Forehead Regional Oxygen Saturation (rSO2)-Related Ear-Level Arterial Pressure and Lower Thigh rSO2 in the Steep Trendelenburg Position with CO2 Pneumoperitoneum and the Beach Chair Position

Introduction

Regional oxygen saturation (rSO2) reflects tissue perfusion. This observational study aimed to examine the change in the forehead and lower thigh rSO2 associated with intraoperative posture, anesthesia regimen, or mean arterial pressure (mAP) at heart and external auditory meatus (ear) levels.

Methods

Patients undergoing robot-assisted laparoscopic radical prostatectomy in the Trendelenburg position at 30° with pneumoperitoneum (TPP) or arthroscopic shoulder surgery in the beach chair position at 70° (BCP) under desflurane-remifentanil (D/R) or propofol-remifentanil (P/R) anesthesia were examined. Bilateral forehead and lower thigh rSO2 values and mean radial artery pressure were measured simultaneously at heart and ear levels.

Results

In TPP, there were no differences under anesthesia regimens in the forehead or lower thigh rSO2change, although one patient with an absolute lower thigh rSO2 of ≤50% in the lithotomy position complained of transient limb pain. No correlation was observed between rSO2 and mAP. In BCP, forehead rSO2 decreased and lower thigh rSO2 increased under either of the anesthesia regimens. The coefficient of correlation between forehead rSO2 andheart-level and ear-level mAP was 0.341 and 0.236, respectively.

Conclusions

There were no differences under anesthesia regimens in the changes of forehead rSO2 and lower thigh rSO2. In TPP, significant changes in forehead rSO2 and lower thigh rSO2 were not observed. Monitoring lower thigh rSO2 might be useful for preventing lower extremity pain. In BCP, forehead rSO2 decreased and lower thigh rSO2 increased from the supine position to the BCP. To prevent brain damage, anesthesiologists should pay attention to heart- and ear-level mAP.

Long-Term Visit-to-Visit Mean Arterial Pressure Variability and the Risk of Heart Failure and All-Cause Mortality

Background: Systolic or diastolic blood pressure (BP) variability is associated with an increased risk of cardiovascular events. We assessed whether BP variability measured by mean arterial pressure (MAP) was associated with increased risk of heart failure (HF) and death in individuals with or without hypertension. Methods: We evaluated 9,305 Atherosclerosis Risk in Communities (ARIC) study participants with or without hypertension and calculated BP variability based on MAP values from visit 1 to 4 [expressed as standard deviation (SD), average real variability (ARV), coefficient of variation (CV), and variability independent of the mean (VIM)]. Multivariate-adjusted Cox regression model and restricted cubic spline curve were used to evaluate the associations of MAP variability with all-cause mortality and HF. Results: During a median follow-up of 16.8 years, 1,511 had an HF event and 2,903 died. Individuals in the highest quartile of VIM were both associated with a 21% higher risk of all-cause mortality [hazard ratio (HR), 1.21; 95% CI, 1.09-1.35] and HF (HR, 1.21; 95% CI, 1.04-1.39) compared with the lowest quartile of VIM. Cubic spline curves reveal that the risk of deaths and HF increased with MAP variability when it reached a higher level. Results were similar in individuals with normotension (all-cause mortality: HR, 1.30; 95% CI, 1.09-1.55; HF, HR, 1.49; 95% CI, 1.12-1.98). Conclusions: In individuals with or without hypertension, greater visit-to-visit MAP variability was associated with a higher risk of all-cause mortality and HF, indicating that the BP variability assessed by MAP might be a potential risk factor for HF and death.

Comparing intravenous dexmedetomidine and clonidine in hemodynamic changes and block following spinal anesthesia with ropivacaine in lower limb orthopedic surgery: a randomized clinical trial

Dexmedetomidine (DEX) can prolong duration of anesthesia and shorten onset of sensory and motor block relative to clonidine. This study attempted to compare the efficacy of intravenous DEX and clonidine for hemodynamic changes and block after spinal anesthesia with ropivacaine in lower limb orthopedic surgery. In a double-blind randomized clinical trial, 120 patients undergoing spinal anesthesia in lower limb orthopedic surgery were recruited and divided into three groups using balanced block randomization: DEX group (n = 40; intravenous DEX 0.2 µg/kg), clonidine group (n = 40; intravenous clonidine 0.4 µg/kg), and placebo group (n = 40; intravenous normal saline 10 mL) in which pain scores were assessed using visual analogue scales (at recovery, and 2, 4, 6, and 12 hours after surgery) and time to achieve and onset of sensory and motor block. Statistically significant differences were found in mean arterial pressure among the groups at all times except baseline (P = 0.001), with a less mean arterial pressure and a prolonged duration of sensory and motor block (P = 0.001) in the DEX group where pain relieved in patients immediately after surgery and at above mentioned time points (P = 0.001). Simultaneous administration of intravenous DEX with ropivacaine for spinal anesthesia prolongs the duration of sensory and motor block and relieves postoperative pain, and however, can decrease blood pressure. Although intravenous DEX as an adjuvant can be helpful during spinal anesthesia with ropivacaine, it should be taken with caution owing to a lowering of mean arterial pressure in patients especially in the older adults. This study was approved by Ethical Committee of Arak University of Medical Sciences (No. IR.Arakmu.Rec.1395.450) in March, 2017, and the trial was registered and approved by the Iranian Registry of Clinical Trials (IRCT No. IRCT2017092020258N60) in 2017.

