Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

A single fast radio burst localized to a massive galaxy at cosmological distance

Fast radio bursts (FRBs) are brief radio emissions from distant astronomical sources. Some are known to repeat, but most are single bursts. Nonrepeating FRB observations have had insufficient positional accuracy to localize them to an individual host galaxy. We report the interferometric localization of the single-pulse FRB 180924 to a position 4 kiloparsecs from the center of a luminous galaxy at redshift 0.3214. The burst has not been observed to repeat. The properties of the burst and its host are markedly different from those of the only other accurately localized FRB source. The integrated electron column density along the line of sight closely matches models of the intergalactic medium, indicating that some FRBs are clean probes of the baryonic component of the cosmic web.

Providing sporting experiences for children in Out of School Hours Care (OSHC) environments: sport and physical activity participation and intentions

The Out of School Hours Sports Program (OSHSP) aimed to provide structured sporting experiences and community links to local clubs for children in Out of School Hours Care (OSHC). The OSHSP involved 17 State Sporting Associations (SSAs), 71 OSHC Services and local club representatives. This study explored children's participation in sport in and outside the OSHSP and parental intention for participation in sport in and outside the OSHSP. Surveys were received from 211 children (76 girls and 125 boys; mean age=7.9 years, S.D.=1.7) and their parents/guardians (37.9% response rate). OSHC is characterised by freedom of choice of participation in activities by children. The OSHSP was used to provide an opportunity to choose to participate in a sport while attending OSHC. At the OSHC Services surveyed, between 7.1 and 100% of the children attending OSHC chose to participate in the OSHSP. Of those children who chose to participate, 85% were participating in a sport, usually a different sport to the one offered in the OSHSP. This participation was largely club-based (49.8%), most often once a week for training and competition (55.2%). Parental intentions for children's participation in the OSHSP sports varied with respect to the number of years attending the OSHSP, where children played and trained in their main sport, and how many times a week a child played and trained in their main sport. Older children tended to play and train for sport more times per week and had been attending the OSHC for more years than younger children.

Peptidomimetic inhibitors of the human cytomegalovirus protease

The development of peptidomimetic inhibitors of the human cytomegalovirus (HCMV) protease showing sub-micromolar potency in an enzymatic assay is described. Selective substitution of the amino acid residues of these inhibitors led to the identification of tripeptide inhibitors showing improvements in inhibitor potency of 27-fold relative to inhibitor 39 based upon the natural tetrapeptide sequence. Small side chains at P1 were well tolerated by this enzyme, a fact consistent with previous observations. The S2 binding pocket of HCMV protease was very permissive, tolerating lipophilic and basic residues. The substitutions tried at P3 indicated that a small increase in inhibitor potency could be realized by the substitution of a tert-leucine residue for valine. Substitutions of the N-terminal capping group did not significantly affect inhibitor potency. Pentafluoroethyl ketones, alpha,alpha-difluoro-beta-keto amides, phosphonates and alpha-keto amides were all effective substitutions for the activated carbonyl component and gave inhibitors which were selective for HCMV protease. A slight increase in potency was observed by lengthening the P1' residue of the alpha-keto amide series of inhibitors. This position also tolerated a variety of groups making this a potential site for future modifications which could modulate the physicochemical properties of these molecules.

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.

Epidemiology of pediatric trauma: importance of population-based statistics

To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared statistical data on the incidence and mortality of pediatric and adult injuries and burns calculated by the New York State Department of Health, based on legally mandated reports of injury deaths and hospital discharges for 1989. During this year, some 488 children, aged 0 to 14 years, died as a result of injuries, a rate of 13.8 per 100,000 annually, of whom 408 (11.6/100,000) died as a result of traumatic injuries or burns, a population-based rate 20% of that observed in adults. During the same period, 16,402 children were hospitalized for treatment of traumatic injuries and burns, a rate of 465 per 100,000 annually, a population-based rate 56% of that observed in adults; and of this number, some 90 children died, yielding an in-hospital mortality "rate" (ie, case fatality ratio) of 0.55%, and a population-based rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of traumatic injuries and burns were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system.(ABSTRACT TRUNCATED AT 250 WORDS)

Ability of dipyridamole-thallium-201 imaging one to four days after acute myocardial infarction to predict in-hospital and late recurrent myocardial ischemic events

