Agreement Between iFR and Other Non-Hyperaemic Pressure Ratios in Severe Aortic Stenosis.

BACKGROUND: Instantaneous wave-free ratio (iFR) can reliably assess the physiological significance of coronary artery disease (CAD). Previous studies have demonstrated its interchangeability with other non-hyperaemic pressure ratios (NHPR), but there is no data exploring whether this association is maintained in patients with severe aortic stenosis (AS). METHODS: Forty-two patients (67 lesions) with severe AS were recruited and underwent invasive pressure-wire assessment. Data were extracted to calculate iFR, resting Pd/Pa, diastolic pressure ratios (DPR and dPR), and Diastolic Hyperaemia-Free Ratio (DFR). iFR was then compared with other NHPR to determine agreement and accuracy. RESULTS: Mean aortic gradient and dimensionless index were 44.3 ± 11.6 mmHg and 0.23 ± 0.04, respectively. Of the 67 vessels, 57% were LAD, 15% LCx, 13% RCA and 12% other. There was strong positive correlation between iFR and all other NHPR, including Pd/Pa (r = 0.91, p < 0.001), DPR (r = 0.99, p < 0.001), dPR (r = 0.97, p < 0.001) and DFR (r = 0.98, p < 0.001). While Bald-Altman analysis demonstrated that Pd/Pa and DFR were numerically different from iFR, ROC analyses demonstrated iFR ≤0.89 was accurately identified by all NHPRs; Pd/Pa (AUC = 0.965, 95% CI [0.928-0.994]), DPR (AUC = 1.000, 95% CI [1.000-1.000]), dPR (AUC = 0.974, 95% CI [0.937-1.000]), DFR (AUC = 0.989, 95% CI [0.968-1.000]). CONCLUSION: In patients with severe AS, all the included NHPR in this analysis accurately predicted iFR < 0.89. These data should reassure clinicians that use of alternative NHPR to iFR is reasonable when assessing the physiological significance of CAD in patients with severe AS.

A new rat model of treatment-naive quiescent choroidal neovascularization induced by human VEGF165 overexpression.

Vascular endothelial growth factor (VEGF) is a crucial stimulator for choroidal neovascularization (CNV). Our aim was to develop a reproducible and valid treatment-naive quiescent CNV (i.e. without signs of exudation and with normal visual acuity) rat model by subretinal injection of an adeno-associated virus (AAV)-VEGFA165 vector. The CNV development was longitudinally followed up in vivo by scanning laser ophthalmoscopy/optical coherence tomography, fluorescein and Indocyanine Green angiographies and ex vivo by electron microscopy (EM) and immunohistochemistry. In total, 57 eyes were analysed. In vivo, a quiescent CNV was observed in 93% of the eyes 6 weeks post-transduction. In EM, CNV vessels with few fenestrations, multi-layered basement membranes and bifurcation of endothelial cells were observed sharing the human CNV features. Human VEGF overexpression, multi-layered retinal pigment epithelium (RPE) (RPE65) and macrophages/activated microglia (Iba1) were also detected. In addition, 19 CNV eyes were treated for up to 3 weeks with bevacizumab. The retinal and CNV lesion thickness decreased significantly in bevacizumab-treated CNV eyes compared with untreated CNV eyes 1 week after the treatment. In conclusion, our experimental CNV resembles those seen in patients suffering from treatment-naive quiescent CNV in wet age-related macular degeneration (AMD), and responds to short-term treatment with bevacizumab. Our new model can, therefore, be used to test the long-term effect of new drugs targeting CNV under precisely-defined conditions.

Masked Hypertension: A Systematic Review.

BACKGROUND: Masked phenomenon, Masked Hypertension (MHT) and Masked Uncontrolled Hypertension (MUCH) is a well-defined clinical entity. However, many aspects of MHT/MUCH remain unclear. METHODS: We systematically reviewed the published literature on MHT/MUCH from 1 January 2000 to 31 June 2018 with a particular focus on epidemiology, clinical significance, evaluation and management. Meta-analyses were performed with respect to prevalence, clinical significance and diagnostic agreement between home blood pressure (HBP) and ambulatory BP (ABP) measurements. RESULTS: The overall weighted-mean prevalence of masked phenomenon was 11% [9,14]; MHT 10% [9,11]; and MUCH 13% [8,17]. The weighted-mean prevalence when expressed as a proportion of patients with normal office BP was 32% [25,40]; MHT 28% [15,41]; and MUCH 43% [29,57]. The prevalence of masked phenomenon determined by ABP (11% [8,14]) and HBP (13% [9,16]), was similar. However, ABP appeared to have a greater sensitivity, i.e. proportion of patients diagnosed as having MHT/MUCH was greater with ABP than with HBP (22% v 16%, p<0.05), when both methodologies were applied to the same cohort of patients. The prevalence of MHT was influenced by ethnicities and comorbidities, and in case of MUCH by anti-hypertensive treatment. MHT/MUCH was associated with increased risk of fatal and non-fatal cardiac/cerebrovascular events (relative risk [RR] 2.09 [1.80, 2.44]), and the risk was comparable to sustained hypertension (SHT) (RR 2.26 [1.84, 2.78]). The increased risk occurred regardless of the method of out of office BP assessment; the relative risks for ABP and HBP were 2.38 [1.90, 2.98] and 1.90 [1.57, 2.29] respectively. The diagnostic agreement between ABP and HBP was only modest, kappa = 0.46 [0.40, 0.52], even though the percentage agreement was 83%. The evidence for the management of MHT was scant. CONCLUSIONS: MHT/MUCH is a common BP phenotype with a risk profile similar to that of SHT. Therefore, high risk patients should undergo out of office BP assessment, probably both by HBP and ABP, to confirm diagnosis and be considered for treatment.

Staggering shifts to rebalance night medical registrar workload.

BACKGROUND: Lone night medical registrars, particularly those working at busy urban hospitals have high workloads and low job satisfaction. Handover of pending referrals from day staff can contribute to further delays in providing care with increased risks for patient safety. AIM: To evaluate the impact of a staggered roster for daytime medical registrar on the workload of night registrar. METHODS: Prospective data were collected of the night medical registrar workload over a 6-month period. The first 3 months included standard shifts from 1330 to 2130 hours with two registrars. The second 3 months followed the introduction of a staggered shift for one registrar to 1530 hour-midnight, providing a 3-h overlap with the night registrar commencing at 2100 hour. Parameters recorded included the number of total admissions, pending admissions, referrals from emergency department, ward reviews and Medical Emergency Team (MET) calls/CODE Blues. Data from weekends and public holidays were not recorded. RESULTS: During the standard rostering period, the average number of medical admissions completed per night shift was 8.66 (n = 60, SD = 3.58). With staggered shifts, the average number was significantly reduced at 6.38 (n = 65, SD = 2.74, P = 0.000057). In addition, there was greater number of ward reviews conducted by the night registrar in the staggered roster period, potentially reflecting greater time availability and reduction in MET calls/codes. CONCLUSION: Rearranging medical registrar shifts can result in significant reduction in night medical registrar workload. It may also have other potential benefits in terms of increased capacity for ward reviews and reduced MET calls/codes.