Background: Kidney transplantation (KTx) requires immunosuppressive drugs such as Tacrolimus (TAC) which is mainly metabolized by CYP3A5. TAC is routinely monitored by trough levels (C0) although it has not shown to be a reliable marker. The area-under-curve (AUC) is a more realistic measure of drug exposure, but sampling is challenging in pediatric patients. Limited-sampling strategies (LSS) have been developed to estimate AUC. Herein, we aimed to determine AUC(0–24) and CYP3A5 genotype in Chilean pediatric kidney recipients using extended-release TAC, to evaluate different LSS-AUC(0–24) formulas and dose requirements.Patients and methods: We analyzed pediatric kidney recipients using different extended-release TAC brands to determine their trapezoidal AUC(0–24) and CYP3A5 genotypes (SNP rs776746). Daily TAC dose (TAC-D mg/kg) and AUC(0–24) normalized by dose were compared between CYP3A5 expressors (*1/*1 and *1/*3) and non-expressors (*3/*3). We evaluated the single and combined time-points to identify the best LSS-AUC(0–24) model. We compared the performance of this model with two pediatric LSS-AUC(0–24) equations for clinical validation.Results: Fifty-one pharmacokinetic profiles were obtained from kidney recipients (age 13.1 ± 2.9 years). When normalizing AUC(0–24) by TAC-D significant differences were found between CYP3A5 expressors and non-expressors . C0 had a poor fit with AUC(0–24) (r2 = 0.5011). The model which included C0, C1 and C4, showed the best performance to predict LSS-AUC(0–24) (r2 = 0.8765) and yielded the lowest precision error (7.1% ± 6.4%) with the lowest fraction (9.8%) of deviated AUC(0–24), in comparison to other LSS equations.Conclusion: Estimation of LSS-AUC(0–24) with 3 time-points is an advisable and clinically useful option for pediatric kidney recipients using extended-release TAC to provide better guidance of decisions if toxicity or drug inefficacy is suspected. The different CYP3A5 genotypes associated with variable dose requirements reinforce considering genotyping before KTx. Further multi-centric studies with admixed cohorts are needed to determine the short- and long-term clinical benefits. Kidney transplantation (KTx) is the therapy of choice for pediatric patients who have reached end-stage kidney disease (ESKD) offering lower mortality and a better quality of life . Kidney (0–24), represents a realistic marker of drug exposure when using extended-release TAC formulations, although it requires sampling at multiple time-points that might be inconvenient in specific cases. To facilitate the clinical routine, TAC is habitually monitored by trough levels (C0) to guide clinical decisions and avoid side effects, but it has not shown to be a reliable marker with a suboptimal correlation with AUC(0–24) ((0–24) has proven to be a more accurate marker, repeated sampling can be difficult in pediatric or outpatient populations ((0–24) in pediatric recipients using TAC, but these equations need to be assayed in different geographic or ethnic populations.TAC is characterized by a narrow therapeutic range and high variability among patients. For this reason, plasmatic TAC levels undergo constant monitoring throughout the post-transplantation period to avoid supra- or sub-therapeutic levels, given that both scenarios increase the risks of adverse events . The eviUC(0–24) . Althougulations . To faceCYP3A5*3 allele) causes a splicing defect that determines that CYP3A5*3/*3 patients, also known as non-expressors, have null enzyme activity and consequently low drug requirements to achieve target TAC levels. In contrast, those patients carrying at least one wild-type CYP3A5*1 allele (genotypes CYP3A5*1/*3 and CYP3A5*1/*1), also known as expressors, usually require TAC doses 1.5–2.0 fold higher than the standard doses , described as the most relevant in TAC metabolism . The A>Grd doses . The disfter KTx .(0–24) equations in pediatric kidney recipients using different brands of extended-release TAC and carrying different CYP3A5 genotypes. Herein, we aimed to evaluate the utility of single and combined time-points to predict an accurate AUC(0–24) with LSS and to explore the role of CYP3A5. Additionally, we compared the performance of the best LSS model with two pediatric LSS-AUC(0–24) equations described previously for clinical validation  and were receiving stable doses of extended-release TAC, were invited to participate in this observational, prospective and longitudinal study. In our center, around 80% of the transplantations were performed with deceased donors during this period of years. We studied 51 recipients who received TAC combined with mycophenolic acid as immunosuppressive therapy with or without steroids, as described previously by our group . All theThe study was conducted according to the declaration of Helsinki with the approval from the Ethic Committee of the Universidad de Chile and from the Director of the Hospital Luis Calvo Mackenna. Parental or legal tutors written informed consent was requested in all cases and patients aged between 12 and 17 years old were asked for assent as their affirmative agreement to participate in this study. Patients with combined liver-kidney transplantation, evidence of graft dysfunction at the time of the study, or parents that denied participation were excluded.0 defined in our center (10–15 ng/mL during the first 3 months and 5–7 ng/mL after the third-month post-KTx). The analysis of AUC(0–24) was conducted on recipients mainly during outpatient visits but also during hospitalization, with stable immunosuppression based on TAC therapy. At the time of the patient’s schedule for AUC(0–24), the daily TAC dose normalized by weight (TAC-D mg/kg) was registered to compare later CYP3A5 expressors and non-expressors. In our center, target AUC(0–24) values range from 170 to 250 ng*h/mL during the maintenance phase  between innovator (Prograf XL®) and bioequivalent users (Tacni XR® or Cidimus XL®) or considered mixed when analyzing LSS-predicted vs. observed AUC(0–24).Therapeutic drug monitoring of TAC was applied regularly to all recipients and dose adjustment was performed whenever necessary to achieve the target Cce phase . Extende0) and after TAC oral dose intake at the following times: 1 (C1), 2 (C2), 4 (C4), 12 (C12), and 24 (C24) hours. Then, plasma TAC concentrations were measured by performing an immunoassay using the Abbott Architect i1000 instrument (Abbott Laboratories). To estimate the AUC0-24 for each patient, we integrated the plasma TAC concentrations against time using the Bolstad2 package for R  and Tmax (timepoint with the highest TAC concentration) were also registered.In all patients, 2 mL blood samples were taken in EDTA tubes at 0 h  was determined using the TaqMan assay® or the PCR-RFLP technique with specific primers and the restriction enzyme SspI, according to the described protocol (CYP3A5*1/*1), heterozygous (CYP3A5*1/*3) and homozygous variant allele (CYP3A5*3/*3). Negative controls with an equal volume of nuclease-free pure water were included. We classified patients’ CYP3A5 genotypes according to the reported effect on CYP3A5 expression: CYP3A5 expressors (genotypes CYP3A5*1/*1 and *1/*3) and CYP3A5 non-expressors (genotype CYP3A5*3/*3).DNA was extracted from whole peripheral blood samples using the QIAmp DNA Blood Mini Kit (QIAGEN) following the manufacturer’s instructions. The protocol . Each as(0–24) values among CYP3A5 genotypes, CYP3A5 expression groups, and TAC brand. We also compared TAC-D and AUC(0–24) normalized by TAC-D between CYP3A5 expression groups by performing ANOVA. For these analyses, we checked the normality of ANOVAs’ residuals and tested the homogeneity of variance using the Fligner-Killen test. s. Differences among groups were considered statistically significant if the p-value was lower than 0.05.Analysis of variance (ANOVA) was performed to compare AUC0, C1, C2, and C4 as predictor variables and AUC0-24 as the response variable. We avoided the use of C12 and C24 to develop an LSS where samples were suitable for the outpatient pediatric population. Regression models including all combinations of C0, C1, C2 and C4 were obtained using the olsrr package for R  and Bayesian information criterion (BIC) weights -trapezoidal AUC(0–24))|/trapezoidal AUC(0–24). Median APE (MAPE) was calculated and compared between the different LSS equations.We also evaluated the precision of the retained LSS models calculating the percentage of the absolute prediction error (APE) that was considered for validation of the LSS equations . APE was(0–24) equation with the best performance identified in this study with two global equations developed previously in pediatric patients from Spain that included together liver and kidney transplants using immediate- or extended-release TAC capsules (We compared the precision of LSS-AUCcapsules :LSS−C0−(0–24) equations. Given the high pharmacokinetic variability, APE values of less than 15% were considered clinically acceptable. In addition, Bland–Altman plots for the three LSS-AUC(0–24) equations were used to analyze the agreement between LSS-predicted and observed AUC(0–24) expressed as the difference between methods (method A- method B) vs. methods A-B average and to compare the limits of agreement with 95% CI around the average difference.MAPE was calculated and compared between the different LSS-AUC® as a single TAC brand or mixed with other brands.Altogether 51 pediatric recipients were included that had undergone KTx at a single transplant center at 7.8 ± 4.0 years, being the structural anomalies the leading cause of ESKD . At the CYP3A5 genotypes were distributed as follows: 4.2% presented the CYP3A5*1/*1 genotype, 29.2% the heterozygous CYP3A5*1/*3 genotype and 66.6% the CYP3A5*3/*3 genotype .The genotype . Altoget(0–24) did not differ significantly among CYP3A5 genotypes , CYP3A5 expression groups  or TAC brand . Then, AUC(0–24) values were pooled for the following analyses. The mean AUC(0–24) was 225 ± 52 (range: min 122—max 361.4) ng*h/mL and the curves fit a two-compartmental model (0 level was 6.2 ± 2.0 ng/mL and we identified 36/51 (70.6%) cases out of the therapeutic range defined in the transplant center. The mean Cmax was 16.7 ± 6.1 (range: min 6.4—max 28.9 ng/mL) and Tmax occurred mainly at C1 (39.2%) and C2 (33.3%) time-points.Trapezoidal AUCal model . The mea(0–24) by TAC-D significant differences were found between CYP3A5 expressors and non-expressors .When normalizing AUC(0–24) values combining C0, C1, C2, and C4 values  (r2 = 0.5011), while C4 had a better predictive value (r2 = 0.7350). According to the clinical criterion that the adjusted r2 of LSS models should be higher than 0.799, we selected 4 LSS models that combined two (model 7), three (models 12 and 13), or four (model 15) time-points , which included three time-points, C0, C1 and C4 (r2 with model 15 (r2 = 0.8748) which included four time-points  = 26.0 + 11.27*C0 + 1.97*C1 + 8.13*C4. The mean LSS-AUC(0–24) values for this equation was 225 ± 55 (range: min 121- max 351) ng*h/mL. This LSS-AUC(0–24) equation was consistent among different clinical conditions, showing the same trend between patients using the innovator, bioequivalent, or a mixed version of these products, , different CYP3A5 expression groups , or different age groups (<13 yo and >13 yo patients) .We observed the best performance in model 12 which used extraction points at 0, 1, and 4 h with the following equation: LSS-AUC(0–24) values using two previously described equations that include three time-points . The mean LSS-AUC(0–24) for the equations described by Almeida-Paulo et al., in 2014 using C0-C1-C4 and C0-C2-C4 values observed in our cohort, yielded 225 ± 52 (range: min 127- max 345) and 223 ± 51 (range: min 129- max 329) ng*h/mL, respectively. Mean values for APE (MAPE) were clinically acceptable for the three LSS-AUC(0–24) equations. However, estimating AUC(0–24) values with the LSS-AUC(0–24) model 12 yielded the lowest MAPE with the lowest fraction (9.8%) of values above 15%. According to the Bland-Altman plots, all three models showed a good concordance with trapezoidal AUC(0–24), with marginally better prediction accuracy in LSS including C0-C1-C4  was close to zero in the three plots.Additionally, we calculated the LSS-AUCC0-C1-C4 . Limits TAC is considered a cornerstone immunosuppressive drug in KTx, but accurate monitoring of drug exposure