascular Sirt3 level and 400% increase in SOD2 acetylation in hypertensive subjects which was linked to increased oxidative stress measured by superoxide overproduction and vascular inflammation due to elevated NfKB activity, VCAM, ICAM and MCP-1 levels. Interestingly, global Sirt3 depletion in mice increases blood pressure, inactivates key mitochondrial antioxidant SOD2 due to acetylation, increases vascular p65, VCAM, ICAM and MCP1, and increased T cell infiltration in kidney, induces cell-senescence and promotes vascular aging while global Sirt3 overexpression prevents these deleterious effects. We tested if Ec Sirt3KO mice have vascular dysfunction and hypertension. Both basal and angiotensin II-induced blood pressure was increased in Ec Sirt3KO mice accompanied by endothelial dysfunction and vascular O 2 • overproduction. Treatment of Ec Sirt3KO mice with SOD2-mimetic mitoTEMPO reduced vascular inflammation, markers of cell-senescence and vascular aging to the wild-type control levels while treatment of Ang II-infused Ec Sirt3KO mice partially rescues from vascular inflammation and attenuates accelerated vascular aging. We suggest that Sirt3 depletion in hypertension promotes both endothelial oxidative stress and metabolic dysfunction. Our data support a therapeutic potential of targeting Sirt3 expression in vascular dysfunction and hypertension.

Effect of temperature and time delay in centrifugation on stability of select biomarkers of nutrition and non-communicable diseases in blood samples

Introduction

Preanalytical conditions are critical for blood sample integrity and poses challenge in surveys involving biochemical measurements. A cross sectional study was conducted to assess the stability of select biomarkers at conditions that mimic field situations in surveys.

Material and methods

Blood from 420 volunteers was exposed to 2 - 8 °C, room temperature (RT), 22 - 30 °C and > 30 °C for 30 min, 6 hours, 12 hours and 24 hours prior to centrifugation. After different exposures, whole blood (N = 35) was used to assess stability of haemoglobin, HbA1c and erythrocyte folate; serum (N = 35) for assessing stability of ferritin, C-reactive protein (CRP), vitamins B12, A and D, zinc, soluble transferrin receptor (sTfR), total cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), tryglicerides, albumin, total protein and creatinine; and plasma (N = 35) was used for glucose. The mean % deviation of the analytes was compared with the total change limit (TCL), computed from analytical and intra-individual imprecision. Values that were within the TCL were deemed to be stable.

Result

Creatinine (mean % deviation 14.6, TCL 5.9), haemoglobin (16.4%, TCL 4.4) and folate (33.6%, TCL 22.6) were unstable after 12 hours at 22-30°C, a temperature at which other analytes were stable. Creatinine was unstable even at RT for 12 hours (mean % deviation: 10.4). Albumin, CRP, glucose, cholesterol, LDL, triglycerides, vitamins B12 and A, sTfR and HbA1c were stable at all studied conditions.

Conclusion

All analytes other than creatinine, folate and haemoglobin can be reliably estimated in blood samples exposed to 22-30°C for 12 hours in community-based studies.

Breast deformation during the course of radiotherapy: The need for an additional outer margin

PURPOSE

The aim of this retrospective study was to investigate and quantify the extent of breast deformation during the course of breast cancer (BC) radiotherapy (RT). The magnitude of breast deformation determines the additional outer margin needed for treatment planning to deliver a full dose to the target volume. This is especially important when using inverse planning techniques.

METHODS

A total of 93 BC patients treated with RT and with daily CBCT image guidance were selected for this study. Patients underwent either only breast-conserving surgery (BCS) (n = 5), BCS with sentinel node biopsy (n = 57) or BCS with radical axillary node dissection (n = 31). The treatment area included the whole breast and chest wall (54%) or also the axillary lymph nodes (46%). 3D-registration was conducted between 1731 CBCT images and the respective planning CT images to assess the difference in breast surface.

