In the measurement of regional PWV values using MPPT, no such relationship was found. Gender groups did not statistically differ in the distribution of atherosclerosis risk factors. cfPWV appears to be more accurate than regional PWV in assessing arterial stiffness in the geriatric population.Artery stiffness is a risk factor for cardiovascular disease (CVD). The measurement of pulse wave velocity (PWV) between the carotid artery and the femoral artery (cfPWV) is considered the gold standard in the assessment of arterial stiffness. A relationship between cfPWV and regional PWV has not been established. The aim of this study was to evaluate the influence of gender on arterial stiffness measured centrally and regionally in the geriatric population. The central PWV was assessed by a SphygmoCor XCEL, and the regional PWV was assessed by a new device through the photoplethysmographic measurement of multi-site arterial pulse wave velocity (MPPT). The study group included 118 patients . Men were characterized by statistically significantly higher values of cfPWV than women (cfPWV 10.52 m/s vs. 9.36 m/s;  In recent decades, we have seen an increase in life expectancy, but cardiovascular diseases (CVD) are still the leading cause of morbidity and mortality ,2. CardiThe measurement of the pulse wave velocity (PWV) between the carotid artery and the femoral artery, which is defined as the carotid–femoral pulse wave velocity (cfPWV), is considered the gold standard for arterial stiffness assessment ,8. Over In addition to the gold standard, which is cfPWV, other parameters resulting from pulse wave analysis (PWA) are often the augmentation index (Aix) or augmentation pressure (AG). AG, defined by the height of the late systolic peak (P1) above the inflection (P2), is the contribution that wave reflection makes to systolic arterial pressure. Aix is calculated as AG divided by pulse pressure (PP) x100 .As the function and diameter of arterial vessels decreases, the composition of the arterial wall changes from the central aorta towards the periphery; centrally, the center of a large elastic artery has an ultrastructure of concentric elastic lamellae, intersected by layers of connective tissue, which contain smooth muscle cells. This microstructure gradually disappears, and the increased content of smooth muscle cells in medium-sized and especially smaller vessels takes over . TherefoEpidemiological studies show that the average life expectancy of men is lower than that of women . In aginThe data were collected during the Geriatric Arterial Stiffness Measurement Evaluation study (GAME). This prospective cohort part of the study aims to investigate the influence of gender differences on markers of arterial stiffness. The criterion for inclusion of patients was age over 60 years. The study group included 118 consecutives patients (mean age 77.2 ± 8.1 years) hospitalized in the Department of Geriatrics of the National Institute of Geriatrics, Rheumatology, and Rehabilitation from December 2018 to July 2019.The study was designed to be observational and not interventional; we decided the PWV result could not influence a change of therapy. The majority of patients in the study were elderly patients with multiple diseases who received standard, continuous pharmacotherapy in accordance with the latest guidelines and the best medical knowledge, also regarding hypertension or atherosclerosis, if necessary. Given that the patients were in a stable condition , their treatment was established, and blood pressure values were adjusted before hospitalization—which also implies before PWV measurements.Exclusion criteria were active cancer, lack of limbs, and advanced dementia process preventing collaboration with the investigator’s recommendations.This study’s protocol complies with the ethical guidelines of the 1975 Declaration of Helsinki and has been approved by the Bioethics Committee at the National Institute of Geriatrics, Rheumatology, and Rehabilitation in Warsaw. Before inclusion in the study, all participants were made to provide written informed consent.The cfPWV value was assessed by a SphygmoCor XCEL from ATCOR . The SphMeasuring cfPWV with the SphygmoCor XCEL apparatus simultaneously detects a carotid pulse by applanation tonometry and a femoral pulse by volumetric displacement with a cuff around the upper thigh . Then, tAfter entering the data about the participant (patient), taking the distance measurements  for 4 participants are shown in Signal graphs come from reports generated by the SphygmoCor XCEL software (version 1.3.2.18). The shown examples of pulse waveforms have different amplitudes, shapes, and durations. These parameters are related to the individual characteristics of the participants. However, this does not have a significant impact on the result because the cfPWV is calculated on the basis of the pulse wave propagation time according to the validated algorithms of the SphygmoCor XCEL apparatus.For multi-site arterial pulse wave velocity measurements, we used a custom-made system called MPPT. This system measures the regional PWV. To measure PWV, it uses PPG (photoplethysmographic) sensors located at different sites. This system was described in detail in . For mulIn addition, localization of the SphygmoCor XCEL sensors (tonometer and cuff on right body site) is shown in the block diagram. Multi-site regional PWV measurement with the MPPT device was described in detail in our previous work . The MPPThe MPPT system calculated the regional PWV from the PPG signals measured at a sampling frequency of 1 kHz. The beginning of the pulse wave for each of the pulses was determined by the intersecting tangent method, according to .Representative PPG signals  measured by MPPT devices for 4 participants are shown in The presented examples of PPG pulse waveforms differ from each other, especially in shape, depending on the site of measurement and the individual characteristics of the participant. However, this does not have a significant impact on the result because, as for the SphygmoCor XCEL, the regional PWV is calculated on the basis of the pulse wave propagation time according to the validated algorithms of the MPPT apparatus.For more accurate results, in our study, we took the measurements according to the same procedure for each participant. After a minimum 15 min rest and after informing the participant about the purpose of the study and obtaining their signed consent, the blood pressure in the left brachial was measured using the SphygmoCor XCEL in pulse wave analysis (PWA) mode. This measurement was performed in the standard sitting position, and its purpose was to determine the brachial  and the aortic  blood pressure. Next, the participant assumed a supine position on a medical settee and rested for about 15 min. During this time, the SphygmoCor XCEL and MPPT apparatus sensors were connected, distances were measured, and signals were checked. Subsequently, the main measurement was performed, lasting exactly 15 min. It should be stressed that the measurements with the SphygmoCor XCEL were performed simultaneously with the measurements with the MPPT apparatus. The MPPT measured the PPG signals continuously for 15 min. At the same time, a minimum of three cfPWV measurements were made at an interval of approximately 3 min. All measurements were performed by the same operator, during working days, from Monday to Friday, from about 10 a.m. to 1 p.m., in a separate and quiet room, with an ambient temperature of about 22–24 °C.The final regional PWV was calculated offline for each participant as the mean of the 15 min recording. Likewise, for each participant the average of the all cfPWV readings was calculated.p < 0.05 was considered statistically significant. For continuous variables, the normal distribution was checked using the Shapiro–Wilk test. Student’s t-test was used to compare normally distributed continuous variables, and data were reported as means with standard deviations. The Mann–Whitney U test was used to compare non-normally distributed variables, and data were reported as medians and interquartile ranges. The Pearson’s chi-square test or chi-square test with Yates correction was used to compare discrete variables depending on the expected values. Linear correlation analysis between PWV and continuous variables was performed, and Pearson’s r coefficient was determined. Variables with Pearson’s correlation coefficients higher than 0.3 (p < 0.05) were included in the multivariable regression model. Brachial systolic blood pressure (bSBP) was chosen as a representative of the strongly correlated variables relating to blood pressure.Statistical analysis was performed using Matlab, R environment, and Statistica v.13. p-value (p = 0.05). In comparison with females, males exhibited a significantly lower HDL-C level (p < 0.001), higher uric acid level (p < 0.001), and higher NTproBNP concentration (p = 0.047). Women had higher inflammation parameters . Men were characterized by statistically significantly higher values of cfPWV than women .Patients of both groups did not statistically differ in the values of age; blood tests such as LDL-C, TG, FPG, eGFR, and TSH; blood pressure values ; or anthropometric measurements such as upper-arm circumference and lower-leg circumference. BMI and TC were higher in women, reaching a statistically significant p < 0.001), degree of heart failure expressed as elevated concentration of NTproBNP , and uric acid level . cfPWV growth was sometimes observed to have a different potency between the groups. Sometimes the differences were discreet, as in aMAP, which increases cfPWV in both women and men; the correlation coefficient is higher in women, but the difference does not reach statistical significance. Our study also presents an analysis of the relationship with age—which significantly correlates in women —and its importance has not been registered in the group of men .The highest correlations in the entire group were found for systolic arterial pressure, both peripheral bSBP (r = 0.443) on the brachial artery as well as systolic pressure of the central estimated aortic measurement aSBP (r = 0.411). Moreover, all pressure parameters  showed a significant relationship with PWV. In the whole group, other significant parameters associated with arterial stiffness were patients’ age  and uric acid value , and two non-modifiable ones: male gender  and age . In the multivariable regression analysis in the group of women, apart from the values of systolic blood pressure , age , and uric acid level , the value of NTproBNP  also had a significant impact on cfPWV. Meanwhile, in the multivariable analysis concerning the group of men, only the value of systolic blood pressure  was significant.The most significant parameters in the whole group were two modifiable factors: systolic blood pressure  influences the increase in PWV; only diabetes  is a stronger factor and is characterized by a greater influence than the presence of hypertension .The multivariate regression analysis of the influence of comorbidities, mainly cardiovascular, included in 2 or a BMI of ≥35 kg/m2 and obesity-related comorbidity), aged 18 to 65 years, the median PWV was significantly higher in men than women (7.3 m/s (IQR 6.6–8.0) and 6.8 m/s (IQR 5.9–8.0), respectively); the lower PWV in women appears to diminish in morbidly obese women after menopause [To the best of our knowledge, this is the first study that demonstrates differences in cfPWV between genders in nearly all homogeneous patients in terms of classic comorbidities such as hypertension, diabetes mellitus, metabolic syndrome, chronic obstructive pulmonary diseases, and heart failure among Polish geriatric patients and shows differences in the impact of individual risk factors on the cfPWV value in gender groups. There are some studies that have assessed the relationship between arterial stiffness and gender, but most of them have been conducted in the younger population ,25,26,27enopause ,29. The enopause . As far enopause . One of enopause . The maiThe development of new methods of measuring arterial stiffness allows us to better understand the different components of stiffness as well as to estimate their impact on the real condition of arteries (possible to be fully unambiguous only in autopsy post mortem).  ResearchRecently, the usefulness of photoplethysmography signals in medicine is being investigated . MethodsThe advantage and novelty of our study is the group of geriatric patients in whom the atherosclerotic process is already developed, which allows for an objective assessment of arterial stiffness measurement methods.However, certain limitations should also be acknowledged. First, most patients are women (83 women vs. 35 men), and therefore we were unable to obtain statistical significance in some relationships. The gender gap is caused by the predominance of women in the older population as well as the predominance of women among those hospitalized.As we aimed at a population study among hospitalized people, every patient hospitalized in the Department of Geriatrics of the National Institute of Geriatrics, Rheumatology, and Rehabilitation from December 2018 to July 2019 was included in the study. The only exclusion criteria were active cancer, lack of limbs, and advanced dementia process preventing collaboration on the investigator’s recommendations.The life expectancy of women in Poland is 8 years longer than that of men. In the analyzed period in the Department of Geriatrics of the National Institute of Geriatrics, Rheumatology, and Rehabilitation, which is comparable to the data of the Polish National Health Fund, women constitute about 65–70% of patients hospitalized in geriatric wards. We did not decide to study only a proportion of women to match their numbers with the men, as then the criteria for inclusion or non-inclusion of a specific man could be unclear. We hope that further, larger observational studies may be interesting, being typical studies of entire populations, e.g., cities or countries, and not taking into account the criterion of the need to hospitalize the patient.The second is the lack of a cut-off point for elevated PWV. It is not described in the current literature, and our study group is too small to extrapolate values recognized by other scientific authorities . We thiAnother limitation of this work is the heterogeneity among geriatric patients in this study. During the measurement process, we did not consider the individual differences of the subjects because our goal was to reproduce the PWV assessment among patients hospitalized in the Department of Geriatrics as authentically as possible. For this reason, we did not use inclusions for chronic diseases  because they constitute the overall clinical picture of the geriatric patient.In conclusion, the result of the current GAME study shows that cfPWV is higher in men than women in the geriatric population. However, the reason for this relationship is still unclear and cannot be explained by the distribution of classical CV risk factors  between genders. Because of the attempts made to reduce this important CVD risk factor in the elderly patient population, further studies aimed at deciphering the secret of increased arterial stiffness in men could be remarkably interesting. In addition, it is necessary to look at gender differences separately. In men and women, various factors affect increases in arterial stiffness and thus increase cardiovascular risk. Therefore, it is worth conducting gender-shield analyses as an introduction to personalized medicine. In addition, taking into account the less clearly differentiated regional PWV values obtained by MPPT, it should be assumed that the main factor affecting the stiffness of these arteries is the competitor of the elastic great central arteries. The main problem of arterial stiffness, and thus of all clinical consequences with the aging of the population, is atherosclerosis and calcification, mainly affecting the aorta and, to a much lesser extent, peripheral muscular arteries.


Hypertension is highly prevalent in patients with kidney transplantation caused by transplantation-related immunologic or non-immunologic risk factors. However, whether a strict definition of hypertension (≥130/80 mmHg) and subdivided blood pressure (BP) groups are associated with an increased risk of graft failure after kidney transplantation using a nationwide large cohort study are still unknown.Using Korean National Health Insurance Service data, we included 14,249 patients who underwent kidney transplantation from 2002 to 2016. Patients were categorized into five BP groups according to the 2021 Kidney Disease: Improving Global Outcomes practice guidelines for BP management: normal BP (<120/80 mmHg), elevated BP (120–129/ < 80 mmHg), incident hypertension (≥130/80 mmHg), and controlled or uncontrolled hypertension with anti-hypertensive medications.The primary outcome was graft failure, which occurred in 1934 (13.6%) participants during the 6-year follow-up. After adjusting for covariates, hypertension was associated with a higher risk of graft failure  than no-hypertension. The AHR for graft failure was the highest in patients with uncontrolled hypertension . The risk of graft failure had a linear relationship with systolic and diastolic BP, and pulse pressure.In this nationwide population-based study, hypertension ≥130/80 mmHg based on the 2021 KDIGO BP guidelines in kidney transplantion recipients, and elevated systolic and diastolic BP, and pulse pressure were associated with the risk of developing graft failure in kidney transplant recipients. Hypertension is highly prevalent in patients with kidney transplantation –3. VarioRecently, the target of BP management was lowered to <120 mmHg in patients with chronic kidney disease based on the Systolic BP Intervention Trial (SPRINT), in which the intensive lowering of clinic systolic BP (SBP) reduced the risk for cardiovascular disease and all-cause mortality . On the https://nhiss.nhis.or.kr/bd/ab/bdaba000eng.do. The study protocol was approved by the Institutional Review Board of Chonnam National University Hospital (CNUH-EXP-2022-274) and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The requirement for written informed consent was waived by the review board because anonymous and de-identified information was used for analysis.In this study, we used a national health insurance claims database established by the KNHIS, which includes all claims data provided by the KNHIS and Medical Aid programs. Data extracted from the KNHIS database were considered representative of the entire South Korean population, and the details of this database have been previously described . DependiInitially, 38, 227 patients who underwent kidney transplantation from 2002 to 2016 were identified. Of these, we included patients who had undergone health checkups from 2009 to 2017 because the questionnaire form changed in 2009. The index date was the date of the first health check-up after 2009. We excluded those aged <20 years, and those with graft failure or death before the index date and within 1-year of follow-up. We also excluded subjects with missing health examination data. Finally, 14, 249 KTR were included in the study and were followed-up from the index date to the date of graft failure during the follow-up period, death, loss of health insurance qualification, or the end of the study period . A detailed enrollment flowchart is shown in 2). We defined obesity as a body mass index ≥ 25 kg/m2 according to the WHO recommendations for Asian populations  ≥ 80 mmHg in the health examination database or a history of using antihypertensive medications according to the 2021 KDIGO BP guidelines and 2017 American College of Cardiology/American Heart Association guidelines , 19. MorThe study outcome was incident death-censored graft failure, defined as the presence of hemodialysis, peritoneal dialysis, or kidney re-transplantation. Patients with death-censored graft failure were identified using a combination of International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10-CM) codes  and a special code  at least three times during 3 months, and kidney transplantation code (V005). We excluded patients with a dialysis code on the same date as an acute kidney failure code (N17.9). In the event of death with a functioning graft, the follow-up period was censored at the date of death.t-test, as appropriate. The incidence rates of graft failure are presented as the number of cases calculated per 1,000 person-years. The cumulative incidence probability of graft failure was estimated using the Kaplan–Meier method, and