Post-exercise Body Cooling: Skin Blood Flow, Venous Pooling, and Orthostatic Intolerance

Athletes and certain occupations (e.g., military, firefighters) must navigate unique heat challenges as they perform physical tasks during prolonged heat stress, at times while wearing protective clothing that hinders heat dissipation. Such environments and activities elicit physiological adjustments that prioritize thermoregulatory skin perfusion at the expense of arterial blood pressure and may result in decreases in cerebral blood flow. High levels of skin blood flow combined with an upright body position augment venous pooling and transcapillary fluid shifts in the lower extremities. Combined with sweat-driven reductions in plasma volume, these cardiovascular alterations result in levels of cardiac output that do not meet requirements for brain blood flow, which can lead to orthostatic intolerance and occasionally syncope. Skin surface cooling countermeasures appear to be a promising means of improving orthostatic tolerance via autonomic mechanisms. Increases in transduction of sympathetic activity into vascular resistance, and an increased baroreflex set-point have been shown to be induced by surface cooling implemented after passive heating and other arterial pressure challenges. Considering the further contribution of exercise thermogenesis to orthostatic intolerance risk, our goal in this review is to provide an overview of post-exercise cooling strategies as they are capable of improving autonomic control of the circulation to optimize orthostatic tolerance. We aim to synthesize both basic and applied physiology knowledge available regarding real-world application of cooling strategies to reduce the likelihood of experiencing symptomatic orthostatic intolerance after exercise in the heat.

Comparison between video-lighted stylet (Intular Scope™) and direct laryngoscope for endotracheal intubation in patients with normal airway

Objective

The Intular Scope™ (Medical Park, South Korea) (IS) is a video-lighted stylet that can be used for endotracheal intubation with excellent visualization by adding a camera to its end. We compared the efficacy of a direct laryngoscope (DL) with that of the IS based on hemodynamic changes, ease of intubation, and postoperative airway morbidities.

Methods

Seventy patients with expected normal airways were randomized for intubation using an IS (n = 35) or DL (n = 35). The primary outcome was the mean arterial pressure during intubation. The secondary outcomes were the time to intubation (TTI), percentage of glottic opening (POGO) score, and number of intubation attempts. The incidence and severity of bleeding, hoarseness, and sore throat after intubation were also recorded.

Results

Hemodynamic changes during intubation were not significantly different between the groups. The TTI was longer in the IS than DL group. The POGO score was higher in the IS than DL group. Hoarseness and sore throat were significantly less severe in the IS than DL group.

Conclusions

Using the IS did not significantly improve hemodynamics and resulted in a longer TTI. However, the IS was associated with less severe postoperative airway morbidities compared with the DL.

Intraparenchymal Neuromonitoring of Cerebral Fat Embolism Syndrome

Objectives:

We aimed to characterize the cerebrovascular physiology of cerebral fat embolism using invasive multimodal neuromonitoring.

Data Sources:

ICU, Vancouver General Hospital, Vancouver, BC, Canada.

Study Selection:

Case report.

Data Extraction:

Patient monitoring software (ICM+, Cambridge, United Kingdom), clinical records, and surgical records.

Data Synthesis:

None.

Conclusions:

Our integrated assessment of the cerebrovascular physiology of fat embolism syndrome provides a physiologic basis to investigate the importance of augmenting mean arterial pressure to optimize cerebral oxygen delivery for the mitigation of long-term neurologic ischemic sequelae of cerebral fat embolism.

Gravity Threshold and Dose Response Relationships: Health Benefits Using a Short Arm Human Centrifuge

Purpose

Increasing the level of gravity passively on a centrifuge, should be equal to or even more beneficial not only to astronauts living in a microgravity environment but also to patients confined to bed. Gravity therapy (GT) may have beneficial effects on numerous conditions, such as immobility due to neuromuscular disorders, balance disorders, stroke, sports injuries. However, the appropriate configuration for administering the Gz load remains to be determined.

Methods

To address these issues, we studied graded G-loads from 0.5 to 2.0g in 24 young healthy, male and female participants, trained on a short arm human centrifuge (SAHC) combined with mild activity exercise within 40–59% MHR, provided by an onboard bicycle ergometer. Hemodynamic parameters, as cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were analyzed, as well as blood gas analysis. A one-way repeated measures ANOVA and pairwise comparisons were conducted with a level of significance p < 0.05.

Results

Significant changes in heart rate variability (HRV) and its spectral components (Class, Fmax, and VHF) were found in all g loads when compared to standing (p < 0.001), except in 1.7 and 2.0g. There were significant changes in CO, cardiac index (CI), and cardiac power (CP) (p < 0.001), and in MAP (p = 0.003) at different artificial gravity (AG) levels. Dose-response curves were determined based on statistically significant changes in cardiovascular parameters, as well as in identifying the optimal G level for training, as well as the optimal G level for training. There were statistically significant gender differences in Cardiac Output/CO (p = 0.002) and Cardiac Power/CP (p = 0.016) during the AG training as compared to standing. More specifically, these cardiovascular parameters were significantly higher for male than female participants. Also, there was a statistically significant (p = 0.022) gender by experimental condition interaction, since the high-frequency parameter of the heart rate variability was attenuated during AG training as compared to standing but only for the female participants (p = 0.004).

Conclusion

The comprehensive cardiovascular evaluation of the response to a range of graded AG loads, as compared to standing, in male and female subjects provides the dose-response framework that enables us to explore and validate the usefulness of the centrifuge as a medical device. It further allows its use in precisely selecting personalized gravity therapy (GT) as needed for treatment or rehabilitation of individuals confined to bed.

