Prevalence, Awareness and Control of Hypertension in Greece before and after the COVID-19 Pandemic: May Measurement Month Survey 2019-2022.

BACKGROUND: The COVID-19 pandemic had an adverse impact on several cardiovascular risk factors. This study investigated the prevalence, awareness and treatment of hypertension in Greece before and after the pandemic. Data were collected in the context of the May Measurement Month (MMM) global survey initiated by the International Society of Hypertension. METHODS: Adult volunteers (age ≥18 years) were recruited through opportunistic screening in public areas across cities in Greece in 2019 and 2022. Medical history and triplicate sitting blood pressure (BP) measurements were taken using validated automated upper-arm cuff devices. The data were uploaded to the international MMM cloud platform. Hypertension was defined as systolic BP ≥140 mmHg and/or diastolic ≥90 mmHg, and/or self-reported use of drugs for hypertension. The same threshold was used to define uncontrolled BP in treated individuals. RESULTS: Data from 12,080 adults were collected (5,727/6,353 in MMM 2019/2022; men 46/49%, p<0.01; mean age 52.7±16.6/54.8±16.2, p<0.001; smokers, 24.7/30.5, p<0.001; diabetics 12/11.5%, p=NS; cardiovascular disease 5/5.8%, p=NS). The prevalence of hypertension was 41.6/42.6% (MMM 2019/2022, p=NS), with 21.3/27.5% of hypertensives being unaware of their condition (p<0.001), 5.6/2.4% aware untreated (p<0.001), 24.8/22.1% treated uncontrolled (p<0.05), and 48.3/47.8% treated controlled (p=NS). CONCLUSIONS: In Greece, the COVID-19 pandemic did not appear to affect the prevalence and control of hypertension, However, the rate of undiagnosed hypertension was higher after the pandemic. National strategies need to be implemented for the early detection and optimal management of hypertension in the general population in Greece.

Visual assessment of Korotkoff sounds improves the accuracy of a validated professional automated auscultatory blood pressure monitor KOROT P3 Accurate.

OBJECTIVE: A novel automated auscultatory upper-arm cuff blood pressure (BP) monitor for office use (KOROT P3 Accurate, previously InBody BPBIO480KV), which displays Korotkoff sound curves for each BP reading was recently developed. This study investigated whether the review of Korotkoff sound curves by healthcare professionals further improves the accuracy of the device by identifying unreliable BP readings. METHODS: Three observers assessed independently the morphology of Korotkoff sound curves of BP measurements obtained during an ISO 81060-2:2018 validation study, and classified them as of good, fair, or poor quality (low amplitude or sound intensity, aberrant morphology, background noise, signal artifact, auscultatory gap, irregular rhythm). The observers were blinded to the study BP measurements. RESULTS: Korotkoff sound curves of 255 BP readings obtained in 85 individuals were analyzed (mean age 57.3 ±â€Š15.0 years, 53 men). Of the SBP readings 80.4/12.2/7.4% were classified as good/fair/poor, and DBP 76.9/12.2/10.9%. Inter-observer agreement in detecting poor-quality curves was 84.7/83.1% (systolic/diastolic). Of poor-quality curves, 10.5/60.7% (systolic/diastolic) clustered in the same individuals. The validation criterion 1 [mean test-reference BP difference ≤5 ±â€Š8 (SD) mmHg] was satisfied for readings with good (0.1 ±â€Š4.9/0.3 ±â€Š3.8 mmHg, systolic/diastolic) and fair-quality curves (-0.4 ±â€Š6.4/0.2 ±â€Š5.0), but not for poor-quality ones (2.7 ±â€Š8.8/3.6 ±â€Š8.1). By excluding poor-quality readings (40 of 255), criterion 1 of the validation study was improved (0.2 ±â€Š4.9/0.2 ±â€Š3.9 versus 0.3 ±â€Š5.5/0.6 ±â€Š4.7 mmHg). CONCLUSION: The visual assessment of Korotkoff sounds generated during automated auscultatory BP measurement by the KOROT P3 Accurate professional monitor identifies unreliable readings and further improves the device accuracy.

Blood pressure variability assessed by office, home, and ambulatory measurements before and during antihypertensive drug treatment: a sub-analysis of the REVERENT randomized trial.