between-group comparisons of the resulting curves were subjected to univariate analysis via the log-rank test. Multivariable analyses were performed using Cox proportional hazard regression models, and calculated hazard ratios (HRs) with 95% confidence intervals (CIs). The proportional hazards assumption was tested visually with the Schoenfeld residual plots. Model 1 was adjusted for age and sex. Model 2 was adjusted for age, sex, income level, smoking status, alcohol consumption status, physical activity, eGFR, obesity, diabetes mellitus, cardiovascular disease and dyslipidemia. Model 3 included all covariates in Model 2, along with the use of antihypertensive medications . Smooth cubic spline HR curves for the graft failure were plotted after adjusting for all covariates (Model 3). Subgroup analyses were conducted according to age, sex, smoking status, and diabetes as well as the duration from kidney transplantation to BP measurement. Interaction terms were added to test for effect modification across the subgroups. All statistical analyses were performed using the Statistical Analysis System (SAS) software . All significance tests were 2-tailed and P-values < 0.05 were considered statistically significant.Continuous variables are described as the mean ± standard deviation and categorical variables are presented as numbers with proportions. Intergroup differences were tested using the chi-squared test or Student's The mean baseline age of the participants was 50.9 years, and 58.2% were men. The baseline characteristics of the study population according to hypertension are presented in During a mean follow-up period of 6.0 ± 2.9 years, 1934 (13.6%) participants developed graft failure. The incidence rates of graft failure were 12.2 and 25.3  in patients without and with hypertension, respectively. The incidence rates of graft failure according to hypertension groups were 11.7, 13.8, 18.9, 22.8, and 31.3 for normal BP, elevated BP, incident hypertension, and controlled and uncontrolled hypertension with antihypertensive medications, respectively . After aParticipants were also classified based on SBP, DBP, and PP levels. The incidence rates and adjusted HRs (Cox Model 3) of graft failure were remarkably increased with an increase in the SBP, DBP, and PP in each group compared with the reference group . These aFor subgroup analyses according to age, the participants were classified into <40, 40–65, and ≥65 years. In all subgroup analyses according to age, sex, smoking, and diabetes mellitus, hypertension was consistently associated with the risk of graft failure, and there was no significant difference between the subgroups .We also analyzed the association between the five hypertension groups, the SBP and DBP groups, and PP groups with graft failure among subgroups . The adjTo determine the association between the duration from kidney transplantation to BP measurement and graft failure, participants were classified into two groups; <5 years and ≥5 years based on this duration. The results were found to be consistent in both subgroups of participants .The present study demonstrated that (1) the presence of hypertension (≥130/80 mmHg) as based on the 2021 KDIGO BP guidelines for KTR increased the risk of graft failure; (2) uncontrolled hypertension (≥130/80 mmHg) albeit taking antihypertensive medications had the highest risk (2.1-fold) of graft failure compared with normal BP; (3) the risk of graft failure increased gradually as the SBP, DBP, and PP increased; (4) this association was present in the ≥120 mmHg SBP, ≥80 mmHg DBP, and ≥50 mmHg of PP groups.Hypertension after kidney transplantation is common, although the prevalence ranges from 50% to 90% and varies depending on the definition, population, and use of antihypertensive medications , 21–24. Our results are consistent with a previous hypothesis that a higher BP is associated with an increased risk of graft failure. Especially, hypertension of ≥130/80 mmHg, as per the 2021 KDIGO BP guidelines, in KTR increased the risk of death-censored graft failure by 1.7-fold compared with non-hypertension. Furthermore, an elevated SBP or DBP of ≥120 mmHg/80 mmHg had a significant association with graft failure, suggesting that a modestly increased BP in KTR could worsen kidney function. Although a retrospective study of 815 KTR who achieved a mean SBP <130 mmHg showed a lower mortality rate, these results were not maintained in graft survival . AlthougOur results also demonstrated that the risk of graft failure was associated with a linear relationship with SBP, DBP, or PP. Moreover, the HRs of uncontrolled hypertension, even while taking antihypertensive medication, increased the risk 2.1-fold than that of normal BP. Considering the results of our study and previous studies , 26, achAnother important finding of this study was that increased PP had a linear association with the risk of graft failure. It is generally accepted that PP, which reflects arterial stiffness, is linked to the progression of CKD and cardiovascular mortality , suggestThe strength of this study was the enrollment of a large population of approximately 14,000 KTR from a nationwide health checkup database over a relatively long follow-up duration. Because of the large population, we classified the patients into several hypertensive groups and subdivided BP groups to determine the association between a lower hypertension definition and various BP levels and the development of graft failure. This study had several limitations. First, we used a single BP measurement taken in the office to determine hypertension. However, BP variability is common in patients with kidney disease, and office BP measurements do not reflect nocturnal hypertension, masked hypertension, and white coat hypertension , 29. SecIn conclusion, this Korean nationwide population-based cohort study found that hypertension ≥130/80 mmHg based on the 2021 KDIGO BP guidelines in KTR, as well as elevated SBP, DBP, and PP were associated with the risk of developing graft failure in patients with kidney transplantation after adjusting for various covariates. Whether intensive treatment of BP can reduce the risk of graft failure needs further large randomized controlled trials.


Hypertension is the most common disease in primary care settings. Only 30% of cases were adequately controlled.To analyze the knowledge and understanding of patients with hypertension regarding the factors that facilitate and limit adherence to treatment and, based on the results, build specific guidelines on hypertension self-care and control.This qualitative study was conducted in a primary healthcare setting.Patients with hypertension who were followed at a primary healthcare unit were interviewed through focus groups, and a qualitative interpretation of their statements according to Bardin’s content analysis was performed.Three focus groups were formed (21 participants), from whose analysis emerged 74 core ideas related to the concept of hypertension, causes of increase in blood pressure, clinical consequences of hypertension, and possible patients’ contributions to help control blood pressure, arising from eating habits, psychosocial conditions, and lifestyle. Patients tend to accept the concept of “high blood pressure” as an inherent condition of the disease in their lives. Eating habits are strongly related to life history and self-perception of health. The association between high blood pressure and nervousness or stress appears to be strong.The experience of having “pressure problem” is unique for each person. It is necessary to optimize listening, recognizing that, for the patient to understand what hypertension is and its management, there must be understanding and convergence of proposals, adjustments, and changes in a positive and personalized way. As a result of this study, we implemented educational actions in primary healthcare units. In Brazil, the disease affects 21.4–32.3% of the population, varying according to the survey’s methodological criteria. Among the risk factors for hypertension development are heredity, age, sex, race, overweight/obesity, excessive sodium consumption, sedentary lifestyle, excessive alcohol consumption, smoking, and socioeconomic factors, such as educational level. Hypertension is directly associated with a higher risk of cardiovascular and renal complications, particularly stroke, myocardial infarction, chronic kidney disease, and other serious complications. There is a slight increase in the mortality rate directly related to hypertension; however, 50% of deaths from cardiovascular disease are associated with hypertension.Hypertension, defined as the persistent elevation of systolic blood pressure (BP) to values ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, is a chronic disease with a high worldwide prevalence. In practice, non-pharmacological treatment mainly involves dietary measures aimed at weight loss and reduction of sodium consumption, regular physical activity, alcohol consumption reduction (when excessive), and smoking cessation. Regarding pharmacological treatment, adherence to medication is essential to achieve BP control.As the main objective of treatment is to reduce cardiovascular and renal morbidity and mortality associated with hypertension, the use of non-pharmacological and pharmacological treatment is essential in the reduction of BP levels and prevention of hypertension complications.Although the diagnosis of hypertension is relatively simple and some consider its treatment easy, the high percentage of individuals with undiagnosed hypertension and the number of patients diagnosed with hypertension who continue to have elevated BP express the complexity of monitoring these patients, requiring great attention and effort from the healthcare system, and there is no doubt about the importance of a multidisciplinary approach.Adherence to a therapeutic plan can be understood as the relationship between the guidance and prescription of the healthcare team and the patient’s conduct to follow them. Compliance with the therapeutic plan is a multidimensional process, which involves several circumstances: lack of knowledge about the disease and lack of motivation to comply with the treatment of a chronic disease; the absence of symptoms; unfavorable socioeconomic and educational background; difficulties