is mandatory to avoid adverse events. One of the key features is that most pharmacokinetic and/or pharmacogenetic studies in KTx are performed in adults, with less evidence in recipients under 18 years as we present herein. Adolescence and young adulthood are considered critical periods with a high risk of graft loss due to bad adherence . FurtherExtended-release TAC capsules were developed later than immediate-release capsules and approved by FDA in 2013. For this reason, multi-center studies and extensive reports have provided strong recommendations regarding immediate-release capsules, while increasing evidence has demonstrated that extended-release capsules are an advisable option as we pretended to explore in this study because they are easier to administer and improve patients’ adherence with the same efficacy .CYP3A5 genotypes  was not influenced by the CYP3A5 genotype which can be explained by the long median time since KTx, where the doses were adjusted whenever necessary to assure C0 values close to the therapeutic range. However, we observed a 50% increase in TAC requirements in CYP3A5 expressors in comparison to non-expressors, as extensively communicated in retrospective studies and recommended by the Clinical Pharmacogenetics Implementation Consortium  than in non-expressors (0.436 L/kg/h). Although TAC absorption rates are not available, an increased depuration might be assumed in the first group of patients, reinforcing their requirement for higher TAC doses to achieve drug exposure within the target.The AUCnsortium . Moreoveed doses . Despite0 was within the therapeutic range, more than half of the cases presented values out of range, equally below and above it. On the other hand, mean trapezoidal AUC(0–24) was also within the therapeutic range, but half of the patients were out of range, and twice more frequently above the upper limit. We are unaware if this might cause adverse effects such as toxicity or viral infections more frequently than signs of rejection since clinical outcomes were not evaluated, but this result might be useful in forthcoming studies to evaluate the limits of the therapeutic AUC(0–24) range.Our patients were considered under stable immunosuppression because dose adjustments had been made prior to this study. Although mean C0 is routinely used to guide clinical decisions irrespective of the TAC release formulation, we observed that it had a poor correlation with AUC(0–24). Interestingly, C4 and C24 (data not shown) presented better results, but r2 was not acceptable. It should be kept in mind that C0 and C24 are theoretically the same time-point, but C24 values present usually a better correlation with AUC(0–24) and represent a time-point with better supervision of the last capsule intake. It has been suggested that C24 might be considered an optimal marker of drug exposure substituting C0, but further studies are required to validate this hypothesis and clinical convenience (Although Cvenience .CYP3A5 genotypes. Previous studies seeking an LSS for adults using extended-release TAC have concluded that the combination of C10 or C12 with other time-points improves the correlation between LSS-predicted and observed AUC(0–24) but might be not convenient in the pediatric population ((0–24)  .(0–24) deviation higher than 15%. Second, after hospital discharge, the AUC(0–24) estimation has limitations in recipients that are not strictly supervised during their daily TAC intakes. Most of our data came from outpatient recipients, conferring this model as a more realistic representation of drug monitoring in underaged patients. Third, our LSS model was compared with ‘global’ LSS equations showing a similar performance, but our model had lower prediction error and AUC(0–24) deviation resulting in a pediatric-friendly LSS with high accuracy and precision in predicting AUC(0–24). Fourth, our LSS model is based on a single equation, which is valid for CYP3A5 both expressor and non-expressor patients.The validation of our LSS equation is desirable to be performed in internal and external cohorts but represents a major challenge in terms of sampling logistics, costs and risks considering the current pandemic scenario, since many patients travel long distances to visit their transplant center and immunocompromised patients have increased risk of illness and death . However(0–24) predictions based on our LSS do not seem to be different between the innovator and the bioequivalent products, as observed previously by other authors ((0–24) values (data not shown).This study has a variety of limitations. Developing countries face many challenges related to economic constraints and, although the Chilean health system guarantees the immunosuppressive scheme, public drug tendering imposes different TAC brands to treat recipients at transplant centers. Although this might introduce heterogeneity it also contributes to representativeness, and the AUC authors . Therefo authors . HoweverClinical trials to define personalized immunosuppressive therapies have been performed mainly on non-Hispanic cohorts of European descendants, while other populations remain underrepresented. Latin Americans are characterized by mixed genetic ancestries and their variable therapeutic response may be caused by multiple genes involved in different biological pathways interacting with epigenetic and environmental factors . Our pat(0–24) is highly recommendable in pediatric kidney recipients who have trough levels that are considered theoretically therapeutic but develop symptoms of drug toxicity or incomplete efficacy. We propose to perform LSS-AUC(0–24) two or three times a year, in complement to routinary trough levels to check if these are similar to those determined as part of previous LSS with AUC(0–24) results considered therapeutic. Taking this decision might avoid excessive sampling during the first years, in accordance with the logistic and financial capacities of each transplant center.In our opinion, the application of LSS-AUC(0–24) with only three time-points, C0-C1-C4, as well as considering CYP3A5 genotyping to guide TAC dosing after KTx and to identify patients at risk of adverse effects. Further studies focused on short- and long-term clinical outcomes are required, to evaluate the cost-efficiency of LSS-AUC(0–24) and CYP3A5 genotyping.In summary, we have demonstrated that the trough level in pediatric kidney recipients using extended-release TAC is a poor surrogate marker of drug exposure. Based on our results, if a reliable drug exposure needs to be determined we recommend considering LSS-AUC


Evidence in the general population suggests that predictors of cardiovascular health such as moderate to vigorous physical activity (MVPA), cardiorespiratory fitness, and systolic blood pressure are associated with cognitive function. Studies supporting these associations in adults with Down syndrome (DS) are limited. The purpose of this study was to examine the associations between systolic blood pressure, cardiorespiratory fitness, and MVPA on cognition in adults with DS.2 Peak), and cognitive function (CANTAB® DS Battery) were obtained. The cognitive battery included tests measuring multitasking, episodic memory, and reaction time. Physical activity (accelerometer) was collected over the week following the laboratory visit. Pearson correlations and linear regressions were used to measure the impact of systolic blood pressure, cardiorespiratory fitness, and MVPA on cognitive outcomes.This is a cross-sectional analysis using baseline data from a trial in adults with DS. Participants attended a laboratory visit where resting blood pressure, cardiorespiratory fitness (VO2 Peak (21.1 ± 4.2 ml/kg/min) and MVPA were low (14.4 ± 14.4 min/day), and systolic blood pressure was 118.3 ± 13.3 mmHg. VO2 Peak was correlated with simple movement time  but was not significant using a linear regression controlling for age and sex. Systolic blood pressure was significantly associated with episodic memory  and reaction time  using age- and sex-adjusted linear regressions. No associations were observed between MVPA and multitasking, episodic memory, or reaction time.Complete data was available for 72 adults with DS . At baseline, VOPredictors of cardiovascular health, including cardiorespiratory fitness and systolic blood pressure, were associated with some aspects of cognition in adults with DS. While future research should examine the role of improved cardiovascular health on delaying decreases in cognitive function and dementia in adults with DS, we recommend that health care providers convey the importance of exercise and cardiovascular health to their patients with DS.NCT04048759, registered on August 7, 2019. Down syndrome (DS) is a genetic condition caused by extra chromosome 21 material in all or some cells of the body and is the most common chromosomal abnormality associated with an intellectual disability .However, with this increase in life expectancy comes an increased risk of Alzheimer’s disease (AD) and dementia. By the age of 65 years, the cumulative incidence of dementia exceeds 90%  and is tPrevious research in adults with DS suggests that MVPA may be associated with cognitive function , 14. HowThis is a cross-sectional analysis using baseline data from a physical activity trial in adults with DS without dementia . ParticiParticipants were adults (≥ 18 years of age) with DS who were living at home with a parent or guardian or in a supported living environment with a caregiver who agreed to serve as a study partner. Additional inclusion criteria were mild to moderate intellectual disabilities, sufficient functional ability to understand directions, ability to communicate through spoken language, ability to participate in physical activity, and walk 10 feet unassisted and having Internet access in the home. Participants were excluded if they had dementia as determined by the Dementia Screening Questionnaire for Individuals with Intellectual Disabilities (DSQIID) ; particiResting blood pressure was measured on the non-dominant arm with participants seated in a chair and both feet flat on the ground. An aerobic step was placed under the feet of those participants who were unable to place their feet on the ground. After 5 min of quiet rest in a chair, blood pressure was taken in duplicate with 2 min separating the first and second measurements. A third measurement was taken for systolic and diastolic values ≥ 5 mmHg apart, and the average of the two closest measures was used for analysis. Systolic blood pressure represents the amount of pressure exerted by blood against your artery walls during ventricular contraction, whereas diastolic blood pressure is the amount of pressure exerted against your artery walls during ventricular rest between contractions. Only systolic blood pressure was used as an outcome since it is a better predictor of cardiovascular outcomes in midlife , 18.2 Peak) measured in ml/kg/min was assessed using a maximal treadmill test, following the protocol described by Fernhall et al. developed for adults with DS [2 and CO2 were measured using indirect calorimetry , which was calibrated with known volume and gas concentrations prior to each test according to the manufacturer’s recommendations. Values were averaged over 15-s intervals across the treadmill protocol. The exercise test was terminated if participants were unable to maintain the treadmill speed or requested that the test be stopped at any time during the treadmill protocol. Otherwise, tests were terminated when participants achieved two or more of the following criteria: (1) volitional exhaustion; (2) a plateau in VO2, i.e., < 150 ml/min or heart rate (HR) < 2 beats/min with increased work rate; (3) a HR within 5 beats/min of HRPeak predicted using the formula of Fernhall et al. [Peak were included in the analysis.Cardiorespiratory fitness −1 were considered spurious [MVPA and sedentary time were assessed using an ActiGraph wGT3XBT tri-axial accelerometer  worn on the non-dominant hip at the anterior axillary line during waking hours for 7 consecutive days. Vertical axis data aggregated over 60 s epochs from the ActiGraph devices were initialized and downloaded using Actilife software version 6.13.3 . Non-wear time was defined as at least 90 consecutive minutes of zero counts, with an allowance for 1–2 min of movement between zero and 100 counts/min . Counts