Blood pressure-related differences in brain health between young African Americans and Caucasian Americans

Background

Although there are moderating effects of race on blood pressure (BP) and brain health in older adults, it is currently unknown if these race‐related differences in cardiovascular and associated brain function are also present in younger adults. The purpose of this study was to investigate the interaction between race and BP on brain health in younger African (AA) and Caucasian Americans (CA).

Methods

We studied 971 younger adults (29.1 ± 3.5 years; 180 AAs and 791 CAs) who volunteered to participate in the Human Connectome Project. Cognitive composite scores, brain volume, and cortical thickness using MRI were cross‐sectionally assessed. ANCOVA was used to examine interactions between race and mean arterial pressure (MAP) on cognitive test scores and brain structure.

Results

After controlling for age, sex, education, and BMI, there were significant Race × MAP interaction effects on cognitive composite scores and cortical thickness. Among AAs but not CAs, as MAP increased, both global cognitive performance and entorhinal cortex (ERC) thickness decreased.

Conclusions

MAP was an important moderator of racial differences in cognitive performance and ERC thickness. Our findings suggest that young AAs may carry a greater hypertension‐associated risk for cognitive brain health deficit. Interventions that address early signs of hypertension in AAs are needed to determine if the racial disparities in BP‐related brain health in late adulthood can be reduced.

Prediction of pre-eclampsia in twin pregnancy by maternal factors and biomarkers at 11-13 weeks' gestation: data from EVENTS trial

OBJECTIVES

First, to validate a previously developed model for screening for pre-eclampsia (PE) by maternal characteristics and medical history in twin pregnancies; second, to compare the distributions of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A) in twin pregnancies that delivered with PE to those in singleton pregnancies and to develop new models based on these results; and, third, to examine the predictive performance of these models in screening for PE with delivery at < 32 and < 37 weeks' gestation.

METHODS

Two datasets of prospective non-intervention multicenter screening studies for PE in twin pregnancies at 11 + 0 to 13 + 6 weeks' gestation were used. The first dataset was from the EVENTS (Early vaginal progesterone for the preVention of spontaneous prEterm birth iN TwinS) trial and the second was from a previously reported study that examined the distributions of biomarkers in twin pregnancies. Maternal demographic characteristics and medical history from the EVENTS-trial dataset were used to assess the validity of risks from our previously developed model. The combined data from the first and second datasets were used to compare the distributional properties of log₁₀ multiples of the median (MoM) values of UtA-PI, MAP, PlGF and PAPP-A in twin pregnancies that delivered with PE to those in singleton pregnancies and develop new models based on these results. The competing-risks model was used to estimate the individual patient-specific risks of delivery with PE at < 32 and < 37 weeks' gestation. Screening performance was measured by detection rates (DR) and areas under the receiver-operating-characteristics curve.

RESULTS

The EVENTS-trial dataset comprised 1798 pregnancies, including 168 (9.3%) that developed PE. In the validation of the prior model based on maternal characteristics and medical history, calibration plots demonstrated very good agreement between the predicted risks and the observed incidence of PE (calibration slope and intercept for PE < 32 weeks were 0.827 and 0.009, respectively, and for PE < 37 weeks they were 0.942 and -0.207, respectively). In the combined data, there were 3938 pregnancies, including 339 (8.6%) that developed PE and 253 (6.4%) that delivered with PE at < 37 weeks' gestation. In twin pregnancies that delivered with PE, MAP, UtA-PI and PlGF were, at earlier gestational ages, more discriminative than in singleton pregnancies and at later gestational ages they were less so. For PAPP-A, there was little difference between PE and unaffected pregnancies. The best performance of screening for PE was achieved by a combination of maternal factors, MAP, UtA-PI and PlGF. In screening by maternal factors alone, the DR, at a 10% false-positive rate, was 30.6% for delivery with PE at < 32 weeks' gestation and this increased to 86.4% when screening by the combined test; the respective values for PE < 37 weeks were 24.9% and 41.1%.

CONCLUSIONS

In the assessment of risk for PE in twin pregnancy, we can use the same prior model based on maternal characteristics and medical history as reported previously, but in the calculation of posterior risks it is necessary to use the new distributions of log₁₀ MoM values of UtA-PI, MAP and PlGF according to gestational age at delivery with PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Outcomes of combined use of topical and intravenous tranexamic acid on surgical field quality during functional endoscopic sinus surgery: Randomized controlled trial

BACKGROUND

Intraoperative bleeding during functional endoscopic sinus surgery (FESS) poses a challenge to both surgeon and anesthetist. The primary aim of this study was to evaluate the effectiveness of local, intravenous and combined use of tranexamic acid (TA) in improving the surgical field quality during FESS.

METHODS

We conducted a randomized controlled double-blinded prospective trial on 120 patients scheduled for elective FESS. After induction of general anesthesia, patients were randomly and evenly assigned to one of four groups; IV TA, local TA, both IV and local TA, and placebo. Surgical field was assessed using five-point Boezaart scale. Total fentanyl and esmolol consumption, operative time, recovery time, and postoperative complications were recorded.

RESULTS

Surgical field quality score was the best in IV and local TA group compared to others (p < 0.001). Mean operative time was found significantly shorter in IV and local TA group than placebo one. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others (p = 0.025). Mean recovery time was significantly shorter for IV and local TA group compared to others. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others. No significant differences were found of mean arterial pressure and heart rate decline in four groups. None of the patients in four groups required esmolol administration. No statistically significant differences were found in change of hemoglobin, hematocrit, prothrombin time, and partial thromboplastin time over time in all groups.

CONCLUSION

The combined use of topical and intravenous TA provided the best surgical field in FESS, less fentanyl consumption, and less recovery time without causing significant side effects.