in the relationship with healthcare services and in scheduling appointments; cost of certain medications and their adverse effects; and other aspects such as cultural and social beliefs and changes in quality of life after treatment initiation.Considering that a patient’s relationship with the healthcare team is an important element in the context of chronic diseases, a multidisciplinary approach in the follow-up of patients with hypertension, which focuses on the therapeutic process, is fundamental to the adherence and maintenance of treatment.In a primary healthcare unit (PHU) in a large city in São Paulo state, a pilot study is underway to evaluate a new systematization of care for the entire population with hypertension and/or diabetes mellitus accompanied by a family healthcare team . This includes nursing care and home visits that aim for BP and glycemic control and individual and family guidance.In the context of this pilot project, medical students working regularly at the PHU dedicated themselves to identifying the factors that facilitate and limit adherence to the treatment of hypertension in this population and understanding, from the patient’s perspective, the meaning and repercussions of the disease in their lives, contributing to the follow-up by the healthcare team.This was an exploratory, qualitative, cross-sectional, analytical observational study. Individuals with hypertension belonging to the territory of a PHU with a family health strategy were invited to participate. The selection of participants with hypertension was aleatory among those attending the PHU. All the participants who agreed to participate were included in the study.The areas of competence related to hypertension self-care were defined through a bibliographic survey in the Virtual Health Library database, considering articles written in Portuguese, English, and Spanish, from 2013 to 2018, using the descriptors “hypertension,” “self-care,” and “health education,” and involved the following topics: general notions about hypertension and its complications, BP self-control, self-care in drug treatment, self-care in the prevention of chronic and acute hypertension complications, and nutritional self-care. From this list of competencies, a script was formulated, which contained questions that guided the focus groups in analyzing patients with hypertension. The focus group discussions were conducted until saturation of alternative answers was achieved and not pre-established. Three focus groups consisted of an average of seven participants per group. The discussions were recorded, transcribed, and analyzed by two authors, aiming to understand the most significant contents, according to the analysis process recommended by Bardin. The units were categorized according to the semantic criteria, establishing thematic categories that were exhaustively reviewed and described below.Focus groups were formed based on the definition proposed by Morgan: “A research technique that collects data through group interactions when discussing a special topic suggested by the researcher,” to understand feelings, beliefs, and participants’ behaviors.The research project and informed consent form were submitted to a research ethics committee, approved on May 8, 2018, and only started after their approval (CAAE 86670318.6.0000.5373).A total of 21 participants with hypertension were included in the focus group. The participants’ characteristics are presented in The content analysis allowed the classification of the speeches into categories in accordance with the core ideas, which summarized the topic addressed in the response. To analyze these core ideas, summary tables were prepared from the statements listed for each issue raised in the discussions. The different statements of the participants were considered and counted. Regarding the first question, “Does anyone know what hypertension or ‘high blood pressure’ is?” some representative expressions of the participants’ understanding of what hypertension is were as follows: “It is a silent disease, I don’t feel anything,” which is related to the absence of symptoms; “It must be a blood problem, right doctor? Change the heartbeat”; and “It messes with the circulation,” which is related to the core idea of cardiovascular disease.Regarding the second question, ‘What can cause hypertension or high blood pressure?’ some examples of how they expressed themselves during the focus groups were as follows: “It’s an unwelcome inheritance, it’s hereditary,” which is related to the heredity of hypertension; “It’s what you eat, what you drink, and what you do during your life, right?,” which is related to dietary habits and lifestyle; “Pressure is nervous, stuff like that”; “The increase in blood pressure … has a lot of emotional influence, a lot of,” which is related to the core idea of nervousness, stress, and/or the nervous system.Regarding the third question, “What are the consequences of high blood pressure?” the consequences were mentioned in a similar way to those illustrated in the following examples, which were obtained from their statements: “It can really cause kidney problems”; “Oh, it causes stroke, [hypertension] can cause a heart attack”; and “My mother died suddenly of a heart attack at age 47, from high blood pressure.”In view of the nature of the answers, analyses of the fourth and fifth questions were grouped. The fourth question was “What can you do to control high blood pressure?” and the fifth was “What can you do to prevent high blood pressure?” Some statement on what helps hypertension control were as follows: “to consume little salt, and eliminate nervousness helps a lot”; “that’s where I think physical activity comes in, right?”; “oh… exercise, walking, medication…”; “you have to control the salt, which is the main thing, … and control the nerves”; “The only thing I do, my whole life, I’ve been taking medication for about 18 years, I take it all together, in the morning and at night.”Focus group discussion, the method selected for this study, provides the appreciation of the individual within the collective, under the influence of social pressure and the reactions that demand it, being in an intermediate position between pure observation and in-depth interviews.In brief, the results showed that the participants expressed the concept that hypertension is an asymptomatic disease caused by hereditary and behavioral factors, particularly dietary habits and lifestyle, and is associated with circulatory and renal diseases and complications. This was also evident in their statements regarding the understanding of emotional factors as possible causes of high BP. Regarding the control of hypertension, they valued adherence to adequate eating habits, physical exercise, emotional control, drug treatment, and access to health services. Self-care and faith were rarely mentioned but were present in their statements. Overweight or obesity was mentioned as a possible cause of hypertension only once. Difficulties in accessing the healthcare system or lack of antihypertensive medications did not emerge as problems in hypertension care. Renovato and Dantas claim that there is a “crisis of understanding” about the disease by patients with hypertension. These authors suggest that the absence of symptoms at the time when the healthcare professional imputes him as sick is responsible for the contradiction, while the constant high BP levels throughout the disease follow-up end up convincing them that there is really something wrong, making them move along this gradient of conviction about being carriers of this “hypertension” entity.Although the definition, awareness of causes, and recognition of complications of hypertension have been mentioned, these concepts were confused and mixed in their statements. Some participants provided the definition of “high blood pressure” as a pressure value achieved by assessing it with measuring devices. Others related it to a problem with the heart or blood vessels, while others associated it with lifestyle habits. Some studies have already shown that most patients do not know how to define or wrongly define hypertension. The nosological category “hypertension” does not exactly match “high blood pressure” in popular vocabulary but the term “pressure problem.” This is due to the fact that patients link the moments of uncontrolled BP, which are represented by pressure peaks, to the term “high blood pressure” and understand this phenomenon as transitory, often related to the emotional status, as arising from a moment of stress. Conversely, having the disease “under control,” without documented moments of pressure peaks, is better understood by patients as a “pressure problem.” This is preceded by the verb “to have,” presenting a permanent character, while “high blood pressure” is usually preceded by the verb “to be/estar,” evidencing its transience.In addition to this difficulty in recognizing the problem, there is still semantic disagreement in the discourse between doctors and patients. Fleischer, in her ethnographic study conducted in Guariroba  on patients with hypertension, recognized the disparity in meanings between the terms used by doctors and what the patient understands. It is evident in the speech of the study participants and in the literature that there is a misconception that these reported symptoms represent hypertension itself and not common complications of the advanced stage of the disease, which are preventable with adequate BP control.Our study also showed that, as a group, patients tended to assume the definition of “high blood pressure” as the practical condition that the disease has in the life of each of them and not on a biomedical basis as was expected by the researchers, which allows us to understand that, in the participant’s view, the full concept of hypertension did not matter only in terms of meaning for them but in what it would pragmatically reflect, that is, its consequences . Moreover, symptoms such as neck pain, dizziness, leg pain, shortness of breath, and tachycardia have been reported, which, from a physician’s perspective, will only be present after the complications of hypertension arise. Food intake is strongly linked to the history of people’s lives, culture, and self-perception of health. Many people have a history of vulnerability or