OBJECTIVES: Blood pressure (BP) variability (BPV) can be assessed using office (OBP), home (HBP), or ambulatory BP (ABP) measurements. This analysis investigated the association and agreement between OBP, HBP, and ABP measurements for BPV assessment at baseline and 10 weeks after initiating antihypertensive drug therapy. METHODS: Untreated hypertensive patients with elevated BPV were randomized to receive an angiotensin-converting enzyme inhibitor (ramipril) or a calcium channel blocker (nifedipine GITS) in a 10-week, open-label, blinded-end point study. BPV was assessed using standard deviation (SD) and coefficient of variation (CV) (reading-to-reading analyses). RESULTS: Data from 146 participants from three research centers (Athens/Greece; Milan/Italy; Shanghai/China) were analyzed [mean age 53 ±â€Š10 (SD) years, male individuals 60%, baseline systolic OBP, HBP, and 24 h ABP 144 ±â€Š9, 138 ±â€Š10, and 143 ±â€Š10 mmHg, respectively]. Post-treatment minus pre-treatment systolic CV difference was: OBP: 0.3%, P = 0.28; HBP: -0.2%, P = 0.20; 24 h ABP: 1.1%, P < 0.001. Home and ambulatory (not office) BPV indices presented weak-to-moderate correlation, both before and during treatment (range of coefficients 0.04-0.33). The correlation coefficient between systolic HBP CV and awake ABP CV was 0.21 and 0.28 before and during treatment, respectively (P < 0.05/< 0.001, respectively). Home and ambulatory (not office) BPV indices presented slight to fair agreement (range 64-73%) in detecting participants with high systolic BPV (top quartile of respective distributions) both before and during treatment (kappa range 0.04-0.27). CONCLUSION: These data showed a weak-to-moderate association between out-of-office (but not office) BPV indices both before and during BP-lowering treatment, with reasonable agreement in detecting individuals with high BPV. Out-of-office BP measurements provide more similar and consistent BPV information than office measurements.

Atrial Fibrillation Screening During Routine Automated Office, Home, and Ambulatory Blood Pressure Measurement: A Diagnostic Test Accuracy Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) is often asymptomatic and undiagnosed. As AF and hypertension often coexist, opportunistic AF detection during routine automated blood pressure (BP) measurement appears to be an attractive screening method. METHODS: A systematic literature search was conducted to identify studies assessing the diagnostic test accuracy of office, home, or 24-hour ambulatory BP measuring devices with AF detection algorithms versus reference electrocardiography. Analyses were performed per participant (AF status based on several BP readings; most office/home devices) or per reading (AF status based on individual readings; all ambulatory devices). A meta-analysis stratified by device type (office/home/ambulatory) was conducted to calculate pooled measures of diagnostic accuracy. Sensitivity/meta-regression analyses were also performed. RESULTS: Among 3096 records initially retrieved, 23 diagnostic test accuracy studies were included. Data derived from 11 093 individuals (weighted age 69 years, males 56%, hypertensives 79%, diabetics 24%, and AF prevalence 17%) indicated a pooled sensitivity 0.97 (95% CI, 0.92-0.99), specificity 0.93 (95% CI, 0.90-0.95), and accuracy 0.93 (95% CI, 0.89-0.95), with generally consistent results using office, home, or ambulatory BP devices (slightly lower specificity with the latter). The positive and negative predictive values were 0.70 (95% CI, 0.60-0.80) and 0.99 (95% CI, 0.98-1.00), respectively. Sensitivity analyses indicated lower specificity in studies implementing reading versus participant analyses. Most studies presented a low risk of bias and minor applicability concerns. CONCLUSIONS: There is considerable and consistent evidence suggesting high diagnostic accuracy of AF detection algorithms implemented in automated BP monitors during routine BP measurements in and out of the office. AF diagnosis requires verification (electrocardiography) before treatment is administered.

Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability.