A Descriptive Study of Perioperative Hemodynamics in Open Cardiac Surgery Patients

OBJECTIVES

The purpose of the present study was to describe how the perioperative hemodynamic profile before and after cardiopulmonary bypass during cardiac surgery is influenced by age and to describe the association between postoperative hemodynamics and one-year mortality.

DESIGN

A retrospective registry-based study.

SETTING

University Hospital of Aarhus, Denmark.

PARTICIPANTS

The study comprised 6,595 patients undergoing elective on-pump cardiac surgery from 2006 to 2016.

MEASUREMENTS AND MAIN RESULTS

Perioperative hemodynamic values were derived from computerized anesthesia and intensive care reports, including mean arterial pressure, cardiac index, and oxygenation saturation from mixed venous blood in the pulmonary artery, during the perioperative period. Perioperative hemodynamic values were stratified according to age. Logistic regression was applied to predict the crude probability of death within one year from surgery according to hemodynamic values at six hours after surgery, stratified by age and use of inotropic agents, respectively. Lower values for cardiac index and mixed venous blood in the pulmonary artery with increasing age, across all points in time in the perioperative course, were observed. Higher probability of death was associated with lower hemodynamic values in the postoperative phase, and the probability of death was modified by age and the need for inotropic agents.

DISCUSSION

This is a large registry based study describing the perioperative hemodynamic profile of patients undergoing cardiac surgery and the results enhance our understanding of age-differentiated values of CI and SvO2 in this specific population.

Intraoperative monitoring parameters and postoperative delirium: Results of a prospective cross-sectional trial

Postoperative delirium (PODE) can be associated with severe clinical complications; therefore, preventive measures are important. The objective of this trial was to elucidate whether haemodynamic or electroencephalographic (EEG) monitoring parameters during general anaesthesia or sevoflurane dosage correlate with the incidence of PODE. In addition, sevoflurane dosages and EEG stages during the steady state of anaesthesia were analyzed in patients of different ages.Eighty adult patients undergoing elective abdominal surgery received anaesthesia with sevoflurane and sufentanil according to the clinical routine. Anaesthesiologists were blinded to the EEG. Haemodynamic parameters, EEG parameters, sevoflurane dosage, and occurrence of PODE were analyzed.Thirteen patients (4 out of 33 women, 9 out of 47 men) developed PODE. Patients with PODE had a greater mean arterial pressure (MAP) variance (267.26 (139.40) vs 192.56 (99.64) mmHg2, P = .04), had a longer duration of EEG burst suppression or suppression (27.09 (45.32) vs 5.23 (10.80) minutes, P = .03), and received higher minimum alveolar sevoflurane concentrations (MAC) (1.22 (0.22) vs 1.09 (0.17), P = .03) than patients without PODE. MAC values were associated with wide ranges of EEG index values representing different levels of hypnosis.The results suggest that, in order to prevent PODE, a great variance of MAP, higher doses of sevoflurane, and deep levels of anaesthesia should be avoided. Titrating sevoflurane according to end-tidal gas monitoring and vital signs can lead to unnecessarily deep or light hypnosis. Intraoperative EEG monitoring may help to prevent PODE.

Association of Fatal and Nonfatal Cardiovascular Outcomes With 24-Hour Mean Arterial Pressure

Major adverse cardiovascular events are closely associated with 24-hour blood pressure (BP). We determined outcome-driven thresholds for 24-hour mean arterial pressure (MAP), a BP index estimated by oscillometric devices. We assessed the association of major adverse cardiovascular events with 24-hour MAP, systolic BP (SBP), and diastolic BP (DBP) in a population-based cohort (n=11 596). Statistics included multivariable Cox regression and the generalized R2 statistic to test model fit. Baseline office and 24-hour MAP averaged 97.4 and 90.4 mm Hg. Over 13.6 years (median), 2034 major adverse cardiovascular events occurred. Twenty-four-hour MAP levels of <90 (normotension, n=6183), 90 to <92 (elevated MAP, n=909), 92 to <96 (stage-1 hypertension, n=1544), and ≥96 (stage-2 hypertension, n=2960) mm Hg yielded equivalent 10-year major adverse cardiovascular events risks as office MAP categorized using 2017 American thresholds for office SBP and DBP. Compared with 24-hour MAP normotension, hazard ratios were 0.96 (95% CI, 0.80-1.16), 1.32 (1.15-1.51), and 1.77 (1.59-1.97), for elevated and stage-1 and stage-2 hypertensive MAP. On top of 24-hour MAP, higher 24-hour SBP increased, whereas higher 24-hour DBP attenuated risk (P<0.001). Considering the 24-hour measurements, R2 statistics were similar for SBP (1.34) and MAP (1.28), lower for DBP than for MAP (0.47), and reduced to null, if the base model included SBP and DBP; if the ambulatory BP indexes were dichotomized according to the 2017 American guideline and the proposed 92 mm Hg for MAP, the R2 values were 0.71, 0.89, 0.32, and 0.10, respectively. In conclusion, the clinical application of 24-hour MAP thresholds in conjunction with SBP and DBP refines risk estimates.

