1199Reduction in blood pressure following renal denervation for patients with differing baseline cardiovascular risk

Background

Lowering blood pressure (BP) reduces clinical events. Renal denervation (RDN) is under investigation for treatment of uncontrolled hypertension and might represent a particularly attractive option for patients with high cardiovascular (CV) risk. To evaluate this proposal, it is important to determine whether baseline CV risk impacts the efficacy of RDN in lowering BP.

Purpose

We evaluated whether BP changes after RDN were dependent on baseline CV risk.

Methods

AHA/ACC Atherosclerosis CV Disease (ASCVD) risk score was calculated for patients in the Global Symplicity Registry (GSR; NCT01534299), a global registry of RDN in patients with uncontrolled hypertension, using baseline office systolic BP, total/HDL cholesterol measurements, diabetic and smoking status, gender, age, and number of baseline anti-hypertensive medications. Patients were separated into 3 groups based on ASCVD risk scores: <10%, ≥10% and <20% and ≥20%. Baseline demographics and 24-hour systolic BP changes at 6 months and 1, 2 and 3 years were compared between groups, as well as rates of adverse events at 3 years.

Results

Individual ASCVD risk scores were calculated for 1,434 patients in GSR. The median ASCVD risk score was 19.4% and 403 patients had a risk score of <10%, 326 a risk score of ≥10 and <20%, and 705 a risk score ≥20%. Patients with ASCVD risk score ≥20% had a higher baseline office systolic BP, were significantly older, and had higher rates of prior myocardial infarction and/or diabetes (all p<0.0001 compared to patients with lower risk scores). RDN reduced BP similarly across all groups of patients. Changes in 24-hour systolic BP at 6 months and 1, 2 and 3 years are shown in Figure 1. Adverse events at 3 years are shown in Table 1.

Adverse events at 3 years ASCVD risk score <10% ASCVD risk score ≥10% & <20% ASCVD risk score ≥20% p-value (N=265) (N=224) (N=468) Death 3 (1.1) 5 (2.2) 41 (8.8) <0.0001 Cardiovascular death 3 (1.1) 2 (0.9) 23 (4.9) 0.0017 Myocardial infarction 6 (2.3) 6 (2.7) 11 (2.4) 0.9513 Stroke 8 (3.0) 9 (4.0) 24 (5.1) 0.3894 Hospitalization for new onset heart failure 4 (1.5) 7 (3.1) 26 (5.6) 0.0194 Values are proportions reported as n (%).

Conclusions

BP changes after RDN were similar for patients with varying baseline ASCVD risk scores, suggesting uniform BP-lowering efficacy of RDN regardless of patients' baseline CV risk. The impact of baseline risk on clinical event reduction by RDN-induced BP reduction will need to be evaluated in further studies.

Acknowledgement/Funding

The Global SYMPLICITY Registry is funded by Medtronic.

Most children with eosinophilic esophagitis have a favorable outcome as young adults

The disease progression of eosinophilic esophagitis (EoE) from childhood into adulthood is unclear. To determine the clinical outcome of patients who were diagnosed with EoE as children, and who now are young adults. Children (<18 years old) diagnosed with EoE were enrolled in a prospective registry on demographics, presenting symptoms, and endoscopic/histologic findings. Subjects who now are adults (≥18 years old) were identified, and a structured telephone interview was conducted to obtain follow-up data on symptom prevalence (dysphagia to solids and liquids, nausea/vomiting, abdominal pain, and heartburn/regurgitation), food impaction, medication usage, health-care utilization, and resolution of atopy/food allergies. A favorable outcome was defined if EoE symptoms were resolved or improved by subjects' assessment. Unfavorable outcomes was defined as symptoms same or worse. Clinical variables that predicted a favorable outcome as an adult were examined. Mayo Dysphagia Scale (MDQ-30: scored 0-100) was administered to validate the outcome assessment. Mantel-Haenszel odds ratio and unpaired t-test were used. Fifty-eight subjects (64% male) who met study criteria were enrolled. Mean age at diagnosis was 12 years (range 4-17) and mean duration of follow-up was 8.3 years (2-16). As children, the most common presenting symptoms were abdominal pain (54%), dysphagia (33%), and vomiting (24%). As young adults, 47 subjects (81%) had a favorable outcome. Total MDQ-30 scores were 4.6 (0-30) and 14.1 (0-50) in subjects with favorable outcome and unfavorable outcome, respectively (P = 0.015). Two-thirds of subjects did not use steroids or proton pump inhibitors in the preceeding 12 months. Male children with EoE were four times more likely to have a favorable outcome as young adults compared with female children. Females were more likely to report nausea/vomiting as young adults (odds ratio 3.23, CI 0.97-10.60). Of all presenting symptoms in EoE children, dysphagia was the most likely to persist into adulthood (odds ratio 6.29, CI 1.85-21.38). Eighty one percent of EoE children had a favorable outcome as young adults. Most patients with symptom resolution did not require any form of steroid therapy or seek healthcare.

Ultrasound-guided selective block of the anterior branch of the obturator nerve for transurethral resection of bladder tumour

Introduction:

Bladder perforation is a serious complication of transurethral resection of bladder tumour (TURBT). One of the risk factors is an “obturator jerk”, caused by stimulation of the obturator nerve, causing powerful adduction of the leg. As almost half of all bladder tumours are located on the lateral wall and 55–100% of resections on the lateral wall can result in obturator jerk; this is not an insignificant risk.