food deprivation at other times in their lives and are negatively associated with restrictions required by their disease at such times, which makes their adherence difficult. The absence of visible signs of the disease in their daily lives makes them question the real need to adopt such habits as well as influence adherence to drug treatment.Participants also mentioned the need for chronic food restriction and drug treatment for the rest of their lives, factors recognized in the literature for influencing quality of life and adherence to treatment. However, it is noteworthy that there was only one mention of overweight and obesity as risk factors for hypertension. Although there were several references to inadequate nutrition as a possible cause of the disease, the participants did not relate carbohydrate excess and weight gain as a risk factor for hypertension nor did they recognize the limitation of the consumption of carbohydrates and fat as a way of reducing weight and consequently BP. We were also surprised by the overestimation of the etiological association between hypertension and nervousness, which were mentioned in terms such as “nervous system,” “nervous,” “nerve,” “emotional,” “stress,” “anxiety,” and “frightening.” Such a relationship has already been demonstrated in other studies, although it is unclear whether the association made by patients is a cause or a consequence. It is assumed that patients perceive the disease as a thermometer of their emotional state, oscillating along with their emotions, even treating the two things as the same entity. The two things are so strongly aggregated in the participants’ imagination that they assume as valid the strategy that it is possible to control the disease just by controlling nervousness, even evoking a curative characteristic of hypertension if the emotions that trigger it were controlled.In the quest to identify the origin of their health problems, participants recognized factors such as high consumption of salt, fatty foods, alcoholic beverages, and cigarettes; sedentary lifestyle; and heredity as present in the genesis of hypertension. Such factors have already been reported by patients in other studies, and the result was not surprising. Although there are physiological bases on the contribution of stress in the development of high BP, the hypertension control programs of our healthcare system do not include effective strategies to deal with these factors. In fact, in many places of the Unified Health System, it is difficult to adequately discuss and treat mental health disorders, a topic shrouded in taboo, which allows the perpetuation of myths and prejudices when referring to the topic of hypertension.Fava et al. and Fleischer discussed in their ethnographic studies how this hypertension–nervousness marriage is taken into account by healthcare professionals who take care of these patients. Moreover, the state of social vulnerability that most patients are in makes it difficult to access healthier life practices.In addition to controlling the emotional state, patients understand that the modification of lifestyle recognized as causes of high BP is a way of exercising self-care and controlling BP. However, this is a challenge in practice. The chronic nature of the treatment is one of the reasons that leads to the discontinuation of these practices, causing discouragement, since the practices that need correction are often the same ones that produce a psychologically compensatory effect for the individuals, considered by them as protectors of the stress that they believe to be the cause of the increase in their BP.Health professionals have an opportunity to intervene in these groups of people, aiming to spread techniques that are economically viable and easily accessible, so that these people can find qualified scientific information.Adherence to pharmacological treatment is ambiguous, as it is frequently associated with the occurrence of symptoms, which are often late in this group. In the absence of BP peaks and symptoms, patients with hypertension carry a conception of having been cured, allowing themselves to interrupt the treatment, even with the opposite orientation.As a result of this study and with the support of medical students who attend the PHU, we are implementing several actions in health units, such as forming support networks via social media that can offer health education, exchanging information, and facilitating the follow-up of patients with hypertension; distributing educational posters and leaflets in PHU with short and direct information; encouraging self-care and self-measurement of BP at home; and establishing simple and direct nutritional guidelines. Some examples of sentences with information and guidelines were communicated:“Did you know that the best medicine to fight the pressure problem is to lose weight?”“People with pressure problem don’t feel any discomfort, but it can hurt their heart, brain, and kidneys.”“If you have pressure problem, learn how to measure your blood pressure at home with automatic (arm) devices. It is very simple and cheap and helps to control your blood pressure.”“If you have high blood pressure and you take medication to control it, keep taking them, even if you have had alcoholic beverages.”“You can help control your blood pressure. Eats with little salt, lose weight if they are overweight, and perform regular physical exercise .”Due to the coronavirus disease 2019 pandemic, we should still avoid crowds to prevent disease transmission; however, as soon as sanitary conditions allow, group meetings will be promoted to encourage self-care educational practices for patients with hypertension.The group approach of patients with hypertension allowed us to analyze how the experience of having “pressure problem” is unique for each person. Being personal, it is not possible to imagine an awareness strategy that can reach everyone. It is important to confirm in this study the perception that these patients need professionals who listen to them, seeking to recognize the meanings of their speeches, in contrast to the use of scientific and biomedical jargon, through pre-shaped recipes for a human being impersonal and generalized. For this, it is necessary to listen to these patients, with a high degree of empathy, recognizing that, for the patient to understand what hypertension is and its management, there must be understanding, convergence of proposals, adjustments, and changes in a positive and personalized way.


Arterial hypertension is considered a risk factor for the development of heart failure. Here we investigate cross-sectional associations of systolic and diastolic blood pressure with subtle functional and morphological changes of left ventricular echocardiographic parameters representing early dysfunction in three representative German population-based studies. We assessed 26,719 individuals without symptomatic heart failure from the Hamburg City Health Study , the Gutenberg Health Study  and the Study of Health in Pomerania . Multivariable linear regression analyses with systolic and diastolic blood pressure as continuous exposure variables were adjusted for common cardiovascular risk factors and antihypertensive medication. Both systolic and diastolic blood pressure were consistently associated with measures of left ventricular hypertrophy (β per standard deviation (SD) for LV mass (g) and systolic blood pressure: 5.09 (p < 0.001); diastolic blood pressure: 2.29 (p < 0.001) in HCHS). Systolic blood pressure correlated with declining diastolic function  and diastolic blood pressure with declining systolic function  in all cohorts. Pending further validation, our results from three independent German population samples suggest differential effects of systolic versus diastolic blood pressure on left ventricular structure and function. Arterial hypertension is the foremost risk factor for developing heart failure2. Newly diagnosed heart failure of any subtype according to Framingham clinical criteria was preceded by arterial hypertension in 91% of subjects in the Framingham Heart Study3.Worldwide, more than 1.2 billion people aged 30–79 years suffer from arterial hypertension5. Pathophysiologically, hypertensive heart disease begins with left ventricular hypertrophy and diastolic dysfunction7. These conditions are considered a result of increased afterload for the left ventricle induced by systolic and diastolic hypertension. Untreated arterial hypertension leads to both cardiac diastolic and systolic dysfunction, finally evinced by manifest heart failure8. In patients with heart failure with preserved ejection fraction, only systolic blood pressure was associated with left ventricular hypertrophy while diastolic blood pressure correlated with diastolic dysfunction9. Differential interplays of systolic and diastolic blood pressure with cardiac function and morphology even occur during normal aging10. Pathological cardiac remodelling including ventricular hypertrophy and diastolic dysfunction often precede symptomatic heart failure11. To better characterise the differential role of systolic blood pressure and diastolic blood pressure for the development of heart failure, we investigated associations of systolic blood pressure and diastolic blood pressure with functional and morphological left ventricular echocardiographic parameters in subjects without apparent heart failure from the Hamburg City Health Study (HCHS) validated in the Study of Health in Pomerania (SHIP) and Gutenberg Health Study (GHS).Chronic elevation of blood pressure results in reverse myocardial remodelling including inflammatory and fibrotic processes with consecutive dysfunction of the macro- and microvasculature12. Measurements were conducted during a single-day visit at the HCHS Epidemiological Study Centre of the University Medical Center Hamburg-Eppendorf between 2016 and 2018. Out of the first 10,000 participants, 8264 underwent a transthoracic echocardiogram. From this group, individuals with self-reported heart failure or dyspnoea (corresponding to NYHA class ≥ II) in conjunction with N-terminal pro-brain natriuretic peptide (NT-proBNP) levels ≥ 125 ng/l (n = 523), left ventricular ejection fraction (LVEF) ≤ 40% (n = 45), or missing blood pressure data (n = 347) were excluded. A total of 7396 participants were included