Recent evidence suggests that an exaggerated blood pressure (BP) response to standing (ERTS) is associated with an increased risk of adverse outcomes, both in young and old individuals. In addition, ERTS has been shown to be an independent predictor of masked hypertension. In the vast majority of studies reporting on the prognostic value of orthostatic hypertension (OHT), the definition was based only on systolic office BP measurements. This consensus statement provides recommendations on the assessment and management of individuals with ERTS and/or OHT. ERTS is defined as an orthostatic increase in SBP at least 20 mmHg and OHT as an ERTS with standing SBP at least 140 mmHg. This statement recommends a standardized methodology to assess ERTS, by considering body and arm position, and the number and timing of BP measurements. ERTS/OHT should be confirmed in a second visit, to account for its limited reproducibility. The second assessment should evaluate BP changes from the supine to the standing posture. Ambulatory BP monitoring is recommended in most individuals with ERTS/OHT, especially if they have high-normal seated office BP. Implementation of lifestyle changes and close follow-up are recommended in individuals with ERTS/OHT and normotensive seated office BP. Whether antihypertensive treatment should be administered in the latter is unknown. Hypertensive patients with ERTS/OHT should be managed as any other hypertensive patient. Standardized standing BP measurement should be implemented in future epidemiological and interventional studies.

Comparison of Integrase Strand Transfer Inhibitors (INSTIs) and Protease-Boosted Inhibitors (PIs) on the Reduction in Chronic Immune Activation in a Virally Suppressed, Mainly Male Population Living with HIV (PLWH).

Background and Objectives: The success of combined antiretroviral therapy (cART) has led to a dramatic improvement in the life expectancy of people living with HIV (PLWH). However, there has been an observed increase in cardiometabolic, bone, renal, hepatic, and neurocognitive manifestations, as well as neoplasms, known as serious non-AIDS events/SNAEs, compared to the general population of corresponding age. This increase is linked to a harmful phenomenon called inflammaging/immunosenescence, which is driven by chronic immune activation and intestinal bacterial translocation. In this study, we examined immunological and metabolic parameters in individuals receiving current cART. Materials and Methods: The study was conducted at Laiko General Hospital in Athens, Greece. Plasma concentrations of sCD14, IL-6, SuPAR, I-FABP, and LBP were measured in virally suppressed PLWH under cART with at least 350 CD4 lymphocytes/µL. We compared these levels between PLWH receiving integrase strand transfer inhibitors (INSTIs) and protease inhibitors (PIs) and attempted to correlate them with chronic immune activation and metabolic parameters. Results: Data from 28 PLWH were analyzed, with a mean age of 52 and 93% being males. Among the two comparison groups, IL-6 levels were higher in the PIs group (5.65 vs. 7.11 pg/mL, p = 0.03). No statistically significant differences were found in the other measured parameters. A greater proportion of PLWH under INSTIs had normal-range LBP (33% vs. 0%, p = 0.04). When using inverse probability of treatment weighting, no statistically significant differences in the measured parameters were found between the two groups (sCD14 p = 0.511, IL-6 p = 0.383, SuPAR p = 0.793, I-FABP p = 0.868, and LBP p = 0.663). Glucose levels were found to increase after viral suppression in the entire sample (92 mg/dL vs. 98 mg/dL, p = 0.009). Total (191 mg/dL vs. 222 mg/dL, p = 0.005) and LDL cholesterol (104 mg/dL vs. 140 mg/dL, p = 0.002) levels were higher in the PIs group. No significant differences were observed in liver and renal function tests. Conclusions: Further investigation is warranted for PLWH on cART-containing INSTI regimens to explore potential reductions in chronic immune activation and intestinal bacterial translocation.

Prognostic value of home versus ambulatory blood pressure monitoring: a systematic review and meta-analysis of outcome studies.

OBJECTIVES: Ambulatory (ABP) and self-home blood pressure (HBP) measurements are known to be superior to office blood pressure (OBP) measurements in predicting cardiovascular events. Whether ABP has superior prognostic ability than HBP, or the reverse, has not been adequately investigated. METHODS: A systematic literature search was conducted to identify outcome studies investigating HBP and ABP in the same population. A meta-analysis was conducted to calculate the pooled measure of risk regarding the primary endpoint of each study for each method. Primary analysis included the comparison of pooled estimates of HBP versus 24 h ABP. RESULTS: Among 2587 articles retrieved, 6 fulfilled the inclusion criteria. Meta-analysis of five studies ( n  = 4439, weighted age 57 years, men 52%, hypertension 68%, diabetes 15%, cardiovascular disease 11%) indicated pooled hazard ratio per 10 mmHg increase in systolic HBP 1.36 (95% CI 1.23-1.50) and in 24 h ABP 1.38 (1.22-1.57) for the primary endpoint of each study ( z -test P  = NS). Meta-analysis of five studies ( n  = 4497, weighted age 58 years, men 51%, hypertension 65%, diabetes 15%, cardiovascular disease 9%) indicated pooled hazard ratio per 10 mmHg increase in systolic HBP 1.29 (1.14-1.47), daytime ABP 1.30 (1.15-1.46) and nighttime ABP 1.31 (1.14-1.50) ( z -test, P  = NS). Data for DBP were similar. All studies were deemed to have low risk of bias. In studies comparing all the three methods, OBP provided the lowest hazard ratio. CONCLUSION: This meta-analysis of the available prospective outcome studies suggested that HBP and ABP have similar ability in predicting outcome and superior to OBP.