spurious . A wear spurious , 23.Cognitive function was assessed using the Cambridge Neuropsychological Test Automated Battery for DS  , 25 admiMultitasking task, a measurement of executive function, assessed the ability of participants to ignore task-irrelevant information. An arrow was presented on either side of the screen pointing in either direction (right or left). Participants had to pay attention to either the side of the screen where the arrow appears or the direction of the arrow (indicated by SIDE or DIRECTION on the screen), by pressing a button on the left or right corner of the screen, respectively. Four key outcomes were collected from the multitasking task: incongruency cost, which is the difference (in milliseconds) between the median latency of response (from stimulus appearance to button press) on the trials that were congruent versus the trials that were incongruent; reaction latency, which is the median latency of response (from stimulus appearance to button press); multitasking cost, which is the difference (seconds) between the median latency of response (from stimulus appearance to button press) during assessed blocks in which both rules are used versus assessed blocks in which only a single rule is used; and total incorrect, which is the number of trials for which the outcome was an incorrect response.The paired associates learning test assessed visual episodic memory. Participants were presented with boxes on the screen in which different visual patterns are shown one by one. After the encoding phase, the different patterns were shown in the middle of the screen and participants had to select the box in which the pattern was previously presented. Outcome measures included the first attempt memory score, which assessed the number of times a participant was able to correctly recall a pattern previously displayed on the computer screen on their first attempt with higher scores indicating better memory, and the total errors, which are the number of times the subject chose the incorrect box for a stimulus on assessment problems plus an adjustment for the estimated number of errors they would have made on any problems, attempts, and recalls they did not reach.The reaction time task, a measure of attention and psychomotor speed, assessed reaction times for motor and mental responses. Previous research suggests that simple reaction time is correlated to memory and verbal fluency, and choice reaction time is related to language, orientation, and verbal fluency –31. Duri2 Peak) measures. Pearson correlations were used to describe the association between (1) systolic blood pressure, (2) cardiorespiratory fitness, and (3) MVPA with 10 cognition measures within 3 domains . Linear regressions were used to further explore the impact of systolic blood pressure, cardiorespiratory fitness, and MVPA on cognition in adults with DS while adjusting for age, sex, and body mass index. R version 4.2.2 was used for this analysis [Sample characteristics were described as mean ± standard deviation or frequency (percentage) for demographic , anthropometric , systolic and diastolic blood pressure, and cardiorespiratory fitness  and 3 measures of reaction time: five-choice movement time , simple movement time , and simple reaction time . When controlling for age and sex, systolic blood pressure had a significant association with both episodic memory measures, five-choice movement time, and simple movement time . Systolic blood pressure was significantly correlated with both episodic memory measures . There was no association between VO2 Peak and cognitive outcomes after adjusting for age and sex in a linear regression; however, the crude association between VO2 Peak and simple movement time was statistically significant , nor were any associations observed when using linear regression controlling for age and sex.Valid accelerometer data was obtained from 59 participants, and the mean MVPA was 14.4 ± 14.4 min/day. MVPA was not significantly correlated with any of the cognitive measures  after 12 weeks of exercise [The results of the current study found a correlation between cardiorespiratory fitness and simple movement time, although this relationship was no longer significant when controlling for age and sex. We are unaware of any previous research examining the association of cardiorespiratory fitness on cognition in adults with DS. In the non-DS population, cardiorespiratory fitness has been associated with improved reaction time in the general population  and in aexercise , suggest2 Peak) [MVPA is thought to impact cognition by multiple pathways, including improving other cardiovascular risk factors  and improving cardiorespiratory fitness (VO2 Peak) . We did 2 Peak) , 14. For2 Peak)  reported2 Peak) . Similar2 Peak) , 52–54. 2 Peak), as well as a relatively large and diverse sample of adults with DS. However, it is limited as the data is cross-sectional and all participants were from a sample of adults with DS who had agreed to participate in a program focused on the promotion of physical activity. One major limitation of the current study is that all participants had low levels of cardiorespiratory fitness (~ 21 ml/kg/min) and MVPA (~ 14 min/day) which was required for inclusion in the clinical trial; therefore, there was a smaller range of MVPA and cardiorespiratory fitness in this sample compared with the general population of individuals with DS, limiting our ability to detect a correlation with cognition. Similarly, participants were younger and cognitively stable; thus, we were unable to examine the cognition of older adults more at risk of dementia or who had already progressed to Alzheimer’s disease.This study benefits from the use of device-based assessments of MVPA and the use of directly measured cardiorespiratory fitness (i.e., VOCardiovascular risk factors, including low cardiorespiratory fitness and high systolic blood pressure, were associated with some aspects of cognition in adults with DS. While future research should examine the role of improved cardiovascular health on delaying decreases in cognitive function and dementia in adults with DS, we recommend that health care providers convey the importance of exercise and cardiovascular health to their patients with DS, especially given the high prevalence of dementia in adults with DS.


Arterial and venous insufficiency are two major causes of chronic wounds with different etiology, pathophysiology, and clinical manifestations. With recent advancements in clinical examination, clinicians are able to obtain an accurate diagnosis of the underlying disease, which plays an important role in the treatment planning and management of patients. Arterial ulcers are mainly caused by peripheral artery diseases (PADs), which are traditionally examined by physical examination and non-invasive arterial Doppler studies. However, advanced imaging modalities, such as computed tomography angiography (CTA) and indocyanine green (ICG) angiography, have become important studies as part of a comprehensive diagnostic process. On the other hand, chronic wounds caused by venous insufficiency are mainly evaluated by duplex ultrasonography and venography. Several scoring systems, including Clinical–Etiology–Anatomy–Pathophysiology (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Venous Disability Score, and the Venous Segmental Disease Score (VSDS) are useful in defining disease progression. In this review, we provide a comprehensive overlook of the most widely used and available clinical examinations for arterial and venous insufficiency wounds. Chronic wounds are defined as wounds that fail to heal in an orderly and timely manner. An acute wound will undergo four phases to achieve good healing: hemostasis, inflammation, proliferation, and remodeling . If any The cause of wound healing disruption can be local or systemic. Local factors that influence healing include tissue hypoxia, infection, the presence of a foreign body, and venous insufficiency. Systemic factors include old age, stress, ischemic status, systemic diseases , medication , alcoholism, smoking, immunocompromised status, and poor nutrition . IdentifArterial ulcers are mainly caused by reduced arterial blood supply, of which the most common etiology is peripheral artery disease  . PeripheA foot ulcer is also one of the major causes of morbidity in diabetes mellitus (DM) patients. In patients with either type 1 or 2 DM, the lifetime prevalence of foot ulcers can be up to 34% . The maiInadequate treatment of diabetes foot ulcers can lead to severe consequences, such as major limb amputation or even death. The 5-year mortality rate for patients who have limb amputation after diabetic foot ulcer infection is 50% . With prDirect palpation of pulsation is part of a thorough physical examination and can be easily performed in an office setting. All major arteries, including femoral, popliteal, posterior tibial, and dorsalis pedis pulses should be palpated during the physical examination and simultaneously compared with the ipsilateral radial artery and contralateral corresponding site ,22. The Hand-held Doppler is the most frequently used noninvasive vascular examination in clinical practice. It is a portable ultrasound device designed to detect pulsation that cannot be palpated manually. Several arteries should be examined during the assessment, as mentioned below.The dorsalis pedis artery, a continuum of the anterior tibial artery, can usually be palpated lateral to the extensor hallucis longus tendon  on the dorsal surface of the foot. However, dorsalis pedis can only be palpated in 78% of healthy extremities. Five percent of dorsalis pedis pulsation can still be missing when using hand-held Doppler . AlthougOn the contrary, the absence of a posterior tibial artery (PTA) pulse always indicates an abnormality of the artery . The PTAThe popliteal artery lies in the popliteal fossa, formed by the semimembranosus muscle and biceps femoris muscle proximally, and gastrocnemius muscle medial and lateral head distally. The popliteal artery originates from the superficial femoral artery and branches into the anterior and posterior tibial arteries distally. Although there is some collateral arterial circulation, the popliteal remains the only major artery that runs through the knee joint . PalpatiThe femoral artery, as a continuation of the external iliac artery, after it passes the inguinal ligament, is the main blood supply to the lower limb. It bifurcates into the superficial and deep femoral arteries. The femoral artery is usually palpated at the femoral triangle. The femoral triangle is bounded superiorly by the inguinal ligament, laterally by the medial border of the sartorius muscle, and medially by the medial border of the adductor longus muscle. Halfway between the pubic symphysis and anterior superior iliac spine and one inch caudal to the inguinal ligament is usually the point where the femoral artery pulse can be palpated. Femoral artery pulse can be palpated when the patient’s systemic systolic blood pressure is over 50 mmHg .The ankle brachial index (ABI) or ankle brachial pressure index (ABPI) is one other measurement that can be performed in the outpatient clinic office. It is non-invasive and inexpensive, which makes it the most widely used measurement in daily practice. The American Heart Association also recommends using the ABI for screening high-risk patients in the clinical setting for PAD .The ABI measures the systolic blood pressure of both ankles and the brachial systolic blood pressure of both arms and then divides each ankle’s systolic blood pressure by the higher systolic brachial blood pressure. Classically, blood pressure is measured by checking the pulsation distal to an inflatable cuff under different degrees of inflation. As the cuff deflates, the pressure measured as the first pulsation is detected is determined to be the systolic pressure. Stethoscopes and Doppler probes can be used to detect the pulse, although recently designed oscillometric and photophlethysmographic devices can help to more accurately detect the pulsation of vessels .A normal ABI range is between 1.00 and 1.40, while an ABI ≤ 0.90 is defined asabnormal and values >1.40, which indicate noncompressible arteries. ABI values of 0.91 to 0.99 are considered borderline ,31. Xu eIt should be noted that both a low (<1.00) and high ≥1.40) ABI may indicate a significant abnormality. A low ABI indicates arterial stenosis of the lower extremities, which is also associated with cardiovascular risk factors such as hypertension, dyslipidemia, and diabetes mellitus ,37. Addi ABI may Above all, despite the efficiency of using the ABI in the diagnosis and evaluation of artery condition and quality, it shows no correlation to wound healing prediction and prognosis of chronic wounds .Transcutaneous oxygen measurement (TcPO2) is another non-invasive method that measures the amount of oxygen in capillaries. TcPO2, also known as transcutaneous oximetry, places an electrode on the skin surface and heats the skin gently to increase blood flow into the area. By measuring the oxygen flow in the capillaries, it can provide an indirect measurement of blood flow to the tissue .TcPO2 is used as one of the factors to predict wound healing after proper treatment. The result of TcPO2 is either shown as O2 pressure or ratio to normal tissue. The normal value of foot TcPO2 during the supine position is approximately 60 mmHg, and the normal chest/foot ratio is approximately 0.9 .Caselli et al. measured diabetic foot ulcer patients’ TcPO2 after receiving percutaneous transluminal angioplasty . Of the p = 0.008). However, there was no significant difference in wound healing when comparing TcPO2 20–40 mmHg patients with either TcPO2 > 40 patients or TcPO2 < 20 patients [Ladurner et al. recruited 141 diabetic patients with non-palpable pedal pulses. They subgrouped patients according to their TcPO2 into three groups: TcPO2 < 20 mmHg, TcPO2 20–40 mmHg, and TcPO2 > 40 mmHg. After one year of proper wound treatment, patients in the group with TcPO2 > 40 mmHg had a significant possibility of wound healing compared to patients with TcPO2 < 20 . They concluded that TcPO2 has a slightly positive correlation with wound healing ability [The power of TcPO2 in predicting diabetic foot ulcer wound healing is also demonstrated by Zubair’s study in 2019, which enrolled 192 patients with diabetic foot ulcers . One hun ability .Although the correlation between TcPO2 and wound healing is still controversial based on the literature review, it remains a useful tool to provide helpful information for the diagnosis of PAD and the management of chronic wounds.Although the ABI has good specificity in detecting peripheral artery stenosis, the presence of arterial calcification known as Mönckeberg’s sclerosis leads to ABI variation in sensitivity when screening for stenosis . Toe sysThe great toe is usually the choice of measurement in toe systolic pressure because of its size. However, the great toe frequently has ulcers or has been amputated. In such cases, second-toe systolic pressure measurement is a reliable alternative. Bhamidipaty et al. demonstrated that second-toe systolic pressure is highly correlated to first-toe systolic pressure (correlation coefficient (r) = 0.908 and 0.877 to 0.931 under a 95% confidence interval) .The Intersociety Consensus for the Management of Peripheral Arterial Disease defined the normal range of the toe systolic pressure in healthy people as approximately 30 mmHg lower than the systolic pressure obtained from the ankle. When toe systolic pressure is under 30 mmHg or the toe brachial index (TBI) is less than 0.7, it is considered abnormal .Clinical usage of toe systolic pressure as the sole evidence of peripheral artery occlusion is questionable. A clinically significant margin of error was found in toe systolic pressure measurement. Considering that the toe systolic pressure may range from 40 to 90 mmHg and around ±26 mmHg of fluctuation error may be found during measurement, toe systolic pressure may not be a reliable vascular assessment option . The samThere is some evidence that the usage of toe systolic pressure as a predictive factor of diabetic foot ulcer healing is feasible. Tay et al. conducted a meta-analysis of the sensitivity and specificity of toe pressure in the prediction of diabetic foot ulcer wound healing . A totalDuring the past five decades, ultrasound technology has advanced dramatically and has been widely adopted in detecting vascular disorders . In addiThe ability to measure the volumetric blood flow in a non-invasive way without contrast agents is the major advantage of arterial Doppler exams . The meaOn the contrary to musculoskeletal ultrasonography, which is an operator-dependent technique, arterial Doppler studies do not exhibit this issue. Tehan et al. conducted a survey comparing variability among different operators when performing an arterial Doppler exam . They rep = 0.003), resulting in amputation [Arterial Doppler studies can also help predict the risk of amputation in diabetic foot ulcers. In Barberan et al.’s study, arterial obstruction found in the Doppler study has an odds ratio of 12.50 , magnetic resonance angiography (MRA), and computerized tomographic angiography (CTA).Digital subtraction angiography (DSA) is the gold standard of contrast arteriography for the assessment of lower extremity PAD. Most diagnostic studies are designed based on comparisons with DSA . DSA is There are still several disadvantages of DSA. Complications resulting from the arterial access site and contrast agent reaction are the major concerns when performing DSA. Clinically significant bleeding, painful hematomas, and pseudoaneurysms are seen in femoral access sites, especially in patients under treatment with antithrombotic agents . Up to 1Magnetic resonance angiography (MRA) is one of the alternative angiography imaging modalities available. An MRA can be performed either with or without contrast enhancement. Contrast-enhanced MRA has a superior image resolution and is widely used in current practice . Due to Computerized tomographic angiography (CTA) is a less time-consuming and less invasive option to obtain the arteriogram of the lower extremities . Easily There are still some shortcomings of CTA. In patients with atherosclerotic calcification, the degree of stenosis may be overestimated . In thisIndocyanine green (ICG) angiography was first introduced in the 1960s  and is wWhen ICG is used for peripheral vascular examination, 0.1 mg/kg of a 0.1% ICG solution bolus infusion is administrated intravenously, immediately followed by 10 mL normal saline. The room light is dimmed, and the limb photo is taken by an infrared camera. A high-intensity contrast-like appearance will be seen within seconds if the limb perfusion is good. This tool has proved to be effective in predicting diabetic foot ulcer wound healing . More clLaser speckle contrast imaging (LSCI) is another technique developed recently. It was first introduced in the 1980s. LSCI detects optical speckle patterns generated by the motion of red blood cells in the skin and provides information regarding microcirculation. Clinically, it has been considered an effective method to distinguish non-ischemic, ischemic, and critical-ischemic patients . SimilarThere are also several innovative techniques based on computed tomography imaging and magnetic resonance imaging that could improve the precision of tissue perfusion evaluation ,87. CompVenous ulceration is the most common cause of lower leg ulcers, accounting for 70–80% of all lower leg ulcers . It alsoThere are several theories regarding pathophysiology following venous hypertension. Browse and Burnand’s theory focuses on the increased intraluminal pressure in the capillary bed . FalangaHistory taking and physical examination serve important roles in the diagnosis of venous ulcer. It is helpful to recognize the characteristics of venous ulcer wounds such as irregular wound edge, granulation, pigmentation, dermatitis, and peri-wound edematous ,112. HowThere are several scoring systems that evaluate the severity of chronic venous insufficiency including Clinical–Etiology–Anatomy–Pathophysiology (CEAP) classification, Venous Clinical Severity Score (VCSS), Venous Disability Score, and Venous Segmental Disease Score (VSDS) ,115. FirCEAP classification includes four categories  in the assessment of clinical venous disorders. Clinical signs include visible clinical manifestations of venous disorders. For example, healed venous ulcers are categorized as C5, and active or recurrent venous ulcers are categorized as C6 or C6r. Etiology is divided into primary, secondary, congenital, and combined etiologies. The anatomy component describes the venous system where venous disorders occurred . The category of pathophysiology designates the presence or absence of venous reflux and/or obstruction ,117,118.The Venous Clinical Severity Score (VCSS) is based on physician-determined and patient-reported elements. Pain, varicose veins, venous edema, pigmentation, inflammation, induration, number of active ulcers, duration of active ulcers, size of active ulcers, and compliance with compression therapy are the parameters, with numerical grading from zero to three (none to severe) ,119. TheDuplex ultrasonography is a combination of B-mode echography and Doppler sonography. It provides a non-invasive, convenient, and effective diagnosis of venous disease, and has been frequently used in the diagnosis and evaluation of deep vein thrombosis, varicose veins, and chronic venous insufficiency ,121. DupThe lower extremity venous system can be divided into superficial, deep, and perforator groups. In general, different frequency probes can be chosen to fit the appropriate depth of the vein. The 5 to 8 MHz linear probe is recommended for deep vein evaluation, while the 10 to 12 MHz linear probe is more suitable for superficial vein assessment. However, 3 to 5 MHz curvilinear probes should be considered in large-diameter legs or edematous limbs, which can provide better ultrasound wave penetration . The assA full examination of duplex ultrasonography in the lower extremities extends to proximal systems, such as the iliac veins and obturator veins. The examination begins with the saphenofemoral junction (SFJ), and several relevant veins with their associated branches should be examined, such as the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), and small saphenous vein (SSV) . ComprehWithin existing literature, duplex ultrasonography demonstrates a sensitivity of 56% to 100% and a specificity of 77% to 100% in the diagnosis of upper extremity deep vein thrombosis . GoodacrVenography is a contrast-based, invasive examination that offers a comprehensive visualization of the venous system. Ascending and descending venography are the primary methods of investigation and can be performed with additional pressure gradient measurements. In addition to immediate visualization of the lower extremity venous system, these methods combined allow for information on luminal diameter, venous flow and washout, thrombus characterization, valvular damage, pressure gradients, and other anatomical pathologies. Another potential benefit of venography is the opportunity for treatment at the time of examination. Disadvantages include limited ability to evaluate the extravascular tissue, limited range of differential diagnosis, a lack of consensus on hemodynamically significant pressure gradients, and the possibility of incomplete assessment due to contrast load, access, or technical difficulties .Venography is performed under initial ultrasound guidance to determine vein access. A sheath is inserted proximal or distal to the suspected pathological region. An ascending venogram is performed by injecting contrast into a vein distal to the region of interest. For example, contrast injected into a dorsal vein of the foot can be directed into the deep venous system with the help of an ankle tourniquet . This can demonstrate collateral venous pathways, regions of occlusion, valvular damage, perforating vein incompetence, and other critical findings. This can be extremely valuable as an adjunct to non-invasive testing results in patients with suspected lower extremity venous disease. The superficial system and perforating systems can also be evaluated with ascending techniques .Descending venography is usually performed with the patient in a standing position using a tilting table. The main goal is to demonstrate venous reflux and points of leakage . Morphology of the venous system can also be visualized with this technique. The cannula can be introduced through the femoral or popliteal vein, proximal to the site