Usefulness of Ankle-Brachial Index Calculated Using Diastolic Blood Pressure and Mean Arterial Pressure in Predicting Overall and Cardiovascular Mortality in Hemodialysis Patients

No study has investigated the predictive ability of ankle-brachial index (ABI) calculated using diastolic blood pressure (DBP) (ABIdbp) and mean arterial pressure (MAP) (ABImap) for overall and cardiovascular (CV) mortality in hemodialysis (HD) patients. Our study was aimed to investigate the issue. Two hundred and seven routine HD patients were enrolled. ABI values were measured by ABI-form device. During the follow-up period (122 months), 124 of the 207 patients (59.0%) died, and 59 deaths due to CV cause. Multivariate analysis showed that low ABIsbp, ABIdbp, and ABImap were all significantly associated with increased overall (p ≤ 0.015) and CV mortality (p ≤ 0.015) in whole study patients. A subgroup analysis after excluding 37 patients with ABIsbp < 0.9 or > 1.3 found ABIsbp and ABIsbp < 0.9 were not associated with overall and CV mortality. However, ABImap and ABIdbp < 0.87 were significantly associated with overall mortality (p ≤ 0.042). Furthermore, ABIdbp and ABIdbp < 0.87 were significantly associated with CV mortality (p ≤ 0.030). In conclusion, ABIsbp, ABIdbp, and ABImap were all useful in predicting overall and CV mortality in our HD patients. In the subgroup patients with normal ABIsbp, ABIsbp and ABIsbp < 0.9 were not useful to predict overall and CV mortality. Nevertheless, ABImap and ABIdbp < 0.87 could still predict overall mortality, and ABIdbp and ABIdbp < 0.87 could predict CV mortality. Hence, calculating ABI using DBP and MAP may provide benefit in survival prediction in HD patients, especially in the patients with normal ABIsbp.

Midodrine Improves the Tolerability of Diuretics in Patients with Acute-on-Chronic Liver Failure-A Pilot Study

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a syndrome of acute portal hypertension with high short-term mortality. ACLF patients have low mean arterial pressure (MAP), systemic vascular resistance, and high cardiac output. This, in turn, leads to an increased incidence of ascites, acute kidney injury, and hyponatremia. We evaluated the role of the early addition of midodrine, which has not been analyzed to date.

METHODS

ACLF patients who were started on midodrine (Gr. A) in addition to standard of care (SOC) for ascites control were included and compared with those who received only SOC (Gr. B). The aim was to assess the hemodynamics, ascites control, diuretic-related complications, and mortality at 1 month.

RESULTS

Forty-five ACLF patients (Gr. A-21; Gr. B-24) were included in the pilot study. At inclusion, the baseline characteristics were similar among the groups. The dose of midodrine was 22.5 (7.5-22.5) mg/day for 22.29 ± 8.75 days in Gr. A. Midodrine significantly improved the MAP and urinary sodium excretion. Only 33.34% of patients required paracentesis in Gr. A compared with 62.5% in Gr. B (p = 0.05). Gr. A patients tolerated a higher dose of diuretics than Gr. B. Diuretic-related complications developed in 54.2% of patients in Gr. B compared with only 23.8% in Gr. A (p = 0.03). Fourteen percent in Gr. A developed side effects to midodrine and required dose modification. Mortality at day 30 was similar in both groups.

CONCLUSION

Addition of midodrine improves the hemodynamics, tolerability of diuretics, and ascites control in ACLF patients.

A randomized parallel design trial of the efficacy and safety of tranexamic acid, dexmedetomidine and nitroglycerin in controlling intraoperative bleeding and improving surgical field quality during septorhinoplasty under general anesthesia

In this blinded clinical trial, we attempted to compare the efficacy and safety of administering tranexamic acid, dexmedetomidine and nitroglycerin in preventing intraoperative bleeding and improving the quality of the surgical field during septorhinoplasty under general anesthesia. A total of 105 patients scheduled for septorhinoplasty were enrolled and randomly assigned into three groups based on the balanced-block randomization method. First group received 1 μg/kg intravenous injection dexmedetomidine, second group received 10 mg/kg intravenous injection tranexamic acid and third group received 0.5 μg/kg nitroglycerin, intravenously. The study sample was composed of 105 participants with the total mean age of 25.85 ± 6.52 years, and 59.05% of participants were female and the mean of body mass index was 24.34 ± 2.57 kg/m². The results showed that there was no statistically significant difference in terms of arterial oxygen saturation, mean arterial pressure, heart rate, bleeding rate, duration of surgery, and surgeon satisfaction among the three groups; however, there was a significant difference in the extubation time, recovery time and the dose of administered propofol among the three groups. Dexmedetomidine reduced the dose of administered propofol while increasing the extubation time and recovery time. In the tranexamic acid group compared with the other two groups, the recovery time was shorter. However, all the three drugs could reduce intraoperative bleeding and lead to surgeon satisfaction. It can be concluded that all these three drugs can be utilized to control bleeding and improve the quality of the surgical field but the ultimate decision lies with the anesthesiologist's judgment and the conditions of the patient. The study protocol was registered in the Iranian Registry of Clinical Trials (registration No. IRCT20141209020258N121) on September 24, 2019 and it was ethically approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU.REC.1397.355) on February 24, 2019.

Competing-risks model for prediction of small-for-gestational-age neonate from biophysical and biochemical markers at 11-13 weeks' gestation

OBJECTIVE

To develop a new competing-risks model for the prediction of a small-for-gestational-age (SGA) neonate, based on maternal factors and biophysical and biochemical markers at 11-13 weeks' gestation.