RESULTS

The largest maximum breast surface expansion (MBSE) was 15 mm; the average was 2.4 ± 2.1 mm. In 294 fractions (17%), the MBSE was ≥5 mm. An outer margin of 8 mm would have been required to cover the whole breast in 95% of the treated fractions. There was a statistically significant correlation between the MBSE and body mass index (r = 0.38, p = 0.001).

CONCLUSIONS

Significant changes in the breast surface occur during the course of BC RT which should be considered in treatment planning. An additional margin outside the breast surface of at least 8 mm is required to take into account the anatomical changes occurring during BC RT.

Quantification of atomic hydrogen anion density in a permanent magnet based helicon ion source (HELEN) by using pulsed ring down spectroscopy

In the present work, a permanent magnet-based helicon plasma source (HELEN) is characterized as a negative ion source. A noninvasive diagnostic technique based on cavity ring down spectroscopy (CRDS) is developed to measure the line-integrated negative hydrogen ion (H^-) density in HELEN. This paper discusses the experimental results in which negative hydrogen ion density is measured for different magnetic field, pressure, and RF (13.56 MHz) power configurations. It is observed that in high power range (800-850 W), the source is operating in helicon wave heating mode with a background plasma density of ∼10¹⁸ m^-3 and electron temperature of ∼2 eV. Negative hydrogen ion density is measured by CRDS method and also by optical emission spectroscopic technique. The measured negative ion density is in the range of ∼10¹⁶ m^-3 under volume mode operational condition even without any use of standard magnetic filter or cesium seeding in the downstream region. The influence of pressure variation (pressure range from 4 × 10^-3 mbar to 4 × 10^-2 mbar) on negative ion density production is not significant, except for a particular axial magnetic field configuration (55 G) and at 8 × 10^-3 mbar pressure, where ∼34% hike is observed.

Effect of electron blocking layer on the efficiency of AlGaN mid-ultraviolet light emitting diodes

The performance of AlGaN-based mid and deep ultraviolet light emitting diodes (LEDs) is severely limited by electron overflow and by the poor hole injection into the device active region. We have studied the effect of various electron blocking layers on the performance of AlGaN LEDs operating at ~280 nm. It is observed that, compared to conventional p-type electron blocking layer, the incorporation of an n-type AlN/AlGaN superlattice electron blocking layer before the active region can significantly improve the device performance by reducing electron overflow without compromising hole injection. Direct on-wafer measurement showed an external quantum efficiency ~4.4% and wall-plug efficiency ~2.8% by optimizing the design of n-type AlN/AlGaN superlattice electron blocking layer, which is nearly a factor of five to ten times better than identical devices but with the incorporation of a conventional p-type electron blocking layer.

A three dimensional (3D) musculoskeletal finite element analysis of DARSN temporomandibular joint (TMJ) prosthesis for total unilateral alloplastic joint replacement

PURPOSE

The purpose of this study was to evaluate the strain and stress distribution for DARSN alloplastic unilateral temporomandibular joint (TMJ) prosthesis and the effects on contralateral natural joint using a finite element analysis (FEA).

METHODS

The replacement of the TMJ may have complications like infection, failure of hardware, facial paralysis and perforation. The understanding of the mechanical forces exerted by muscles of mastication and jaw movement on the joint helps in identifying the regions on alloplastic TMJ with various maximum forces, which makes that area more prone for failure of hardware. A three dimensional structural FEA was applied using a validated finite element model (FEM) where the areas of stress and strain were evaluated in the alloplastic joint and the contralateral natural joint. As the pattern of stress and strain can be influenced by the materials used for alloplastic joint and geometry of the design, mechanical property of bone and the attached musculature were also considered while construction the FEM analysis.

RESULTS

The forces of the muscles of mastication has a vital role on the amount of stress and strain present across the alloplastic joint. Masseter and temporalis exhibited the greatest resultant force on the alloplastic as well as the natural condyle with a magnitude of 272 N and 329 N. This study assessed the maximum stress and strain on the condyle-ramus unit and fossa.