Validation of the oscillometric home blood pressure monitor Braun BUA4000 with wide-range cuff in a general population according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard.

OBJECTIVE: To evaluate the blood pressure (BP) measurement accuracy of the Braun BUA4000 automated oscillometric upper-arm cuff device for self-home use in a general population according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018) and its Amendment 1.2020-01. METHODS: Participants were recruited to fulfill the age, sex, BP and limb circumference distribution criteria of the AAMI/ESH/ISO Universal Standard in a general population using the same arm sequential BP measurement method. A single wide-range cuff of the test device was used for arm circumference range 22-42 cm. RESULTS: A total of 98 individuals were recruited and 85 were analyzed [mean age 60.3 ±â€…16.1 (SD) years, 44 men, arm circumference 31.5 ±â€…5.1 cm, range 22-41.5 cm]. For validation criterion 1, the mean difference ± SD between the test device and reference BP readings ( N  = 255) was 0.9 ±â€…6.4/-0.3 ±â€…6.4 mmHg (systolic/diastolic; threshold ≤5 ±â€…8 mmHg). For criterion 2, the SD of the averaged BP differences between the test device and reference BP per individual ( N  = 85) was 5.15/5.81 mmHg (systolic/diastolic; threshold ≤6.88/6.95 mmHg). CONCLUSION: The Braun BUA4000 automated oscillometric BP monitor fulfilled all the requirements of the AAMI/ESH/ISO Universal Standard in a general population and can be recommended for self-monitoring of BP by patients at home.

Diagnostic and Therapeutic Challenges in a Military Recruit Training Center of the Hellenic Navy: A Retrospective Analysis of the Poros Registry Serving as a Quality Improvement Project for Medical Officers.

INTRODUCTION: Basic military training (BMT) has been associated with increased morbidity burden. Nevertheless, the exact epidemiology of the encountered cases in the BMT of Greek recruits has never been assessed. The aim of this quality improvement project was to investigate for the first time the clinical patterns, rates, and severity of symptoms leading recruits to visit the infirmary of a recruit training center and use this knowledge to provide a practical guidance for the physicians in charge. MATERIALS AND METHODS: All medical cases which were consecutively examined for the time range from November 2021 to September 2022 at the infirmary of the Hellenic Naval recruit training center in Poros, Greece, were retrospectively analyzed. Logistic regression analyses were performed to identify independent predictors of "severe clinical status" (i.e., overnight sick bay confinement and/or transfer to a tertiary hospital within 24 h) and absence from BMT for at least 1 day. RESULTS: A total of 2,623 medical cases were examined during four recruit seasons from November 2021 to September 2022. Upper respiratory tract infections (URTIs) and musculoskeletal injuries were the most frequent reasons for a recruit's visit to the infirmary (33.9% and 30.2%, respectively). 6.7% of the total cases were identified as having "severe clinical status." Specifically, in psychiatric, urological, and cardiovascular cases, febrile events were all independently associated with increased risk of "severe clinical status." There was a positive association between training week and absence from BMT, while febrile events and spring recruit season were also independently linked with increased probability of absence from BMT for at least 1 day. CONCLUSIONS: URTIs and musculoskeletal complaints were the primary reasons for recruits' presentation at the infirmary of a Greek recruit training center, leading to severe rates of attrition. Further registries and quality improvement projects are warranted to reach specific conclusions and reduce BMT-related morbidity and its subsequent implications.

Seasonal effects on blood pressure variability in treated hypertensive patients assessed by office, home, and ambulatory measurements.