METHODS

This was a prospective observational study in 60 875 women with singleton pregnancy undergoing routine ultrasound examination at 11 + 0 to 13 + 6 weeks' gestation. All pregnancies had pregnancy-associated plasma protein-A and placental growth factor (PlGF) measurements, 59 001 had uterine artery pulsatility index (UtA-PI) measurements and 58 479 had mean arterial pressure measurements; 57 131 cases had complete data for all biomarkers. We used a previously developed competing-risks model for the joint distribution of gestational age (GA) at delivery and birth-weight Z-score, according to maternal demographic characteristics and medical history. The likelihoods of the biophysical markers were developed by fitting folded-plane regression models, a technique that has already been used in previous studies for the likelihoods of biochemical markers. The next step was to modify the prior distribution by the likelihood, according to Bayes' theorem, to obtain individualized distributions for GA at delivery and birth-weight Z-score. We used the 57 131 cases with complete data to assess the discrimination and calibration of the model for predicting SGA with, without or independently of pre-eclampsia, by different combinations of maternal factors and biomarkers.

RESULTS

The distribution of biomarkers, conditional to both GA at delivery and birth-weight Z-score, was best described by folded-plane regression models. These continuous two-dimensional likelihoods update the joint distribution of birth-weight Z-score and GA at delivery that has resulted from a competing-risks approach; this method allows application of user-defined cut-offs. The best biophysical predictor of preterm SGA was UtA-PI and the best biochemical marker was PlGF. The prediction of SGA was consistently better for increasing degree of prematurity, greater severity of smallness, coexistence of PE and increasing number of biomarkers. The combination of maternal factors with all biomarkers predicted 34.3%, 48.6% and 59.1% of all cases of a SGA neonate with birth weight < 10^th percentile delivered at ≥ 37, < 37 and < 32 weeks' gestation, at a 10% false-positive rate. The respective values for birth weight < 3^rd percentile were 39.9%, 53.2% and 64.4%, and for birth weight < 3^rd percentile with pre-eclampsia they were 46.3%, 66.8% and 80.4%. The new model was well calibrated.

CONCLUSIONS

This study has presented a single continuous two-dimensional model for prediction of SGA for any desired cut-offs of smallness and GA at delivery, laying the ground for a personalized antenatal plan for predicting and managing SGA, in the milieu of a new inverted pyramid of prenatal care. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Association of obesity and pulse pressure with hypertension in an Iranian urban population

Objective:

Nowadays, obesity is an important health problem and pulse pressure (PP) is a good predictor of cardiovascular events. The aim of study was to determine the association of obesity and PP with hypertension (HTN) in individuals aged 30 years or older in the urban population of Jahrom, Iran.

Materials and Methods:

In this study, we used a multistage stratified sampling method to select participants among the urban population aged 30 years or older. Height, weight, and blood pressure were obtained by a trained physician. Obesity was defined according to the World Health Organization classification. Angina was assessed with reliable and validate Rose questionnaire. Data were record by SPSS-16. Categorical and continues variables analyzed by Chi-squared, independent t-test, and one-way ANOVA test. Binary logistic regression analysis method was used for the association of PP and obesity with HTN and Rose angina that adjusted for age, gender, education class, marital status, smoking, total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein. A P < 0.05 was considered as statistical significance.

Results:

The prevalence of obesity was 18.1% that was greater in women (24.8% vs. 9.9%, P < 0.001). The prevalence of Rose angina and HTN in obese individuals were more than in normal weight individuals (24.8% vs. 16.4%, P = 0.027) and (42.0% vs. 31.1%, P < 0.001), respectively. Furthermore, patients in higher PP groups were older, were more possible to had HTN and had greater diastolic blood pressure (DBP), systolic blood pressure (SBP), and mean arterial pressure (MAP) in compared to individuals in the lower PP group. The individuals with HTN had greater DBP, SBP, MAP, PP, and body mass index (BMI) than individuals without HTN. However, individuals who had Rose angina, only had higher PP and BMI in compared to ones without Rose angina. The obese individuals had 1.97 (1.22–3.17, P = 0.005) fold for HTN risk than individuals with normal weight. In addition, PP weakly increased the risk of HTN about 1.09 fold (1.07–1.10, P < 0.001). However, Rose angina was associated only to overweight status (odds ratio = 1.51, confidence interval 95%: 1.03–2.20), P = 0.035) than individuals in normal weight group.

Conclusion:

Obesity and PP were higher in hypertensive individuals and overweight in individuals with Rose angina. It is time to pay more attention to abnormal BMI.

New methods of differentiation between primary and secondary hypertension in a pediatric population: A single-center experience

BACKGROUND

Kidney diseases are the main causative factors of secondary hypertension (HTN) in children. Although primary HTN is less common in the pediatric population, its increasing prevalence, especially among teenagers, makes early diagnosis an emerging issue.

OBJECTIVES

To analyze the potential differences between primary HTN and HTN secondary to renal diseases, in order to tailor diagnostic procedures to pediatric patients with suspicion of HTN.

MATERIAL AND METHODS

A retrospective evaluation was performed of medical records of 168 children (aged from 1 month to 18 years) diagnosed with arterial HTN in the Pediatric Nephrology Department of Wroclaw Medical University (Poland). The comparative analysis concerned demographics, causes of HTN, clinical picture, laboratory tests, and parameters of ambulatory blood pressure monitoring (ABPM).

RESULTS

Out of 168 children, 47% were diagnosed with primary HTN and 53% with secondary renal HTN. The patients with primary HTN were significantly older than those with HTN secondary to renal disease. Among the children with primary HTN, 26% were overweight and 42% were obese; among those with renal HTN, the proportions were 16% and 19%, respectively. The patients with primary HTN had significantly higher body mass index (BMI) percentiles and z-scores, and tended toward higher pulse pressure (PP) values. In the group with secondary HTN, ABPM parameters of diastolic blood pressure (DBP) and total cholesterol were significantly elevated. The BMI z-scores correlated positively with PP in the whole group.