for subsequent analysis. For validation purposes, data from 4608 individuals from the Study of Health in Pomerania (SHIP) and 14,715 participants of the Gutenberg Health Study (GHS) were assessed  were examined. The HCHS is a long-term, prospective, population-based cohort study involving a random selection of participants from Hamburg, Germany12. Blood samples were collected under fasting conditions on the day of examination. NT-proBNP levels were assessed in all patients using stored serum samples . Blood pressure was measured twice using an Omron 705IT device  on the right upper arm while the participant was seated, following a 5-min rest period; the results were then averaged. Medications classified as antihypertensive drugs encompassed ACE inhibitors, angiotensin II receptor blockers, beta blockers, calcium channel blockers, renin inhibitors, thiazide diuretics and loop diuretics15. Atrial fibrillation was considered present if indicated in the questionnaire, diagnosed via a 12-lead electrocardiogram, or both. Diabetes mellitus was determined based on a fasting glucose level of ≥ 126 mg/dl or the use of antidiabetic medications. Coronary artery disease was self-reported and defined as having a history of one or more of the following conditions: myocardial infarction, percutaneous coronary intervention (PCI), or coronary artery bypass surgery.Demographic and clinical characteristics were evaluated using standardized interviews carried out by specially trained medical personnel and questionnaires adhering to established standard operating proceduresThe local ethics committee of the Medical Association Hamburg  approved the HCHS. All participants provided written informed consent. The HCHS study's review board approved the study protocol, which conforms to the principles outlined in the Declaration of Helsinki.16. For continuous quality assessment, every 100th TTE exam was additionally analysed by a second investigator. Qualitative and quantitative image analyses were performed using an off-line workplace (Siemens syngo SC2000 version 4.0 software).TTE was conducted and analysed by cardiologists and sonographers (technicians) during the baseline visit, following a standardized protocol in accordance with the guidelines set forth by the American Society of Echocardiography (ASE) and the European Society of Cardiovascular Imaging (EACVI)Left-sided volumes and ejection fraction (LVEF) were calculated using the two-dimensional biplane method of disks summation. Left-sided diameters were measured in the parasternal long-axis view. Left ventricular mass was calculated using the Devereux cube formula, based on interventricular septum thickness, LV end-diastolic diameter, and posterior wall thickness. Mitral inflow patterns were assessed in the apical four-chamber view by positioning the pulsed-wave (PW) Doppler sample volume between the mitral leaflet tips. PW tissue Doppler imaging (TDI) e′ velocity was measured in the apical four-chamber view by placing the sample volume at the lateral and septal basal regions. E/E′ was determined as the mean of E/E′ septal and E/E′ lateral.13. In brief, a random cluster sample (age range 20 to 79 years) was drawn from the population of West Pomerania, the north-eastern region of Germany. The net sample (without migrated or deceased persons) comprised 6265 eligible individuals with 4308 (2193 women) of them participating in the baseline (SHIP-START-0) study (response rate 68.8%). All subjects who participated in the baseline SHIP were re-invited to take part in the first examination follow-up (SHIP-START-1), which was realized from 2002 to 2006. Of the 3949 persons eligible for SHIP-START-1, 3300 subjects were re-examined, resulting in a follow-up response of 83.6%. For the second examination follow-up (SHIP-START-2) conducted from 2008 to 2012, all 3708 eligible individuals that participated in the baseline study were re-invited. Of them, 2333 were re-examined (follow-up response of 62.9%).SHIP is a population-based investigation conducted in Pomerania, Germany. The study's design and recruitment strategy have been detailed in previous publicationsWhile SHIP-START-2 was being conducted, between 2008 and 2012, a second independent cohort was established, called SHIP-TREND-0, covering the same region as the initial SHIP. A stratified random sample of 8826 adults, aged 20 to 79 years, was selected. Participation in the initial SHIP-START cohort was an exclusion criterion. In total, 4420 individuals participated in SHIP-TREND-0 (response rate 50.1%). For the present study, we performed cross-sectional analyses using pooled data from SHIP-START-2 and SHIP-TREND-0 . We excluded participants with previous self-reported heart failure or dyspnoea  combined with NT-proBNP ≥ 125 ng/l (n = 656), LVEF, determined by echocardiography, lower or equal than 40% (n = 4). We also excluded individuals with missing values for echocardiography (n = 1427), blood pressure (n = 22) or any of the covariables (n = 36). The final analytical sample comprised 4608 subjects  aged 20 to 90 years  combined with NT-proBNP ≥ 125 ng/l (n = 198) or LVEF ≤ 40% (n = 47) or missing values in data on systolic or diastolic blood pressure (n = 16) were excluded. Finally, 14,761 subjects remained for subsequent analyses. The local ethics committee and data protection officer approved the study protocol before initiation. Written informed consent was provided by all study participants. Study procedures were conducted in line with the principles outlined in the Declaration of Helsinki.Conducted in Mid-Western Germany between April 2012 and April 2017, GHS is a large population-based, prospective, single-centre cohort study. A description of the study design was published beforeContinuous variables are presented as median and interquartile range, categorical variables are presented as absolute numbers and percentages. Comparisons between subgroups were performed using the Mann–Whitney-U-Test for continuous variables and the Fisher test for categorical variables. In order to examine the association of systolic blood pressure, diastolic blood pressure, and pulse pressure with various parameters, a multiple linear regression model was calculated with blood pressure as a predictor and the respective echocardiographic parameters as outcome. A separate model was created for each outcome and BP. Adjustment was performed for age, sex, body mass index (BMI), smoking, coronary artery disease, diabetes, antihypertensive medication, and LV mass. The numerical predictors were centered and scaled, i.e. each divided by their standard deviation after subtracting the mean, so that the result of the estimation parameter beta can be interpreted in terms of standard deviation. A p-value of < 0.05 was considered as statistically significant. All tests were two tailed. Data analysis was performed using R version 4.0.3. Each cohort data set was analysed independently.2  and median diastolic blood pressure 82.0  mmHg. 3478 (47%) had a systolic blood pressure of ≥ 140 mmHg, a diastolic blood pressure of ≥ 90 mmHg or both (high blood pressure). Those with high blood pressure were older, had a higher BMI as well as a higher burden of diabetes and atrial fibrillation than those with normal blood pressure.2 or maximal velocity of tricuspid regurgitation (TR Vmax) > 2.8 m/s was present in 1013 (14.5%) participants. Six (0.1%) participants fulfilled all three criteria of diastolic dysfunction all of which had a blood pressure of ≥ 140 mmHg/90 mmHg.Baseline left atrial and ventricular echocardiographic parameters including LV mass, LVEF, E/E′, and volumes are shown in Table In multivariable linear regression analysis adjusted for common cardiovascular risk markers, continuous blood pressure measures were strongly associated with indicators of left ventricular hypertrophy in all cohorts Table . SystoliDiastolic blood pressure was associated with declining systolic function in all cohorts with a β per SD (in %) of -0.32  for LVEF in HCHS. Systolic blood pressure was associated with declining systolic function as indicated by increasing E/E′  in HCHS, GHS, and SHIP.Higher systolic blood pressure was associated with increased left atrial volume in HCHS  and SHIP as indicated by associations with left atrial end-diastolic diameter (LAEDD). Data on left atrial volume in GHS were not available.Higher diastolic blood pressure was associated with reduced left ventricular end-diastolic volume in HCHS and GHS as demonstrated by a β per SD (in ml) of − 1.99  in HCHS. The same trend, but lacking statistical significance, was detectable in SHIP .Pulse pressure showed associations with left ventricular mass and wall thickness and declining diastolic function but not with declining systolic function throughout all cohorts Table .The described associations of systolic blood pressure and diastolic blood pressure with morphological and functional measures persisted after additional adjustment for left ventricular mass  Study found no associationParticipants of HCHS as well as from the validation cohorts SHIP and GHS were mainly of Caucasian descent. Accordingly, our findings cannot be transferred to other ethnic groups.The definition of heart failure comprised self-reported heart failure, dyspnoea equivalent to NYHA II-III, and an NT-proBNP concentration of more than 125 pg/ml and LVEF ≤ 40%. Heart failure might thus be underreported. Blood pressure was measured by medical professionals at the day of the baseline visit, which might have led to falsely high values. Additionally, the intake of antihypertensive medication might considerably influence the reported results. In order to reduce the risk of relevant confounding we have adjusted for antihypertensive medication and performed a sensitivity analysis excluding those taking antihypertensive medication (Supplemental Table In this large community-based study of three German adult populations, both elevated systolic and diastolic blood pressure were associated with left ventricular hypertrophy. Only systolic blood pressure was related to declining diastolic function whereas diastolic blood pressure was associated with declining left ventricular systolic function. These results suggest a differential role of systolic blood pressure and diastolic blood pressure for the development of heart failure.Supplementary Information.