Patients:

We have introduced regional anaesthetic nerve block of the anterior branch of the obturator nerve in patients with known lateral wall tumours undergoing TURBT.

Methods:

This procedure was performed by two consultant anaesthetists in our unit. Patients are positioned supine with the leg slightly abducted and laterally rotated. Ultrasound (US) is used to identify the anterior branch of the adductor longus, brevis and magnus muscles in the medial thigh, 2–3 cm inferior to the inguinal crease. The obturator nerve is situated in the plane between adductor longus and adductor brevis, medial to pectineus. An insulated needle is passed under US guidance and a nerve stimulator is used to elicit a twitch. Levobupivicaine is used to infiltrate the anterior branch of the obturator nerve to achieve motor block of the adductor brevis, adductor longus and gracillis muscles. TURBT is then performed.

Results:

This prospective pilot series includes 18 TURBT procedures. These were performed under spinal anaesthetic ( n=16) or general anaesthetic without muscle relaxant ( n=2). Tumours characteristics were; large flat areas of re-resection ( n=5), flat bladder lesions ( n=1) or exophytic lesions ( n=12). There were no incidences of obturator jerk observed during TURBT (0/18). There were no intra or post-operative complications.

Conclusion:

This simple technique can be easily applied to patients undergoing TURBT. Larger studies are required, but our series supports the use of this technique to reduce obturator jerk, which is an important risk factors for bladder perforation.

Esophageal dilation: simple and effective treatment for adults with eosinophilic esophagitis and esophageal rings and narrowing

The goal of this article is to present the results of the long-term treatment with esophageal dilation of a consecutive series of adults with eosinophilic esophagitis (EoE). EoE in adults is a disease of middle aged white males, with recurrent food impactions and dysphagia. The exact treatment of EoE is unknown due to the uncertainty of the pathogenesis. Currently, the long-term follow-up of adult EoE patients is limited. Sixteen consecutive adult patients (12 males/4 females between ages 27 and 58 years) with EoE underwent a detailed history and baseline upper gastrointestinal endoscopy (EGD) with multiple esophageal biopsies. Thirteen had esophageal dilation. Fifteen were on proton pump inhibitor (PPI) therapy. After dilation, one patient was treated with a restrictive diet. One patient took prn fluticasone. Most of the patients had allergy testing for food and aeroallergens. Follow-up evaluation with similar testing was on average 22 months (range: 12-40 months). Six patients were not available for follow-up. None of the remaining 10 patients had a food impaction; one required further esophageal dilation. Only two patients had intermittent dysphagia. The average dysphagia score decreased from 2.1 to 0.3 (P < 0.002). The average number of eosinophils at follow-up was not significantly different from baseline (120 eosinophils/HPF proximally and 165 eosinophils/HPF distally (P= 0.75). The gross endoscopy findings were unchanged in all patients except one who normalized. A total of 62% and 75% of patients had positive tests for aeroallergens and food allergens, respectively. Over an average of two years, esophageal dilation provided excellent symptomatic relief among 10 adult EoE patients despite no improvement in the mucosal eosinophilia or gross endoscopic appearance.

Gene-based prediction of PSA recurrence for clinically localized prostate cancer patients

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Background: Accurate estimates of the risk of recurrence are needed for the optimal management of patients with clinically localized prostate cancer. We combined an established nomogram and novel molecular predictors into a new prognostic model of prostate specific antigen (PSA) recurrence. Methods: Gene expression profiles from formalin-fixed, paraffin-embedded (FFPE) localized prostate cancer tissues were analysed to identify genes associated with PSA recurrence. The profiles of the identified markers were reproduced by reverse-transcriptase-polymerase-chain-reaction (RTPCR). The RTPCR profiles from 3 of these genes, along with the output from the Kattan post-operative nomogram, were used to produce a predictive model of PSA recurrence. Results: After variable selection, a model of PSA recurrence was built that combined expression values of 3 genes and the postoperative nomogram. The 3-gene plus nomogram model predicted 5-year PSA recurrence with a concordance index (c-index) of 0.77 in a validation set compared to a c-index of 0.67 for the nomogram. This model identified a subgroup of patients that were at high risk for recurrence which were not identified by the nomogram. Conclusions: This new gene-based classifier has superior predictive power when compared against the 5-year nomogram to assess risk of PSA recurrence in patients with organ-confined prostate cancer. Our classifier should provide a more accurate stratification of patients into high and low risk groups for treatment decisions and adjuvant clinical trials.

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On the use of simulated annealing to automatically assign decorrelated components in second-order blind source separation

In this paper, an automatic assignment tool, called BSS-AutoAssign, for artifact-related decorrelated components within a second-order blind source separation (BSS) is presented. The latter is based on the recently proposed algorithm dAMUSE, which provides an elegant solution to both the BSS and the denoising problem simultaneously. BSS-AutoAssign uses a local principal component analysis (PCA)to approximate the artifact signal and defines a suitable cost function which is optimized using simulated annealing. The algorithms dAMUSE plus BSS-AutoAssign are illustrated by applying them to the separation of water artifacts from two-dimensional nuclear overhauser enhancement (2-D NOESY) spectroscopy signals of proteins dissolved in water.