The ability of dipyridamole-thallium-201 imaging to predict in-hospital and late cardiac events when performed very early (62 +/- 21 hours, range 23 to 102) after acute myocardial infarction (AMI) was tested in 50 patients. During hospitalization, 1 patient developed recurrent AMI and 8 patients developed recurrent angina after MI associated with ST-segment depression at 60 +/- 42 hours after the dipyridamole-thallium-201 imaging; of these, 6 required urgent coronary revascularization. No patient died in-hospital. There were no serious adverse effects during the dipyridamole protocol. Using stepwise multivariate logistic regression analysis, the best and only statistically significant predictor of in-hospital ischemic cardiac events was the presence of thallium-201 redistribution within the infarct zone (p = 0.0001). Of 20 patients with infarct zone thallium-201 redistribution, 9 (45%) developed in-hospital ischemic cardiac events compared to 0 of 30 patients without infarct zone thallium-201 redistribution (p less than 0.0001). During a follow-up 12 +/- 7 months after discharge, 3 additional patients with infarct zone thallium-201 redistribution developed recurrent AMI or unstable angina, whereas no patient without infarct zone thallium-201 redistribution developed ischemic cardiac events. These data suggest that dipyridamole-thallium-201 imaging performed very early after AMI may identify a subgroup of patients at high risk for in-hospital and late ischemic cardiac events. Such patients may benefit from early cardiac catheterization and revascularization. Patients without infarct zone thallium-201 redistribution appear to be at very low risk for in-hospital and late ischemic cardiac events and may be candidates for early discharge.

Effects of acute central LH-RH administration of the skin temperature response in morphine dependent rats

There are numerous reports of a temporal relationship between LH secretion and a subsequent flushing response in menopausal women. We have developed a morphine-dependent animal model to study the mechanisms of the hot flush. Administration of naloxone to these animals results in a surge in LH secretion which precedes the elevation in tail skin temperature (TST). In the present study, we utilized central administration of an LH-RH agonist and antagonist to evaluate the skin temperature response in our animal model. Ovariectomized female rats were fitted with unilateral cannula in the lateral ventricle (LV). One week later these animals were midly restrained to allow for continuous measurement of tail skin temperatures (TST). Central administration of naloxone was without effect in controls but produced a 5-6 degree C rise of TST in the morphine-dependent rat while central administration of 10 microliters of the saline vehicle produced no changes in TST in either group. A similar increased sensitivity to LH-RH was observed in morphine-dependent rats. Administration of 5 or 10 micrograms of the LH-RH agonist (Des-Gly10, [im-Bzl-D-His6]LH-RH ethylamide) into the LV produced a significantly greater elevation in TST (4 degrees C) in the morphine-dependent rats compared to a negligible rise in TST in the control rats; however, administration of a larger dose of 20 micrograms of the LH-RH agonist produced similar TST responses of about 4 degrees C in both groups. Intravenous administration of the LH-RH agonist (10 micrograms) was ineffective in producing any temperature effect in morphine-dependent rats. Thus, it appears that the morphine-dependent rat is more sensitive to the LH-RH agonist and the temperature response is mediated by a central mechanism which is similar to that observed following administration of a dose of naloxone. In a subsequent study central administration of the LH-RH agonist (5 micrograms/10 microliters) resulted in a similar rise in serum LH in both control and morphine-dependent rats, suggesting that the elevation in TST is not closely associated with LH secretion. Further support for a role of LH-RH in our animal model was obtained following central administration of an LH-RH antagonist [( D-Phe2.6, Pro3]LH-RH) which blocked the rise in TST associated with systemic administration of naloxone (1 mg/kg, s.c.) in morphine-dependent rats.(ABSTRACT TRUNCATED AT 400 WORDS)

Ejaculatory failure and urinary dysfunction secondary to labetalol

We describe 3 men with moderate to severe essential hypertension in whom ejaculatory failure developed after therapy with labetalol, an antihypertensive drug with alpha-1 and beta-adrenergic blocking properties. No decrease in libido or erectile dysfunction was reported by any of the patients. Previous and subsequent antihypertensive therapy with either alpha or beta-adrenergic blocking agents failed to cause similar symptoms. These findings reveal a unique spectrum of genitourinary dysfunction associated with the multireceptor blocking properties of labetalol.