IND, n = 28) or a control with a fixed PEEP of 5 cm H2O . Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEPIND maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP5 maintained a PEEP of 5 cm H2O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEPIND was 16 cm H2O (ranging from 12 to 18 cm H2O). EIT-guided PEEPIND was associated with higher PaO2/FiO2 before extubation compared to PEEP5 . Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia . Additionally, PEEPIND was associated with lower driving pressures  and better compliance . Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021.Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEP Robot-assisted laparoscopic radical prostatectomy is associated with high abdominal pressure and requires an extreme Trendelenburg position for optimal surgical access . During 2O, both in morbidly obese and normal patients undergoing laparoscopic surgery [Several techniques have been used to determine individual PEEP, also known as optimal PEEP ,8,9. Che surgery ,16. Howe surgery ,17 and i2O PEEP in patients undergoing robot-assisted laparoscopic radical prostatectomy.Therefore, we tested the hypothesis that EIT-guided individualized PEEP without recruitment maneuvers also improves intraoperative oxygenation, when compared to 5 cm HThis prospective, randomized, controlled, single-center study was approved by the ethics committee of Fudan University Shanghai Cancer Center (number: IRB2010225-11) and registered with the China Clinical Trial Registration Center (ChiCTR2100053839). The first patient was recruited on 15/12/2021 by the Fudan University Shanghai Cancer Center. Informed consent was obtained from every patient before enrollment. An investigator assessed patients for eligibility the day before surgery.Patients undergoing elective robot-assisted prostate surgery under general anesthesia;American Society of Anesthesiologists (ASA) grade I~III;2.BMI < 30 kg/mUntreated ischemic heart disease;Acute or chronic respiratory failure and moderate to severe obstructive or restrictive pulmonary diseases, including chronic obstructive pulmonary disease and asthma;Previous lung or airway surgery;Neuromuscular diseases;2 (in room air) < 95%.Preoperative SpOThe demographic data and clinical characteristics were recorded after patients entered the operating room. Standard monitoring protocols were applied, including ECG, pulse oximetry, and capnography. Intravenous access was established, and a radial arterial line was established for invasive blood pressure monitoring and arterial blood gas (ABG) analysis. Pre-oxygenation was performed for 3 min  before anesthesia. The anesthetic induction was conducted with an intravenous-targeted control infusion (TCI) of propofol (Marsh mode) at 4 μg/mL, sufentanil at 0.3 μg/kg, remifentanil (Minto mode) at 2 ng/mL, and rocuronium at 0.6 mg/kg. A 7.0-size tracheal tube was inserted, and correct placement was confirmed through auscultation and the presence of bilateral equal breath sounds. General anesthesia was maintained with the continuous TCI infusion of propofol 3–4 μg/mL and remifentanil 1–2 ng/mL, as well as the intermittent administration of rocuronium in order to maintain adequate muscle paralysis.2 = 0.5, PEEP = 18 cm H2O in the PEEPIND Group , and a respiratory rate of 12–15 beats/min was set to maintain the end-tidal CO2 partial pressure between 35 and 45 mmHg.After tracheal intubation, patients were provided with pressure-regulated volume-controlled ventilation . The ventilation was set at a tidal volume of 6–8 mL/kg predicted body weight (PBW), FiO0) 5 and 60 min after the PEEP setting  and 10 min after extubation (T3).Demographic data and medical characteristics, including sex, age, BMI, PBW, ASA classification, medical history, invasive blood pressure, and heart rate, were collected. Intraoperative tidal volume, dynamic respiratory system compliance (Cdyn), driving pressure, plateau pressure, and ABG at 5 and 60 min after an individual or fixed PEEP setting and before extubation were recorded. The ABG analysis  was performed simultaneously. We collected regional lung ventilation distribution before anesthetic induction  after PEEP levels had been set in both groups. In the present study, an EIT electrode belt, which carries 16 electrodes with a width of 40 mm, was placed around the thorax in the fifth intercostal space, and a reference electrode was placed on the right thorax.TM Xi Robot and AirSealTM iFS device . The individual PEEP titration with EIT in the PEEPIND Group started after the patient’s placement in the Trendelenburg position and peritoneal insufflation  until extubation. There were no intermittent recruitment maneuvers in either group.All patients were placed in a steep 30-degrees Trendelenburg position prior to incision. Abdominal access, insufflation, and docking of the robot occurred at a pneumoperitoneum pressure of 14 mmHg. All cases were completed using the Davincifflation . PEEP stnce loss  using cunce loss . After i2/FiO2 before extubation. Other outcome parameters included:(1)Intraoperative driving pressure, plateau pressure, and Cdyn;(2)Ventral over dorsal ventilation distribution ratio;(3)Intraoperative hemodynamics;(4)2 < 92% were on room air after extubation) in the PACU.The incidence of postoperative hypoxemia .The mean individualized PEEP guided by EIT in the PEEP2/FiO2 in the PEEPIND Group was 14.8 kPa higher than the PEEP5 Group before extubation , resulting in significantly lower driving pressures  and better Cdyn . The results are shown in Before extubation, the individualized PEEP level guided by EIT was associated with higher plateau pressure when compared to the 5 cm HThe hemodynamic parameters, such as heart rate, blood pressure, doses of vasopressor, and fluid infusions, during mechanical ventilation were similar between the two groups .2O PEEP during mechanical ventilation  can be associated with higher lung ventilation and oxygenation in prostate patients undergoing robot-assisted endoscopic procedures with their heads below 25° [Intermittent recruitment maneuvers were not combined with individualized PEEP in our study. Girrbach et al. applied recruitment maneuvers and individualized PEEP to significantly improve intraoperative oxygenation . Howevergenation . Furthergenation . The indgenation ,30,31,32elow 25° . At the 2/FiO2 was 14.8 kPa higher than the control group before extubation . Additionally, EIT-guided PEEP titration was associated with lower driving pressures and better compliance. These improvements could be explained by the distribution of local lung ventilation. These results indicate that postoperative pulmonary complications can be improved in such patients, and prognosis might also be improved. Though we did not follow up with postoperative pulmonary complications, the feasibility and advantages of using EIT in individualized PEEP titration undergoing robot-assisted prostatectomy were demonstrated.Our data show that a high incidence of postoperative hypoxemia (26.9% in the control group) was found after robot-assisted prostatectomy, which extended the PACU stay and increased costs. With the implementation of EIT-guided PEEP titration, PaOHigh-level PEEP may aggravate hemodynamic instability, especially in critically ill patients ,35. HoweOur results suggest that improved regional lung ventilation distribution, as evidenced by a better ventral/dorsal distribution ratio, might contribute to improved perioperative oxygenation using EIT-guided individualized PEEP. The ventral/dorsal distribution ratio was calculated based on the percentage of tidal variation in regions of interest, and it was easily calculated by bedside personnel . PatientThe application of EIT technology requires specialized training, and the equipment is expensive, which may require the consideration of its cost-effectiveness. However, our results show that EIT technology can improve intraoperative oxygen and decrease the incidence of postoperative hypoxemia, which may shorten patients’ hospital stays and decrease postoperative comorbidity. The EIT examination itself generates almost no cost . The overall cost-effectiveness could be in favor of applying EIT-guided PEEP, especially for high-risk patients prone to lung atelectasis.2O to 8 cm H2O. If optimal PEEP was outside this range, which would be rare, our method would not be able to find it. Nevertheless, the PEEP values achieved in our study resulted in better perioperative oxygenation. However, since the sample size was small, the effect of individualized PEEP on postoperative pulmonary complications, such as atelectasis and pneumonia, was not determined in the present study.There are several limitations to this study. Firstly, individualized PEEP guided by EIT limited the regions of overdistension and collapse, which might not be the “optimal” PEEP in other aspects, e.g., transpulmonary pressure. The individualized PEEP titration ranged from 18 cm HCompared with a fixed PEEP level, the individualized PEEP level achieved using EIT without recruitment maneuvers could also improve perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which may benefit patients at risk of intraoperative hemodynamic instability caused by recruitment maneuvers. However, whether this individualized PEEP without intermittent recruitment maneuvers can reduce the incidence of postoperative pulmonary complications should be further studied.