of interest. Contrast injection then assists in evaluating the extent of the reflux, altered venous anatomy, and competence of junctions and valves. Results may help to determine a roadmap for venous system reconstruction through stenting procedures .Due to the risks associated with invasive testing, contrast venography has largely been replaced by duplex ultrasonography for most clinical scenarios. Risks associated with venography include complications associated with the procedure itself, such as bleeding, thrombosis, tissue injury, and infection, and complications associated with contrast use, such as contrast media allergy and acute renal failure . HoweverAn overview of the common diagnostic procedures and their significance has been provided in this review. A precise diagnosis of the etiology and underlying factors leading to chronic wounds is critical to the therapeutic planning of these difficult pathologies. A combination of accurate patient history taking, detailed physical examination, and suitable diagnostic procedure selection will help the physician select the most effective treatment for the underlying condition. There are still limitations during wound assessment diagnostics, such as providing cost-effective instruments with bedside availability (ease of access). Furthermore, some invasive techniques may not provide enough information about tissue perfusion and vessel conditions, which weighs against invasive risk. New techniques that have become available recently still require validation by rigorous research under appropriate methodology. In our opinion, the future direction of diagnostic tools for chronic wound assessment will focus on examinations that are less invasive, cost-effective, and available at the bedside. The accuracy of the currently available technologies can also be improved by conducting further studies.


Besides, the rate of upper-limb swelling was also significantly lower in the novel device group , as well as the rate of DPI . Furthermore, the pain score in the experimental group was significantly lower than in the control group . There were no significant differences in the rate of rebleeding  between the two groups. In addition, no RAO occurred in any of the groups. The novel automatic pressure-controlled radial compression device could reduce the hemostasis time and decrease the rate of adverse complications. It might be a promising and effective compression device in TRA coronary invasive procedures.This study was conducted to design a novel radial compression device with the function of automatic pressure control and evaluate the feasibility and safety of this new technique. Patients who underwent transradial access (TRA) coronary angiography and percutaneous coronary intervention (PCI) in the First Hospital of Jiaxing between August 2021and October 2021 were prospectively enrolled in this pilot interventional study. The patients were grouped in a 1 : 1 ratio to receive compression with a novel device  or a conventional device without pressure control (the control group). The primary endpoint was the compression time, and the main secondary endpoints were rebleeding, upper-limb swelling, radial artery occlusion (RAO), and device-related pressure injury (DPI). Eighty-four patients were enrolled in this study. No significant differences were found in the baseline clinical characteristics between the two groups. Compared with the control group, the compression time in the experimental group was significantly reduced (207.4 ± 15.5 vs. 378.1 ± 19 min,  Currently, percutaneous coronary intervention (PCI) is one of the most extensive and effective treatment strategies used for patients with coronary artery disease (CAD) . TransraNevertheless, despite the advantages of TRA in the perioperative and long-termfollow-up compared with TFA, access site complications, such as radial artery occlusion (RAO), upper-limb swelling, and rebleeding, remain huge challenges , 7, 12. Herein, we designed a new radial artery compression device with a pressure control technique  that canThis prospective, single-center, interventional pilot trial included patients with coronary heart disease requiring coronary artery puncture or angiography treated in the Cardiology Department of a large tertiary grade A hospital in Jiaxing, Zhejiang Province, China. In this trial, we compared two radial artery compression devices after TRA coronary procedures. This study was conducted in accordance with the Helsinki Declaration II, and the prospective trial was approved by the Ethics Committee of the First Hospital of Jiaxing .n = 42) and the conventional device group (n = 42). The inclusion criteria were (1) patients with coronary heart disease according to diagnosis criteria, (2) patients ≥18 years of age, (3) patients with clear consciousness with a certain level of understanding and expression ability, and (4) patients who are willing to participate in the study and provide written informed consent. The exclusion criteria were (1) patients with upper-limb disability or deformity, (2) patients with local skin or tissue edema or infection, (3) patients with abnormal coagulation function, or (4) patients with severe comorbidities.Eighty-four patients admitted to our hospital between August 2021 and October 2021 for invasive coronary assessment were enrolled. Depending on the type of device used after TRA, the patients were divided into two groups: the novel device group  When the SBP of a patient exceeds 180 mmHg clinically, except for critically ill patients, the PCI operation would be suspended and restarted once the SBP is <180 mmHg. Therefore, based on the upper limit of 180 mmHg of systolic blood pressure that can be used for PCI, we increased it by 40 mmHg  to obtain 220 mmHg, and the SpO2 of the thumb of the operating limb is monitored to remain ≥95% to ensure the blood supply. (3) The research on the appropriate pressure value of the radial artery compressor is inconclusive. The first pressure value of the compressor was mainly determined by experience.The pressure value of the compressor was set to 220 mmHg for the first time. When the patient returns to the ward, the pressure setting is started according to the patient's blood pressure value. The reasons for setting it to 220 mm Hg for the first time are as follows: (1) at the end of the operation, according to the SBP of the patient, the operator adjusted the pressure of the hemostat at 150–200 mmHg, with a reference value of 30–50 mmHg higher than the patient's systolic blood pressure, and the maximum pressure was not >250 mmHg. The catheter room nurse adjusts the hemostatic pressure by monitoring the thumb SPOAccording to the color code pressure reference index in the product manual of the hemostat, 150–200 mmHg was generally selected for the first time, that is, the middle or bottom of the green color code. The pressure was increased by 25 mmHg every time the cap was tightened, and the maximum pressure did not exceed the yellow color code (200–250 mmHg). During the operation, the operator confirmed the puncture point of the radial artery. After the operation was completed, the sheath of the artery was withdrawn with a range of 1–2 cm. The puncture point of the patient was ensured and covered with sterile gauze. Then, the pressure plate of the hemostat was firmly pressed vertically on the puncture point, and another operator fixed the adhesive buckle on the patient's wrist, tightened and stuck it around the wrist, rotated the handle of the hemostat clockwise to exert pressure on the puncture site through the pressure plate, and at the same time, pulled out the arterial sheath and adjusted the handle of the hemostat until no blood leakage was seen –16. The The primary endpoint was the compression time after transradial procedure completion, which refers to the time from the withdrawal of the sheath to the removal of the compression device with satisfactory hemostasis. The secondary endpoints included (1) rebleeding, defined as any visible bleeding from the access site after initial removal of the compression device, (2) upper-limb swelling on the operative side, (3) RAO, defined as no anterograde flow in the radial artery detected by vascular ultrasound, (4) device-related pressure injury (DPI), and (5) pain score, determined using the NRS Pain Assessment Scale.t-test between the two groups. The categorical variables were expressed as n (%) and analyzed using the χ2-test. All statistical analyses were conducted using SPSS 22.0 . Two-tailedp < 0.05 was considered statistically significant.The continuous variables with a normal distribution were expressed as means ± standard deviations and analyzed using Student's pvalues 0.168, 0.322, 0.306, and 0.802, respectively). Among the 84 participants, only seven underwent PCI, and the dose of heparin in the two groups did not significantly differ .Among the 84 enrolled patients, 58 were male, and their average age was 65.30 years. The baseline characteristics are summarized in p < 0.001). In both groups, rebleeding occurred after the removal of the compression device occurred in three patients in the experimental group and six in the control group . The rates of upper-limb swelling and DPI were significantly lower in the novel device group compared with the control group . In addition, the pain score in the experimental group was also significantly lower than the control group . Finally, no RAO occurred in any of the groups.All patients had the radial artery compression removed after a certain time. Study endpoints are presented in In this study, we evaluated the efficacy of a new radial artery compression device with automatic pressure control and found that compared with the conventional device, this novel device could significantly reduce the compression time without increasing the rate of rebleeding, upper-limb swelling, DPI, and RAO. Moreover, the novel device could alleviate the pain caused by compression and further increase the comfort and satisfaction of the patients , 18.In clinical practice, it is always recommended to compress the radial puncture site for at least 4 h after coronary intervention , 20. In Our results revealed a significant reduction in the rate of upper-limb swelling on the operative side between the two groups. The main reason might be that the pressure at the radial artery puncture point can be set according to the individual SBP in the experimental group. Moreover, the compression time is also reduced, decreasing the rate and degree of swelling.In the present study, the intervention group had a lower incidence of DPI but a similar rate of rebleeding compared with the control group. It might be because a more uniform pressure was distributed on the surface and the pressure on the puncture site decreased with time in the experimental group.Nowadays, pain is regarded as the fifth vital sign. Since the pressure was visible and controllable in the experimental group and after 2 h, the compression pressure decreased gradually; the patients felt less pain than those in conventional compression.The total duration of conventional compression can exceed 4–6 h in clinical practice –24. The In addition to its effectiveness and safety, this novel automatic pressure-controlled radial compression device could reduce the workload of medical staff and provide economic benefits.There are several limitations in the present study. First, as mentioned above, the sample size was relatively small, and the involved patients were from a single hospital; therefore, the results might not be generalizable to other centers. Second, as only a few patients underwent PCI, it remains unclear whether this novel device would have the same effectiveness with the increased dose of heparin. Third, the puncture site might differ for different individuals, and the operator's proficiency might also influence the interpretation of the results. Finally, the results of this pilot study will have to be verified in multicenter, larger-scale trials.In conclusion, radial compression time after an invasive coronary procedure is important for reducing TRA-related complications. The novel automatic pressure-controlled radial compression device can dramatically reduce the compressing time and decrease complications associated with conventional devices. Larger clinical trials are needed to verify the efficiency and safety of this novel technique.