This study investigated the seasonal effect on blood pressure (BP) variability. Patients on stable antihypertensive drug treatment were assessed with office (OBP), home (HBP), and ambulatory BP (ABP) measurements in winter, next summer, and in next winter. Fifty-eight participants with full data for winter and summer were analyzed (mean age 65.2 ± 7.9 [SD], 64% males). OBP, HBP and ABP (24-h; daytime) were lower in summer than in winter (P < 0.01), whereas nighttime ABP was unchanged (p = NS). Standard deviation (SD), coefficient of variation (CV) and average real variability (ARV) for systolic OBP were higher in winter than summer (p < 0.01/ < 0.05/ < 0.01, respectively). These indices for HBP and ABP measurements did not differ in winter and summer (p = NS). Forty participants had complete data for winter-summer-next winter and HBP/ABP variability indices did not differ for both winters versus summer. These preliminary data suggest that BP variability is unaffected by seasonal changes in contrast to average BP levels.

Efficiency and Safety of Patent Ductus Arteriosus Surgical Ligation in Extremely Low Birth Weight Infants Without Chest Tube Placement.

Patent ductus arteriosus (PDA) has been associated with increased morbidity and mortality in preterm infants. Surgical ligation (SL) is generally performed in symptomatic infants when medical management is contraindicated or has failed. We retrospectively reviewed our institution's experience in surgical management of PDA for extremely low birth weight (ELBW) infants without chest tube placement assessing its efficiency and safety. We evaluated 17 consecutive ELBW infants undergoing SL for symptomatic PDA (January 2012-January 2018) with subsequent follow-up for 6 months postdischarge. Patients consisted of 9 (53%) females and 8 (47%) males. Mean gestational age (GA) at birth was 27.9 ± 2.1 weeks. Median values for surgical age (SA) from birth to operation was 10 days (interquartile range [IQR]: 8-12); PDA diameter 3.4 mm (IQR: 3.2-3.5); surgical weight (SW) 750 g (IQR: 680-850); and days of mechanical ventilation (DMV) as estimated by Kaplan-Meier curve 22 days (95% confidence interval: 14.2-29.8). We observed a statistically significant negative association between DMV and GA at birth (rho = - 0.587, p = 0.017), SA (rho = - 0.629, p = 0.009) and SW (rho = - 0.737, p = 0.001). One patient experienced left laryngeal nerve palsy confirmed by laryngoscopy. Otherwise, there were no adverse events to include surgical-related mortality, recurrence of PDA, or need for chest tube placement during follow-up. SL of PDA in ELBW infants without chest tube placement is both efficient and safe. Universal consensus recommendations for the management of PDA in ELBW neonates are needed. Further study is required regarding the use of the less invasive option of percutaneous PDA closure in ELBW infants.

Chlorthalidone versus hydrochlorothiazide for preventing cardiovascular disease in hypertension: Is the case closed?

The optimal diuretic choice [hydrochlorothiazide (HCTZ) or chlorthalidone (CTD)] for the management of hypertension has been an ongoing debate for several years. HCTZ is widely used in the form of single-pill combinations, whereas CTD is a more potent drug vs. HCTZ, especially in reducing nighttime blood pressure (BP), with some indirect evidence suggesting a superiority in terms of cardiovascular (CV) risk reduction. In addition, recent data showed that CTD was safe and effective in terms of BP lowering in predialysis patients with stage 4 chronic kidney disease. The Diuretic Comparison Project was the first head-to-head pragmatic, open-label trial that randomly assigned elderly patients with hypertension under HCTZ therapy to continue with HCTZ or to switch to CTD (equivalent doses). Office BP was similar for both groups throughout the study. The trial showed no difference in major CV events or non-cancer-related deaths during a median follow-up of 2.4 years; yet, CTD was associated with a benefit in participants with a previous myocardial infarction or stroke, which might be a chance finding but could also indicate that a high-risk population is more suitable for revealing the impact of slight differences in the 24-hour BP profile in a relatively short-term follow-up. Interestingly CTD vs. HCTZ was associated with higher hypokalemia rates apart from the latter group of patients where there was no difference. Overall, the available data do not confirm the superiority of CTD over HCTZ in general, but this could be questionable in selected patients.

European Society of Hypertension recommendations for the validation of cuffless blood pressure measuring devices: European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability.