CONCLUSIONS

As expected, HTN secondary to renal disease prevails in younger children, but primary HTN has become an emerging issue in teenagers. The diagnostics of HTN secondary to kidney disease have revealed risk factors worsening the prognosis, including higher values of cholesterol or of parameters connected with DBP. Primary HTN risk factors include obesity and a tendency towards higher PP values.

Caffeic and chlorogenic acids modulate altered activity of key enzymes linked to hypertension in cyclosporine-induced hypertensive rats

OBJECTIVES

This study aimed to explore the protective mechanism of caffeic acid (CAA) and chlorogenic acid (CHA) on cyclosporine (CSA) induced hypertensive rats.

METHODS

Effect of CAA and CHA on diastolic blood pressure (DBP), mean arterial pressure (MAP), angiotensin-converting enzyme (ACE), e-nucleotide triphosphate dephosphorylase (e-NTPDase), 5' nucleotidase and adenosine deaminase (ADA) activity in CSA-induced hypertensive rats were determined.

RESULTS

CAA and CHA administration stabilized hypertensive effect caused by CSA administration. Also, altered activity of ACE (lung), e-NTPDase, 5' nucleotidase, ADA as well as elevated malondiadehyde (MDA) level was restored in all the treated hypertensive rats in comparison with the untreated hypertensive rats.

CONCLUSION

Hence, these observed results could underlie some of the mechanisms through which CAA and CHA could offer antihypertensive effect.

Study for Improving Maternal Pregnancy And Child ouTcomes (IMPACT): a study protocol for a Swedish prospective multicentre cohort study

INTRODUCTION

First-trimester pregnancy risk evaluation facilitates individualised antenatal care, as well as application of preventive strategies for pre-eclampsia or birth of a small for gestational age infant. A range of early intervention strategies in pregnancies identified as high risk at the end of the first trimester has been shown to decrease the risk of preterm pre-eclampsia (<37 gestational weeks). The aim of this project is to create the Improving Maternal Pregnancy And Child ouTcomes (IMPACT) database; a nationwide database with individual patient data, including predictors recorded at the end of the first trimester and later pregnancy outcomes, to identify women at high risk of pre-eclampsia. A second aim is to link the IMPACT database to a biobank with first-trimester blood samples.

METHODS AND ANALYSIS

This is a Swedish prospective multicentre cohort study. Women are included between the 11th and 14th weeks of pregnancy. At inclusion, pre-identified predictors are retrieved by interviews and medical examinations. Blood samples are collected and stored in a biobank. Additional predictors and pregnancy outcomes are retrieved from the Swedish Pregnancy Register. Inclusion in the study began in November 2018 with a targeted sample size of 45 000 pregnancies by end of 2021. Creation of a new risk prediction model will then be developed, validated and implemented. The database and biobank will enable future research on prediction of various pregnancy-related complications.

ETHICS AND DISSEMINATION

Confidentiality aspects such as data encryption and storage comply with the General Data Protection Regulation and with ethical committee requirements. This study has been granted national ethical approval by the Swedish Ethical Review Authority (Uppsala 2018-231) and national biobank approval at Uppsala Biobank (18237 2 2018 231). Results from the current as well as future studies using information from the IMPACT database will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03831490.

Screening for pre-eclampsia at 11-13 weeks' gestation: use of pregnancy-associated plasma protein-A, placental growth factor or both

OBJECTIVE

First-trimester screening for pre-eclampsia (PE) is useful because treatment of the high-risk group with aspirin reduces the rate of early PE with delivery at < 34 weeks' gestation by about 80% and that of preterm PE with delivery at < 37 weeks by 60%. In previous studies, we reported that the best way of identifying the high-risk group is by a combination of maternal factors, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF). An alternative biochemical marker is pregnancy-associated plasma protein-A (PAPP-A), which is used widely as part of early screening for trisomy. The objective of this study was to examine the additive value of PlGF and PAPP-A in first-trimester screening for preterm PE by maternal factors, MAP and UtA-PI and define the risk cut-off and screen-positive rate to achieve a desired detection rate of PE if PAPP-A rather than PlGF was to be used for first-trimester screening.

METHODS

This was a non-intervention screening study. The data were derived from prospective screening for adverse obstetric outcomes in women with singleton pregnancy attending for a routine first-trimester hospital visit. Patient-specific risks of delivery with PE at < 37 weeks' gestation were calculated using the competing-risks model to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics and medical history, with multiples of the median (MoM) values of MAP, UtA-PI, PlGF and PAPP-A. The performance of screening in the total population and in subgroups of women of white and black racial origin was estimated. McNemar's test was used to compare the detection rate, for a fixed screen-positive rate, of screening with and without PlGF and PAPP-A. Risk cut-offs and screen-positive rates to achieve desired detection rates of preterm PE were determined in screening with and without PlGF and PAPP-A.