IntroductionTransoral robotic surgery (TORS) has become increasingly popular for the removal of pharyngeal and laryngeal cancers with the objective to improve functional and aesthetic outcomes. Feyh-Kastenbauer (FK) retractor is one such routinely used retractor during TORS. The setting up of this retractor has been seen to be accompanied by hemodynamic fluctuations.MethodologyThis prospective observational study was carried out on 30 patients undergoing TORS. All patients were administered general anesthesia using a pre-defined anesthesia protocol. The primary outcome was to compare hemodynamic fluctuations following endotracheal intubation with that after FK retractor insertion. Any requirement of a bolus dose of sevoflurane and fentanyl was recorded in response to hemodynamic fluctuations recorded in secondary outcomes.ResultsThere was no statistically significant increase in mean heart rate, systolic, diastolic, and mean arterial blood pressure from baseline to endotracheal intubation and following retractor insertion . On subgroup analysis, hypertensive patients reported a greater rise in blood pressure following two minutes post FK retractor insertion compared to non-hypertensive patients (p=0.03). Out of 30 patients, five patients required a bolus dose of sevoflurane.ConclusionFK retractor insertion had a comparable hemodynamic response as endotracheal intubation during TORS. Hypertensive patients showed a rise in blood pressure at both endotracheal intubations and at FK retractor insertion. Transoral robotic surgery (TORS) has become increasingly popular for the removal of pharyngeal and laryngeal cancers with the objective to improve functional and aesthetic outcomes without worsening survival. The presence of long working arms provides the greatest advantage in reaching the posteriormost part of the oral cavity. The main advantage is allowing better surgical access, via the mouth, to areas where hands and instruments probably reach with difficulty through the mouth itself . TORS isUnfortunately, without TORS, the surgery required can be quite invasive, including splitting the mandible (mandibulotomy) to expose the base of the tongue. Presently partial laryngectomies are also being performed completely through the mouth with the robot technique. However, having read about all these advantages, TORS is also associated with some potential sequelae. TORS procedure requires the placement of complex retractors followed by the docking of robotic arms inside the oral cavity . Feyh-KaMethodologyThe present study was conducted in the Department of Anaesthesia and Intensive Care in collaboration with the Department of Otolaryngology-Head Neck surgery at a tertiary care center in Northern India. The present study is a prospective observational study. The study was approved by the institutional ethics committee of Postgraduate Institute of Medical Education and Research (PGIMER) with letter no INT/IEC/2020/JPL-52 and was also registered with the central clinical trials registry (CTRI) with reference no. CTRI/2020/07/026857. A total of 30 patients were enrolled in the study after receiving written informed consent Figure .The inclusion criteria were: Patients undergoing TORS for oral cavity pathologies, American Society of Anaesthesiology (ASA) category I and II, and aged 18-60 years. Patients with suspected difficult airways were excluded. Patients undergoing robotic-assisted ENT surgeries for other than oral cavity cancers and ASA category III and above were also excluded.All patients were assessed one day prior to surgery and a detailed pre-anaesthetic check-up was done including pre-operative orders given by a trained anesthetist. The following relevant points were noted from this pre-anaesthetic check-up: history of smoking, snoring, the parameter of complete airway examination: mouth opening (MO), Mallampati grading (MPG), thyromental distance (TMD), sternomental distance (SMD) and dentition. Within the operation theatre, all ASA essential monitoring was placed including non-invasive blood pressure (NIBP), pulse oximetry (SpO2), electrocardiogram (ECG) and end-tidal CO2 (EtCO2) monitoring. Baseline vitals including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and oxygen saturation by pulse oximetry were noted. The intravenous line was secured. A standard induction protocol for general anesthesia was followed which included injection fentanyl 1 µg/kg, injection propofol 2-2.5 mg/kg, and injection atracurium 0.5 mg/kg. This was followed by endotracheal intubation after complete muscle relaxation checked by loss of jaw tone and after bag-mask ventilation for four minutes following the administration of muscle relaxation. Following the confirmation of the endotracheal tube, the tube was secured and the inhalation agent sevoflurane was titrated to maintain minimum alveolar concentration (MAC) between 1.2-1.4. The maintenance of anesthesia was done by nitrous 60%, oxygen 40%, and sevoflurane titrated to achieve a MAC of 1.2. Ten minutes following the stabilization of MAC at 1.2, the patient was handed over to the surgeons for the insertion of the FK retractor. Hemodynamic parameters which included HR, SBP, DBP, and MAP were recorded continuously at one-minute intervals following endotracheal intubation and thereafter at retractor insertion till the end of the surgical procedure. Other parameters which were recorded included EtCO2, MAC, end-tidal concentration of inhalation agent, SpO2, and requirement of a bolus dose of opioid. The time of retractor insertion and removal and the total duration of retractor placement were also recorded.Hypertension was defined as an SBP of more than 120% of the baseline value or more than 160 mmHg, whereas hypotension was defined as an SBP of less than 70% of the baseline value or less than 90 mmHg. Tachycardia and bradycardia were defined as HR greater than 120 beats/min and less than 60 beats/min, respectively. The episodes of hypertension, hypotension, tachycardia, and bradycardia were recorded throughout the study. A dysrhythmia was defined as any ventricular or supraventricular premature beat or any sustained rhythm other than sinus. The incidence of dysrhythmia after intubation and following retractor insertion was recorded.If SBP or DBP is more than 120% of baseline value or more than 160 mmHg for SBP and 100 mmHg for DBP, a bolus dose of inhalation agent-sevoflurane was delivered to increase the MAC to 1.8%. Similarly, a rise in heart rate greater than 120 beats/min was dealt with with a bolus dose of fentanyl 0.5 µg/kg.OutcomesPrimary outcome was to compare the hemodynamic fluctuations i.e the mean change from baseline in the heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure following endotracheal intubation with that following FK retractor insertion during TORS.Secondary outcome was intervention done to decrease the hypertensive response observed during intubation and retractor insertion. The intervention is defined as a bolus dose of an opioid drug or increasing the depth of anesthesia measured in terms of the end-tidal concentration of the inhalation agent and MAC.Statistical analysisData entry and analysis were done with the help of Office Excel 2007  and SPSS software version 21 . Descriptive analysis was done using frequency, percentages, and mean (+/-S.D.). The normality of data was checked by the Kolmogorov-Smirnoff test. Statistical analyses of the data for each hemodynamic parameter were performed by an appropriate test of significance i.e. t-test and two-way analysis of variance with repeated measures (rANOVA). p<0.05 was considered statistically significant.A total of 40 patients were screened from which five patients were excluded due to anticipated difficult airway, three patients did not give consent and two patients were excluded being the ASA III category. The data of 30 patients who underwent TORS was collected and a final analysis was done. The demographic details of the patients including age, gender, height, weight, BMI, and ASA category are summarized in Table Primary outcomesHeart Rate (HR)The mean heart rate at baseline was 79.04 ± 12.89 at intubation was 88.38 ± 12.19, at one-minute post-intubation was 89.29 ± 12.72 and at 10 minutes was 76.58 ± 15.09. At retractor insertion, the HR was 81.58 ± 14.79, at one-minute post retractor insertion was 82.50 ± 15.88, and at 10 minutes post retractor insertion was 72.52 ± 12.91. The change in heart rate over time was not statistically significant following endotracheal intubation or FK retractor insertion . A post-adhoc analysis was also done to see at which specific time points the heart rate differed significantly. The heart rate (BPM) differed significantly from the baseline at the following time points: 135 minutes post retractor insertion (RI) (p=0.018), 140 minutes post RI (p=0.01), and 145 minutes post RI (p=0.01). These time points correlated to the time of extubation of the patient. Although the maximum change from the baseline timepoint was observed at the one-minute post-intubation timepoint none of the patients had HR > 120 (tachycardia) or HR < 60 beats per minute (bradycardia) . Following this, a rise in blood pressure was noted one minute post retractor insertion, where the mean SBP was 140.38 ± 27.3. Though there was a rise in mean SBP following intubation and retractor insertion, it was less than 120% of baseline and statistically not significant (p=0.2). Further, during the surgical period the change in mean BP was not significant either clinically or statistically. A post hoc analysis was performed and values at three-time points i.e. 135 minutes, 140, and 145 minutes post retractor insertion were statistically significant. These were time points of extubation and recovery from where such hemodynamic changes can be observed.Diastolic Blood PressureThe diastolic blood pressure followed a similar trend as the systolic blood pressure did, with a rise in blood pressure over baseline at one-minute post-intubation and one-minute post-retractor insertion. The baseline mean DBP was 78±11.85, at one-minute post-intubation was 86.79 ± 16.59 and at post one-minute retractor insertion was 84.17 ±15.49. These variations in diastolic blood pressure also failed to reach any clinical or statistical significance(p-0.6). The DBP did not show a large deviation from the baseline means DBP at the rest of the time points. The data for DBP was normally distributed hence parametric test and the repeated measures of the ANOVA test were used for statistical inference.Mean Arterial Blood Pressure (MAP)Clinical variations were observed in the MAP over time, and changes were observed at the time of intubation and at retractor insertion as seen in both the systolic and diastolic blood pressure measurements. These changes were not found to be significant clinically or statistically and did not require any intervention p=0.3). The post hoc analysis revealed only two significant values, that is at 140 and 145 minutes post retractor insertion corresponding to the time of extubation and recovery when systolic and diastolic blood pressures were also significantly reduced from the baseline. The variation in the MAP is depicted in Figure . The posSecondary outcomesOut of 30 patients, five patients required the administration of a bolus dose of sevoflurane to increase the MAC to 1.6 