BACKGROUND: There is intense effort to develop cuffless blood pressure (BP) measuring devices, and several are already on the market claiming that they provide accurate measurements. These devices are heterogeneous in measurement principle, intended use, functions, and calibration, and have special accuracy issues requiring different validation than classic cuff BP monitors. To date, there are no generally accepted protocols for their validation to ensure adequate accuracy for clinical use. OBJECTIVE: This statement by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability recommends procedures for validating intermittent cuffless BP devices (providing measurements every >30 sec and usually 30-60 min, or upon user initiation), which are most common. VALIDATION PROCEDURES: Six validation tests are defined for evaluating different aspects of intermittent cuffless devices: static test (absolute BP accuracy); device position test (hydrostatic pressure effect robustness); treatment test (BP decrease accuracy); awake/asleep test (BP change accuracy); exercise test (BP increase accuracy); and recalibration test (cuff calibration stability over time). Not all these tests are required for a given device. The necessary tests depend on whether the device requires individual user calibration, measures automatically or manually, and takes measurements in more than one position. CONCLUSION: The validation of cuffless BP devices is complex and needs to be tailored according to their functions and calibration. These ESH recommendations present specific, clinically meaningful, and pragmatic validation procedures for different types of intermittent cuffless devices to ensure that only accurate devices will be used in the evaluation and management of hypertension.

Requirements for design and function of blood pressure measuring devices used for the management of hypertension: Consensus Statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and STRIDE BP.

OBJECTIVE: To develop scientific consensus recommendations for the optimal design and functions of different types of blood pressure (BP) measuring devices used in clinical practice for the detection, management, and long-term follow-up of hypertension. METHODS: A scientific consensus meeting was performed by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability and STRIDE BP (Science and Technology for Regional Innovation and Development in Europe) during the 2022 Scientific Meeting of the ESH in Athens, Greece. Manufacturers were also invited to provide their feedback on BP device design and development. Thirty-one international experts in clinical hypertension and BP monitoring contributed to the development of consensus recommendations on the optimal design of BP devices. STATEMENT: International consensus was reached on the requirements for the design and features of five types of BP monitors, including office (or clinic) BP monitors, ambulatory BP monitors, home BP monitors, home BP telemonitors, and kiosk BP monitors for public spaces. For each device type "essential" requirements (must have), and "optional" ones (may have) are presented, as well as additional comments on the optimal device design and features. CONCLUSIONS: These consensus recommendations aim at providing manufacturers of BP devices with the requirements that are considered mandatory, or optional, by clinical experts involved in the detection and management of hypertension. They are also directed to administrative healthcare personnel involved in the provision and purchase of BP devices so that they can recommend the most appropriate ones.

Clinical and Oncological Impact of the Toll-like Receptor-3 and -4 in Esophageal and Gastro-esophageal Junction Adenocarcinoma.

BACKGROUND/AIM: Esophageal and gastro-esophageal junction cancer is a major cause of cancer-related mortality, with poor prognosis. Toll-like receptors (TLRs) play a significant role in the innate immune system; their increased expression has been associated with esophageal adenocarcinoma. This study aimed to determine the association between TLR-3 and TLR-4 expression with clinical and oncological outcomes of patients that underwent esophagectomy for cancer. PATIENTS AND METHODS: This is a retrospective analysis of prospectively collected data from consecutive patients within a 2-year period. Primary endpoints of the study were the assessment of the expression of TLR-3 and TLR-4 in primary tumors as well as in metastatic lymph nodes. Secondary endpoints were the correlation of TLR-3 and TLR-4 values with the clinical, pathological, and oncological outcomes. RESULTS: A significantly higher expression of TLR-3 and TLR-4 in primary tumors and metastatic-lymph nodes was observed. There was a significant association between TLR-3 expression and T-stage, as well as TLR-4 expression and grade of differentiation in the primary site. Additionally, metastatic-lymph node TLR-4 expression was significantly correlated with N-stage. A strong correlation between TLR-4 expression and overall or progression-free survival rates was detected. CONCLUSION: This study found a significantly increased TLR expression in malignant tissue/metastatic lymph nodes, as well as a significant positive correlation between TLRs and worse clinical outcomes. TLRs have a pivotal role in the inflammation pathway in the esophagus and during esophageal carcinogenesis. This study highlights the need for further investigation into TLR-mediated signaling pathways and their potential role as diagnostic and therapeutic targets.