RESULTS

The study population was composed of 60 875 singleton pregnancies, including 1736 (2.9%) that developed PE. There are three main findings of this study. First, the performance of first-trimester screening for PE by a combination of maternal factors, MAP, UtA-PI and PlGF is superior to that of screening by maternal factors, MAP, UtA-PI and PAPP-A; for example, in screening by maternal factors, MAP, UtA-PI and PlGF, at a screen-positive rate of 10%, the detection rate of PE with delivery at < 37 weeks' gestation was 74.1%, which was 7.1% (95% CI, 3.8-10.6%) higher than in screening by maternal factors, MAP, UtA-PI and PAPP-A. Second, addition of serum PAPP-A does not improve the prediction of PE provided by maternal factors, MAP, UtA-PI and PlGF. Third, the risk cut-off and screen-positive rate to achieve a given fixed detection rate of preterm PE vary according to the racial composition of the study population and whether the biomarkers used for screening are MAP, UtA-PI and PlGF or MAP, UtA-PI and PAPP-A. For example, in screening by a combination of maternal factors, MAP, UtA-PI and PlGF in white women, if the desired detection rate of preterm PE was 75%, the risk cut-off should be 1 in 136 and the screen-positive rate would be 14.1%; in black women, to achieve a detection rate of 75%, the risk cut-off should be 1 in 29 and the screen-positive rate would be 12.5%. In screening by a combination of maternal factors, MAP, UtA-PI and PAPP-A in white women, if the desired detection rate of preterm PE was 75%, the risk cut-off should be 1 in 140 and the screen-positive rate would be 16.9%; in black women, to achieve a detection rate of 75%, the risk cut-off should be 1 in 44 and the screen-positive rate would be 19.3%.

CONCLUSION

In first-trimester screening for PE, the preferred biochemical marker is PlGF rather than PAPP-A. However, if PAPP-A was to be used rather than PlGF, the same detection rate can be achieved but at a higher screen-positive rate. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Exaggerated blood pressure response to exercise is associated with subclinical vascular impairment in healthy normotensive individuals

BACKGROUND

This study was designed to evaluate the possible association between an exaggerated blood pressure (BP) response to exercise and subclinical vascular impairment in normotensive individuals.

METHODS

The study participants consisted of 92 untreated normotensive men (aged 42 ± 9 years) without a history of cardiovascular disease or stroke. A graded exercise test was conducted using a bicycle ergometer, and the mean arterial pressure (MAP) during submaximal exercise was evaluated. The brachial-ankle pulse wave velocity (baPWV) was measured as an index of arterial stiffness. The second peak of radial systolic BP (SBP2) was used as an estimate of central BP. The albumin-to-creatinine ratio (ACR) values were determined as the mean of two nonconsecutive spot urine specimens.

RESULTS

Compared with individuals with a normal response (MAP z-score < +1.0, n = 60), those with an exaggerated BP response to exercise (MAP z-score ≥ +1.0, n = 32) exhibited significantly higher baPWV (1412 ± 158 vs. 1250 ± 140 cm/s), radial SBP2 (122 ± 11 vs. 106 ± 13 mmHg), and greater log-ACR (0.93 ± 0.30 vs. 0.59 ± 0.23 mg/gCre). Multiple regression analysis revealed that an exaggerated BP response to exercise was significantly associated with baPWV (β = 0.198, P= .043), radial SBP2 (β = 0.156, P = .049), and log-ACR (β = 0.276, P = .006) independent of potential confounding factors.

CONCLUSIONS

These results suggest that subclinical vascular impairment is associated with an exaggerated increase in BP during exercise even in the absence of clinical hypertension.

First-trimester pre-eclampsia biomarker profiles in Asian population: multicenter cohort study

OBJECTIVES

To (i) evaluate the applicability of the European-derived biomarker multiples of the median (MoM) formulae for risk assessment of preterm pre-eclampsia (PE) in seven Asian populations, spanning the east, southeast and south regions of the continent, (ii) perform quality-assurance (QA) assessment of the biomarker measurements and (iii) establish criteria for prospective ongoing QA assessment of biomarker measurements.

METHODS

This was a prospective, non-intervention, multicenter study in 4023 singleton pregnancies, at 11 to 13 + 6 weeks' gestation, in 11 recruiting centers in China, Hong Kong, India, Japan, Singapore, Taiwan and Thailand. Women were screened for preterm PE between December 2016 and June 2018 and gave written informed consent to participate in the study. Maternal and pregnancy characteristics were recorded and mean arterial pressure (MAP), mean uterine artery pulsatility index (UtA-PI) and maternal serum placental growth factor (PlGF) were measured in accordance with The Fetal Medicine Foundation (FMF) standardized measurement protocols. MAP, UtA-PI and PlGF were transformed into MoMs using the published FMF formulae, derived from a largely Caucasian population in Europe, which adjust for gestational age and covariates that affect directly the biomarker levels. Variations in biomarker MoM values and their dispersion (SD) and cumulative sum tests over time were evaluated in order to identify systematic deviations in biomarker measurements from the expected distributions.

RESULTS

In the total screened population, the median (95% CI) MoM values of MAP, UtA-PI and PlGF were 0.961 (0.956-0.965), 1.018 (0.996-1.030) and 0.891 (0.861-0.909), respectively. Women in this largely Asian cohort had approximately 4% and 11% lower MAP and PlGF MoM levels, respectively, compared with those expected from normal median formulae, based on a largely Caucasian population, whilst UtA-PI MoM values were similar. UtA-PI and PlGF MoMs were beyond the 0.4 to 2.5 MoM range (truncation limits) in 16 (0.4%) and 256 (6.4%) pregnancies, respectively. QA assessment tools indicated that women in all centers had consistently lower MAP MoM values than expected, but were within 10% of the expected value. UtA-PI MoM values were within 10% of the expected value at all sites except one. Most PlGF MoM values were systematically 10% lower than the expected value, except for those derived from a South Asian population, which were 37% higher.

CONCLUSIONS

Owing to the anthropometric differences in Asian compared with Caucasian women, significant differences in biomarker MoM values for PE screening, particularly MAP and PlGF MoMs, were noted in Asian populations compared with the expected values based on European-derived formulae. If reliable and consistent patient-specific risks for preterm PE are to be reported, adjustment for additional factors or development of Asian-specific formulae for the calculation of biomarker MoMs is required. We have also demonstrated the importance and need for regular quality assessment of biomarker values. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.