following retractor insertion. None of the patients required additional doses of fentanyl. However, no statistically significant increase in MAC was observed throughout the surgery. A rise is seen from a baseline value  to the time of intubation where maximum end-tidal sevoflurane concentration was noted as required during induction. Further, during the maintenance phase the MAC was maintained between 1-1.2 with no significant variations in the delivery of the inhalation agent even during retractor insertion and following it. The mean MAC increased from a minimum of 0.36 at the baseline timepoint to a maximum of 1.18 at the four-minute post RI timepoint and then decreased to 1.00 at the 145-minute post RI timepoint. This change was also not statistically significant (p=0.188). On post hoc analysis none of the values both for end-tidal sevoflurane and MAC had significant differences from baseline versus intubation and at retractor insertion. Statistically, significant values were found after 125 minutes of retractor insertion till 145 minutes (end of the procedure). This corresponds to the time when surgery was completed and patients were in the recovery phase of general anesthesia. Hemodynamic Changes in Hypertensive PatientsAn intragroup analysis comparing hypertensive versus non-hypertensive patients was done, in which out of 30 patients, eight patients were hypertensive. In the hypertensive group, the mean SBP just before intubation (108.62 ±39.10 mm of Hg) was significantly lower compared to the non-hypertensive group . Following retractor insertion at two minutes, the increase in systolic blood pressure was clinically more in hypertensive patients compared to non-hypertensive patients. We also found a significant increase in DBP and MAP at two minutes post retractor insertion (p=0.03) on comparison of hypertensive and non-hypertensive patients. This required administration of a bolus dose of sevoflurane to increase MAC to 1.6 in five hypertensive patients two minutes after retractor insertion. Further, during points of retractor manipulation and removal, the hypertensive group showed a significant increase in heart rate from 20 minutes post RI to up to 50 minutes post retractor insertion (Table These hemodynamic fluctuations up to 50 minutes post retractor insertion all indicate increased sympathetic stimulation in the hypertensive group to retractor insertion in comparison to non-hypertensive patients. There were no statistically significant differences in MAC, EtCO2, and end-tidal sevoflurane concentrations.Though all patients successfully underwent surgery and were extubated at the end, one patient had to be re-explored due to bleeding at the surgical site. Another patient experienced delayed extubation, had unequal pupil size, and had to be ventilated electively in the Intensive care unit for 24 hours, following which the patient recovered and was extubated. The non-contrast computed tomography of the patient reported normal. Both these patients were hypertensive and required bolus doses of inhalational agents to maintain the SBP within 120% of baseline.As the primary outcome of interest, we observed comparable hemodynamic responses following endotracheal intubation and FK retractor insertion. We also found an exaggerated hypertensive response to both endotracheal intubation and FK retractor insertion in the hypertensive subgroup. There was also an increased requirement for inhalational agents in the hypertensive group as compared to the normotensive group.The adverse cardiovascular changes and catecholamine discharge seen during laryngoscopy and tracheal intubation appear in two phases. The effects of laryngoscopy should be distinguished from the effects seen while the endotracheal tube is placed through the trachea. Shribman et al. showed the differences between these two events. Even with stable anesthesia, laryngoscopy alone without intubation can cause a supraglottic stimulus. As a result, SBP and DBP increase in contrast to the measurements before induction. However, no significant increase in HR occurs during laryngoscopy. An increase in BP is due to norepinephrine, while an increase in HR is due to epinephrine discharge. Infraglottic stimulus caused by placing the endotracheal tube occurs in phase two. In this situation, an extra cardiovascular response and catecholamine discharge occur. Stress response increases at this stage and both SBP and DBP measurements increase by 36-40% in contrast to control levels. HR levels increase more than 20% with tracheal intubation in contrast to laryngoscopy . This isFK retractor comprises a tongue blade and a suspension arm which helps fix the retractor to the left side of the operation table. Once adequately placed inside the oral cavity, it allows better exposure to the surgical field and movement of robotic arms. The precise placement and setting up of robotic arms inside the oral cavity requires a lot of manipulation of retractors and robotic instruments. Nevertheless, these manipulations are also associated with significant hemodynamic fluctuations which are found equivalent to those occurring following endotracheal intubation. This study compares the hemodynamic changes following endotracheal intubation with FK retractor insertion during TORS.The primary aim of our anesthetic management is to maintain the hemodynamics of the patient within a particular range and avoid large variations within the same. Advances in anesthesia in the availability of drugs and various aids for intubation have largely helped us in reducing this hemodynamic response to laryngoscopy and intubation. These methods include deepening the plane of anesthesia , the useIn our study, the hemodynamic response to laryngoscopy and intubation has been studied for the first 10 minutes. After these 10 minutes, the FK retractor was inserted by the otorhinolaryngologist Figures , 3. We cJeyarajah et al. in their review article on perioperative concerns in patients with robotic-assisted ENT surgeries advocate the use of opioids like fentanyl, remifentanil, and beta-blockers to obtund the sustained hemodynamic response to retractor placement . In anotLimitationAs this is only a pilot study, due to the small sample size it is not powered enough for assessing the primary outcome. However, our study did answer the pragmatics of recruitment and the feasibility of a larger study. Second, we did not quantify and compare the amount of fentanyl used in hypertensive and non-hypertensive patients. Therefore, we feel more future research on the role of opioids in attenuating the hemodynamic response following FK retractor insertion can be planned.FK retractor insertion had a comparable hemodynamic response to endotracheal intubation during TORS. Hypertensive patients showed a rise in blood pressure at both endotracheal intubations and at FK retractor insertion requiring increased requirement of anesthetic agents.


Mineralocorticoid receptor antagonists (MRAs) are often empirically used for patients with low-renin hypertension (LRH) or probable primary aldosteronism (PA) who decline surgery. However, the optimal approach to MRA therapy is unknown. Studies have shown that a rise in renin is an effective biomarker of prevention of cardiovascular complications of PA. This study aimed to determine whether empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin is associated with a decrease in blood pressure and/or proteinuria.Retrospective single-center cohort study from 2005 to 2021 included adults with LRH or probable PA . All patients were empirically treated with an MRA, targeting renin ≥1.0 ng/ml/h.P < 0.001 for both). Similar blood pressure reductions were seen whether patients had high (>10 ng/dl) or low (<10 ng/dl) aldosterone levels. The majority  of patients had at least one baseline anti-hypertensive medication stopped. Among the six patients who had detectable proteinuria and albumin-to-creatinine (ACR) measurements post-treatment, the mean ACR decreased from 179.0 to 36.1 mg/g (P = 0.03). None of the patients studied had to completely stop treatment due to adverse reactions.Out of 39 patients studied, 32 (82.1%) achieved unsuppressed renin. Systolic and diastolic blood pressure decreased from 148.0 and 81.2 to 125.8 and 71.6 mm Hg, respectively (Empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin can safely and effectively improve blood pressure control and reduce proteinuria.  We, therefore, conducted a retrospective study that evaluated an approach to treatment of patients with LRH or probable PA with MRAs that involves gradual titration of MRAs targeting unsuppressed renin. We hypothesized that this approach will be associated with a decrease in blood pressure and/or proteinuria in a safe manner.While primary aldosteronism (PA) is often categorized as a discrete condition, recent evidence indicates that PA exists across a broad continuum of pathophysiology, thereby blurring the distinction between PA and low-renin hypertension (LRH).We conducted a retrospective observational cohort study of consecutive patients from the practice of coauthor Alexander Turchin between 1 January 2005 and 31 December 2021. The purpose of this study was to determine whether MRA treatment of patients with LRH or probable PA to induce a rise in renin was associated with a decrease in blood pressure and/or proteinuria.This study was approved by the institutional review board at Mass General Brigham. The requirement for written informed consent was waived.Study participants included hypertensive patients with suppressed (<1.0 ng/ml/h) plasma renin activity (PRA) and detectable aldosterone levels (≥4 ng/dl) who favored empiric medical therapy over further diagnostic testing for PA . The study participants, therefore, included individuals who probably had PA as well as those who had LRH. All patients were treated with an MRA. MRA therapy was started at 25–50 mg daily of spironolactone  or eplerenone , and the dose was gradually increased in 25–50 mg increments to target a PRA ≥1.0 ng/ml/h or the maximum tolerated dose. Further intensification of the MRA was halted if the patient developed hypotension (asymptomatic systolic blood pressure (SBP) <100 mm Hg or SBP <120 mm Hg associated with lightheadedness), sustained hyperkalemia (K > 5.0 mEq/l) refractory to treatment with diuretics or potassium binders or a sustained decrease (≥25%) in estimated glomerular filtration rate (eGFR).a priori and included demographic information , baseline measurements , albumin-to-creatinine ratio (ACR), serum creatinine, number of anti-hypertensive medications), pre-existing medical conditions , proteinuria out of proportion to hyperglycemia (defined as ACR ≥30 mg/g and either HbA1c <8.0% (64 mmol/mol) or no diagnosis of diabetes), diabetes, heart failure, and heart failure with reduced ejection fraction), side effects from MRA treatment and use of thiazides, loop diuretics, or potassium binding resins for hyperkalemia. Patients’ blood pressures were measured based on standard methodology utilized in the clinic when the patient was seen, which includes the use of an automatic sphygmomanometer or manually by the auscultation method, with the patient in a seated position. To calculate spironolactone equivalent MRA dose, eplerenone doses were divided by two.22 For use in population-level calculations, 0.6 