CONCLUSION

FEA shows that alloplastic DARSN TMJ prosthesis distributes stress and strain equally between the alloplastic joint site and the contralateral natural joint causing minimal adverse effects to the natural joint. FEA also evaluated the stress and strain on alloplastic component and resulted in drawing clinical implications for operating surgical team.

Effect of Diabetes on the Male Reproductive System—A Histomorphological Study

Introduction Type 1 diabetes is an autoimmune disorder characterized by lack of insulin production by the β cells of the pancreas. This lack of insulin causes a variety of systemic effects on the metabolism of the body, one of which is reproductive dysfunction. The present study investigates the effects of diabetes on the male reproductive system of streptozotocin (STZ)-induced diabetic rats.

Material and Methods A total of 18 adult male Wistar rats weighing ∼ between 250 and 300 g were included in the present study. The animals were divided into normal and diabetic groups. The diabetic group was further subdivided into 2 subgroups with durations of 24 and 48 days. A single dose of STZ (40 mg/kg body weight) was administrated intraperitoneally to the animals of the diabetic group. After the planned duration, the testes and epididymides were dissected, and their gross weight was measured. The tissues were then processed for histological study.

Results The gross weight of the testes and epididymides in diabetic rats at 24 and 48 days showed a decrease in comparison to the control. (p < 0.01 for testes and epididymides).

Diabetic animals presented a significant decrease in the diameter of the seminiferous tubules compared with the control group (p < 0.01). The epididymides in the diabetic groups showed a considerable reduction in the tubular surface area compared with the control group (p < 0.01). There was also a reduction in the mean diameter, which was measured using the maximum and minimum diameter of the tubules (p < 0.01).

Conclusion The present study is an insight into the adverse effects that diabetes can have on the tissue structure of the testes, of the epididymides, and ultimately on the process of spermatogenesis.

Broadly tunable wideband optical single sideband generation using self-coupled silicon resonator

We propose and demonstrate a tunable broadband optical single sideband generation using self-coupled silicon micro-ring resonator. We exploit self-coupling in a ring cavity to generate tunable resonance splitting. Using the proposed device, single sideband with carrier signal is generated from a double sideband signal. Experimental verification of power fading free transmission through a 43 km signal mode optical fiber is achieved for an RF frequency range of 1-20 GHz, extendible to higher frequencies. We also achieved a spurious free dynamic range of > 99.9±1.05 dB.Hz^2/3 over the demonstrated frequency range. Furthermore, error-free data transmission of 1-12 Gbps over a 43 km fiber is also demonstrated with a detailed analysis of bit error rate as well.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A Case of Sirolimus-Induced Interstitial Lung Disease After Liver Transplantation

Mammalian target of rapamycin inhibitors (mTORis) are immunosuppression agents that are commonly used in solid organ transplantation. Available mTORis include sirolimus and everolimus. Interstitial lung disease (ILD) is an uncommon side effect of mTORis in liver transplantation. A high index of suspicion is needed, and timely intervention can reverse the disease. We present a case of sirolimus-induced ILD that improved after discontinuation of sirolimus.

Clinical Trials Registry - India: An overview and new developments

The Clinical Trials Registry – India (CTRI), launched over 10 years ago, is a free, searchable online platform for registration of clinical trials being conducted in India and as well as countries which do not have a Primary Registry of their own. The objective of the present article is to appraise the current status and the new developments of CTRI, which registers all types of clinical studies, including postgraduate theses. The CTRI which was until now allowing both prospective and retrospective registration is moving towards only prospective trial registration. From April 1, 2018, only those trials where the first patient enrollment has not yet commenced will be registered. Further, the CTRI is in the process of implementing structured summary results disclosure of all interventional clinical trials in the near future.