Obesity is a widely recognised risk factor for chronic and gestational hypertension. Influence of gestational weight gain on blood pressure control throughout the pregnancy is not well characterised.Women in the third trimester of a singleton pregnancy were recruited to the study. Medical records were analysed and a special survey was conducted to obtain history on hypertensive disorders in pregnancy and weight changes during pregnancy. Blood pressure measurements were taken during the office visit in line with international guidelines. Relationships between gestational weight gain and maximal and office values of systolic and diastolic blood pressure values were analysed.Data of 90 women in normal pregnancy, 40 with gestational hypertension and 21 with chronic hypertension were analysed. Gestational weight gain was 11.9 ± 4.6 kg in the normal pregnancy group, 13.0 ± 5 kg in the gestational hypertension group and 10.6 ± 3.4 kg in the chronic hypertension group. Gestational weight gain positively correlated with both office  and maximal blood pressure values  in normal pregnancy and with maximal blood pressure values  in women with chronic hypertension. No correlation was observed between gestational weight gain and blood pressure values among women with gestational hypertension.In normal pregnancy and in women with chronic hypertension greater gestational weight gain is related to higher blood pressure values in the third trimester. Hypertensive disorders in pregnancy (HDP) including pre-existing/chronic hypertension (CH), gestational hypertension (GH), pre-existing hypertension with superimposed gestational hypertension with proteinuria and antenatally unclassifiable hypertension are associated with different risk factors and complication rates in pregnancy . Althoug2 of prepregnancy body mass index (BMI), the risk for GH rises by 6% [With every 1 kg/mes by 6% . Gestaties by 6% . OverweiThere is emerging evidence on the role of gestational weight gain (GWG) on short- and long-term maternal and neonatal health outcomes. Additionally, GWG has been linked with increased risk of obesity in the mother  and cardDuring normal pregnancy blood pressure decreases in the first and second trimester and begins to rise from the mid-third trimester, achieving prepregnancy values . The facChronic hypertension was defined as hypertension diagnosed before or during the first 20 weeks of pregnancy. Women with secondary hypertension were excluded from the study. Hypertension diagnosed after the twentieth week of pregnancy constituted gestational hypertension. As no data on postpartum resolution of blood pressure abnormalities were collected, this criterion was not a part of the used definition of gestational hypertension. There were no women with pre-existing hypertension with superimposed gestational hypertension with proteinuria in the studied group. This is a substudy of a project financed by the National Science Centre, Kraków, Poland (NCN 2013/11/N/NZ5/03388). The project was approved by the local Ethical Committee (opinion number 17/2013). Women were included in the study after providing a written informed consent.Women in the third trimester of a singleton pregnancy were recruited for the study. This was a single-center prospective trial carried out between October 2014 and June 2017. Data regarding anthropometric and demographic factors – such as height, pregestational weight, gestational weight at the time of the examination, the history of hypertensive disease – were obtained by a questionnaire and compared, when available, with obstetric records to ensure accuracy. The analysed information regarding hypertension includes the time of diagnosis, highest values of systolic and diastolic blood pressure during pregnancy, treatment, and number of ambulatory blood pressure measurement tests. Each women had an office blood pressure measurement obtained according to recommended guidelines with an Omron device certified for use during pregnancy . MeasureWe analysed the results for women in normal pregnancy and for women with hypertensive disorders of pregnancy separately. Afterwards a subanalysis of women with CH and GH was carried out. Body mass index (BMI) was calculated as weight in kilograms / height in meters squared. Descriptive data are presented as a mean or median depending on the distribution pattern. Differences between the groups regarding weight and BMI were calculated by Mann–Whitney U test. We decided to use the nonparametric test because of the size of the compared groups. Spearman correlation was calculated to examine the relationship between anthropometric parameters and blood pressure in each prespecified subgroup. SPSS Statistics 23 statistical software was used for the analysis. P value of less than 0.05 was considered as statistically significant.The study group consisted of 61 women with HDP, 40 with GH, and 21 with CH, and 90 women in normal pregnancy. They were assessed during the third trimester. Between women in normal pregnancy and HDP there were no differences in age  nor duration of pregnancy . Subanalysis of the HDP group showed that women with GH had slightly higher gestational age compared with CH group at the time of assessment . In the Both office systolic and diastolic blood pressure differed significantly among all three studied groups. Maximal blood pressure values were similar between the GH and CH group. Details are provided in In the normal pregnancy group, higher GWG was associated with higher office and maximal measurements of blood pressure  and 2.Cumulative analysis of HDP group showed no correlation between blood pressure control parameters and GWG and BMI gain nor with prepregnancy weight and BMI values .Correlations between blood pressure and weight: gestational and chronic hypertension group subanalysis Correlation analysis between blood pressure measurements and anthropometric parameters was calculated in both types of HDP. Interestingly, although there were no correlations present in the GH group, a correlation between GWG and both maximal systolic and maximal diastolic blood pressure values measured during pregnancy were found in the CH group. A similar correlation with BMI change was noticed . Details are shown in The present study is the first to demonstrate the different impact on blood pressure control of gestational weight gain in women with GH and CH. Additionally we observed that the higher the GWG is, the greater the blood pressure values are during normal pregnancy.Excess GWG is a major health concern affecting almost half of pregnant women . So far Presented results show that greater GWG up to the third trimester of pregnancy correlates with higher office and maximal blood pressure measurements. This finding is in line with evidence from the literature. In a study of 158 healthy pregnant women, GWG in the second and third tertiles resulted in lack of mid-trimester drop in systolic and diastolic blood pressure . MacdonaDespite those findings there are no clinical recommendations regarding more screening, for example with ambulatory blood pressure monitoring, in women with excessive gestational weight gain for early diagnosis of HDP.Excessive gestational weight gain, especially in early pregnancy, is recognised as a risk factor for GH, even independently of obesity prior to pregnancy . AdditioIn our study there was a positive correlation between GWG and maximal systolic and diastolic blood pressure values during pregnancy, suggesting that it might be one of the parameters influencing blood pressure control. We did not observe correlation between GWG and measurement results obtained in the office, probably as a result of proper hypotensive treatment throughout further pregnancy.No data on influence of GWG on blood pressure profile control in pregnant women with chronic hypertension were found. However, it is known that higher than recommended GWG increases maternal, obstetric and neonatal risks in this subgroup . ExcessiIn the third trimester of a normal pregnancy, a greater GWG is related to higher blood pressure values. Despite that in women with hypertensive disorders in pregnancy such dependency was not observed, a separate analysis revealed that greater weight gain in women with CH is related to higher maximal values of systolic and diastolic blood pressure. These observations underline pathophysiological differences between CH and GH. The GWG has similar influence on blood pressure in normal pregnancy and in women with CH during pregnancy, but not in women with a diagnosis of GH. This study highlights the need for further assessment of GWG and blood pressure profiles in pregnancy.There are several limitations of our study. First, a small number of cases for particular subtypes of the HDP group was included. Second, we did not analyse the influence of GWG on pregnancy complications in the studied patients. Third, a 24-h ambulatory blood pressure monitoring was not performed as a part of the study protocol, which would have provided more averaged values of the measurements. And finally, the impact of treatment with antihypertensive medications was not evaluated.orcid.org/0000-0003-3761-1924)Tomasz Mikołaj Maciejewski 0000-0003-3761-1924 (https:// https://orcid.org/0000-0002-4921-4726)Ewa Szczerba 0000-0002-4921-4726 (https://orcid.org/0000-0002-6664-9705)Agnieszka Zajkowska 0000-0002-6664-9705 (https://orcid.org/0000-0001-7756-1963)Katarzyna Pankiewicz 0000-0001-7756-1963 († 0000-0002-8773-0908 (https://orcid.org/0000-0002-8773-0908)Anna Bochowiczhttps://orcid.org/0000-0003-4143-2777)Grzegorz Szewczyk 0000-0003-4143-2777 (https://orcid.org/0000-0003-4744-2554)Grzegorz Opolski 0000-0003-4744-2554 (https://orcid.org/0000-0002-7078-4918)Maciej Małecki 0000-0002-7078-4918 (https://orcid.org/0000-0002-2225-9684)Anna Fijałkowska 0000-0002-2225-9684 (Tomasz Mikołaj Maciejewski: Conceptualisation, methodology, investigation, data curation, supervision, project administration, visualisation, writing – original draft, writing – review & editingEwa Szczerba: Conceptualisation, methodology, investigation, resources, data curation, formal analysis, visualisation, funding acquisition, writing – original draft, writing – review & editingAgnieszka Zajkowska: Conceptualisation, investigation, resources, data curation, formal analysis, writing – review & editingKatarzyna Pankiewicz: Data curation, investigation, resources, writing – review & editingAnna Bochowicz: Data curation, methodology, investigation, resources, supervisionGrzegorz Szewczyk: Data curation, investigation, resources, supervision, writing – review & editingGrzegorz Opolski: Conceptualisation, methodology, supervision, writing – review & editingMaciej Małecki: Conceptualisation, methodology, project administration, supervision, writing – review & editingAnna Fijałkowska: Conceptualisation, methodology, investigation, resources, data curation, formal analysis, visualisation, supervision, project administration, funding acquisition, writing – review & editing