and 0.1 ng/ml/h were used in place of PRA measurements reported as “<0.6 ng/ml/h” and “<0.1 ng/ml/h,” respectively. eGFR was calculated using 2021 version of chronic kidney disease epidemiology collaboration equation.23Patients’ medical history and demographic information were obtained from the Electronic Medical Record (EMR) system at Mass General Brigham. Patient characteristics that were collected were determined Summary statistics of patient characteristics were analyzed using measures of central tendency (mean and median) and variation (standard deviation and interquartile range) for continuous variables and frequencies and proportions for categorical variables. Blood pressure, ACR, and other patient characteristics at baseline versus after maximum tolerated MRA dose was achieved were compared using a Wilcoxon signed-rank test. To assess the relationship between the MRA dose needed to achieve unsuppressed renin, a Spearman’s correlation coefficient was calculated, and a linear regression model was constructed with the baseline aldosterone level as a predictor and the spironolactone equivalent MRA dose required to attain unsuppressed renin as the dependent variable.All statistical analyses were performed using SAS, version 9.4 .Of the 41 patients with suppressed renin treated with an MRA protocol to target an unsuppressed renin, 39 patients had available information on baseline characteristics and outcomes and were included in the analysis. The median age of study patients was 67 years; all had hypertension; the majority had diabetes . Most (3MRA therapy was titrated over a median of 59 (IQR 0–322) days involving a mean of 3.6 (SD 3.9) titrations to the median dose of 50 (IQR 25–150) mg of spironolactone equivalent; 12 (30.8%) patients were titrated to a spironolactone equivalent >100 mg daily. Patients who achieved unsuppressed renin were titrated over a median of 54 (IQR to 6.5–344) days involving a median of 2.5 (IQR 1–4) titrations to the median dose of 50 (IQR 25–131.3) mg of spironolactone equivalent. The MRA dose required to achieve unsuppressed renin correlated with the baseline aldosterone levels . On averP < 0.001 for both). Mean PRA increased from 0.49 (SD 0.22) to 4.66 (SD 5.58) ng/ml/h (P < 0.001). Changes at the individual patients’ blood pressure and renin levels are shown in P < 0.001). The majority  of patients had at least one baseline anti-hypertensive medication stopped during the course of MRA up-titration. Mean potassium levels increased from 4.18 (SD 0.48) to 4.66 (SD 0.41) mEq/dl (P < 0.001). Mean eGFR decreased from 71.9 (SD 19.9) to 61.9 (SD 21.1) ml/min/1.73m2 (P < 0.001).Over the course of treatment, mean SBP decreased from 148.0 (SD 18.4) to 125.8 (SD 11.8) mm Hg and mean DBP from 81.2 (SD 17.5) to 71.6 (SD 11.6) mm Hg (P < 0.001 for both). The mean number of anti-hypertensive medications decreased from 3.4 (SD 1.3) at baseline to 2.4 (SD 1.5) after achievement of unsuppressed PRA (P < 0.001).In the subgroup of 32 (82.1%) patients who achieved unsuppressed PRA, the mean systolic and DBP decreased from 144.9 (SD 14.6) and 78.8 mm Hg (SD 14.9) at baseline to 125.3 (SD 11.5) and 71.4 mm Hg (SD 11.1), respectively (P < 0.01 for both). Patients whose baseline aldosterone was <10 ng/dl had a similar mean decrease in both systolic  and diastolic  blood pressures to the patients whose baseline aldosterone was ≥10 ng/dl. Among the six patients who had detectable proteinuria and ACR measurements post-treatment, the mean ACR decreased from 179.0 (SD 102.1) at baseline to 36.1 (SD 49.2) mg/g (P = 0.03).Among the 15 patients who had baseline aldosterone <10 ng/dl, the mean systolic and DBP decreased from 144.6 (SD 16.5) and 78.4 mm Hg (SD 13.1) at baseline to 121.9 (SD 12.6) and 67.9 mm Hg (SD 9.5), respectively  patients had their MRA dose reduced due to experiencing adverse reactions to MRA treatment, including hyperkalemia, symptomatic hypotension, and acute kidney injury . All adv25In this retrospective observational study, we found that MRA therapy targeting unsuppressed renin levels in patients with LRH or probable PA was associated with substantial decreases in blood pressure and proteinuria, in the context of minimal adverse events that could be easily managed. Importantly, the effectiveness of this treatment approach was similar regardless of whether patients had a likely LRH phenotype  or likely PA phenotype , implying that empiric MRA therapy in patients with LRH could be an effective and pragmatic approach to achieve blood pressure control and potentially prevent complications in this underdiagnosed and undertreated condition.26–28 Unlike some of the previously reported investigations,29 blood pressure reductions were similar between spironolactone and eplerenone, while eplerenone doses were approximately twice as high as spironolactone, consistent with their relative MR antagonist potency.22The treatment strategy of targeting unsuppressed renin was highly effective in lowering blood pressure, with a mean decrease in SBP in excess of 20 mm Hg, despite the majority of patients discontinuing at least one baseline anti-hypertensive medication. This magnitude of blood pressure reduction compares favorably to what has been seen in most studies of other anti-hypertensive medications who had baseline blood pressure at a similar level.31 It is also larger than the 20–30% decrease in ACR reported when patients with proteinuric chronic kidney disease are treated with MRA therapy without regard to baseline or achieved renin levels.33 Notably, several of the study patients had proteinuria despite having only modest hypertension well controlled with non-MRA anti-hypertensives at study entry. These findings suggest that, in addition to uncontrolled hypertension, unexplained proteinuria in conjunction with suppressed renin could also serve as an indication for MRA therapy.Another important benefit of MRA treatment in our study was the reduction in proteinuria. The study found a mean decrease in ACR of 79.8% among the patients who had proteinuria. This reduction is greater than that reported in the randomized controlled trials in patients with proteinuria treated by ACEi and ARBs.34–36 and patiromer,37–39 recently became available and may further facilitate titration of MRA therapy to achieve unsuppressed renin in this patient population.40 Even at a relatively high mean spironolactone equivalent dose of nearly 100 mg, none of the men in the study developed gynecomastia or any other symptoms of hypogonadism, as they were all treated with eplerenone.Treatment with MRAs in our study was safe. No participant had to stop treatment completely due to an adverse reaction. All of the adverse reactions observed in the study, with the most common being hyperkalemia, were reversible. Effective and safe treatments for hyperkalemia, such as sodium zirconium cyclosilicateIt is important to note that the MRA dose needed to achieve unsuppressed renin in this series was reached carefully and in gradual 25–50 mg escalations. Based on the results of our study, we encourage clinicians to use our estimated final MRA dose reached of approximately 25 + 5*x, where x is the baseline aldosterone level (in ng/dl), as a guidance instead of a dose that is specifically targeted or started with. It is important to also note that hyperkalemia can happen at any time during dose escalation, even before renin is unsuppressed; therefore, clinicians should carefully monitor patient’s potassium after each escalation.13 Other studies have examined MRA treatment focused on the achieved absolute renin levels,16 the changes in renin levels,10 the baseline aldosterone-to-renin ratio,12 or the potassium levels.11 Importantly, multiple recent studies have shown that the residual cardiovascular risk in PA patients treated with MRA may be limited to individuals with persistently suppressed renin, and that a substantial rise in renin may mitigate this excess risk.15–21 In the recent report that focused on targeting potassium levels, patients with PA only benefited from intensification of MRA therapy if they had suppressed renin at baseline.11 The present study therefore adds to this body of literature that suggests that unsuppressed renin may serve as a biomarker of adequate MR antagonism against activation by excessive aldosterone and patients with suppressed renin and related symptoms (hypertension and/ or proteinuria) should be considered for MRA therapy targeting normal renin levels. As reductions in blood pressure were similar across the spectrum of aldosterone levels and aldosterone-to-renin ratios, it is likely that this approach could be used both for patients with hypertension and suppressed renin and for patients with PA who choose medical therapy.There is currently no consensus on the optimal approach to or the biochemical treatment targets for MRA therapy in patients with PA. Current Endocrine Society guidelines for medical therapy of PA, published in 2016, recommend MRA titration up to a fixed dose (100 mg of spironolactone), but do not specify targeting a particular renin level.The present study had a number of strengths. It included an unselected patient population that was treated with a uniform protocol. It offers a pragmatic approach that utilizes tests that are widely available in primary care setting and off-patent medications. Finally, the study found effects that were so considerably pronounced that they were highly statistically significant even in a relatively small population.The findings presented in this study should be interpreted in light of its limitations. In absence of a control group, the study cannot make any causal claims. The sample size was relatively small. However, because the effects of MRA therapy were nearly uniform, the findings were robust. Because data collected in this analysis came from a single center from the practice of a single physician in eastern Massachusetts, the results may not be generalizable to other settings. Formal testing for PA was not conducted; however, this was deliberate, as the patients opted for pragmatic medical therapy. Other factors that could have affected renin levels  were not evaluated. The sample size was too small to evaluate for the potential effects of concomitant beta-blocker use. Most patients also could not stop all their non-MRA anti-hypertensive drugs (sometimes because of indications not related to treatment of hypertension), which could influence the explanatory component on blood pressure and renin measures from MRA therapy. We also do not have information on the laboratory methodologic data on the assays used to measure aldosterone and PRA. The sample size was too small to evaluate risk factors for hyperkalemia in study patients. Finally, clinical outcomes were not a focus in our study.In conclusion, the findings from this study suggest that suppressed renin may be sufficient to identify hypertensive patients who could benefit from MR blockade, irrespective of whether they have LRH or probable PA, and that MRA therapy targeting normal renin levels is effective and safe in this patient population. This study presents a pragmatic approach to the treatment of LRH that could be easily and broadly implemented. Further research is needed to confirm these findings in a controlled study design and to establish long-term clinical effects.