Effects of central application of naloxone on the skin temperature response in morphine-dependent rats

This study was designed to identify if the surge in tail skin temperature (TST) observed following systemic administration of naloxone to morphine-dependent rats is mediated by a specific brain locus. Female rats were fitted with cannula located either in the preoptic area-anterior hypothalamus, locus coeruleus, or the frontal cortex. TST was monitored every 5 min for 60 min following central administration of naloxone (1-40 micrograms/0.4 microliters), in morphine-dependent rats. Regardless of the central site of naloxone injection, TST was significantly increased 4-5 degrees C. A threshold dose of 20 micrograms/0.4 microliters (10 micrograms/0.2 microliters, bilaterally) of naloxone was identified to produce this surge in TST in all three brain regions. These results suggest that morphine dependency sensitizes several brain regions to administration of naloxone such that the narcotic antagonist produces a similar change in TST as is observed following its systemic administration. These data further support the use of our morphine-dependent rat model to study the central mechanisms of the menopausal hot flush, and provide additional evidence that the flush response is centrally mediated.

Effect of chronic estrogen on the skin temperature response to naloxone in morphine-dependent rats

It is well documented that opioids and sex steroids modify body temperature in the rat. We have previously reported that the temperature responses to naloxone in the morphine-dependent rat was more pronounced in the female than in the male rat. In addition, ovariectomy but not castration resulted in altered temperature responses in the morphine-dependent rat, which suggests a role for estrogen in modifying the temperature responses. This study was designed to evaluate the effect of sex steroid hormones on the surge in tail skin temperature associated with administration of naloxone to morphine-dependent female rats. Ovariectomized female rats were treated with estrogen (0.5 mg pellet), progesterone (5 mg pellet), or the combined therapy for 21 days. Administration of naloxone to these morphine-dependent rats resulted in a 5.9 +/- 0.5 degrees C rise in tail skin temperature in the placebo control rats and 5.7 +/- 0.5 degrees C in the progesterone-treated group; there was a significantly reduced elevated in tail skin temperature of 3.1 +/- 1.0 degrees C and 2.9 +/- 1.0 degrees C in the and estrogen-progesterone treated groups. Body weights also were significantly depressed in the estrogen-treated groups. In a subsequent study, the effects of several doses of chronic estrogen treatment were evaluated (0.1-50 mg pellets). The elevation of tail skin temperature in response to administration of naloxone to morphine-dependent rats was significantly reduced at all doses of estrogen when compared with placebo-treated controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of opioid antagonists and their quaternary analogs on temperature changes in morphine-dependent rats

Subcutaneous administration of three opioid antagonists; naloxone, naltrexone and nalmefene, produced a significant rise in tail skin temperature and a subsequent fall in rectal temperature in morphine dependent rats. However, subcutaneous administration of equimolar concentrations of the quaternary derivatives of these opioid antagonists (naloxone methobromide, naltrexone methobromide and n-methylnalmefenium iodide) failed to produce any significant alterations in either tail skin or rectal temperatures in the morphine dependent rat. At doses of naloxone methobromide 6 to 9 times greater than naloxone, there was a slight reduction of rectal temperatures with no significant elevation of skin temperature. However, the fall in rectal temperature was still significantly less than that achieved with administration of naloxone. When each of these six agents were administered centrally (20 micrograms/5 microliter, icv) in the morphine dependent rat, similar increases in tail skin temperature and decreases in rectal temperature were observed. These temperature changes were similar to those observed following systemic administration of the opioid antagonist. Previously, we have suggested that acute withdrawal in the morphine-dependent rat may serve as an animal model for the mechanism of the menopausal hot flush. Collectively, these results suggest that the temperature changes associated with morphine-withdrawal in our rat model for studying the mechanisms of the menopausal hot flush are centrally mediated.

Regional skin temperature changes in a rat model for the menopausal hot flush

Administration of naloxone to morphine-dependent male and female rats produced a significant rise in both tail skin temperature and foot temperature with a subsequent fall in colonic temperature. The magnitudes of the skin temperature surges were similar in the two regions, with the elevation in foot temperature preceding the rise in tail skin temperature. These regional skin temperature surges were similar in magnitude, duration and temporal pattern in both the male and female rat, and are similar to those exhibited in men and women undergoing flushing episodes. Castration of males did not alter these temperature responses. The only difference in response between male and female rats was the more pronounced fall in colonic temperature observed in morphine-dependent female rats following administration of naloxone. Neither the administration of naloxone to placebo-treated animals nor that of saline to morphine-dependent animals produced any changes in skin or colonic temperature in either male or female rats. These results suggest that the pattern of skin temperature alterations associated with morphine withdrawal in both the male and female rat is similar to the pattern of skin temperature surges associated with the hot flush in men and women, which provides additional evidence for the morphine-dependent rat as a model for women who exhibit flushing episodes. Additionally, this is the first report of a potential model for men who exhibit flushing episodes.