Citations

Background: Supine hypertension, or elevated blood pressure while lying down, is often underrecognized in clinical settings. Though more common in older adults and those with autonomic dysfunction, its long-term cardiovascular impact remains unclear. Growing evidence suggests it may contribute to higher risks of cardiovascular disease (CVD), stroke, heart failure, and mortality. Methods: A meta-analysis evaluated the association between supine hypertension and primary cardiovascular outcomes were searched using standard electronic databases. MeSh term including “supine hypertension” and “cardiovascular outcomes” were used for Search. Studies reporting hazard ratios for CVD events, stroke, heart failure, cardiovascular, and all-cause mortality were included. Random-effect models were used for pooled analysis, with heterogeneity assessed using the I2 statistic and p value <0.05 considered significant. Results: A total of 13 studies were included in the analysis, comprising a combined study population of 241,765 individuals with a mean age of 59 years and follow up for 12.4 years. Cardiovascular Events: Six studies showed a significant association between supine hypertension and increased CVD events (HR = 1.41, 95% CI: 1.28–1.55, p<0.05). Cardiovascular Mortality: Five studies indicated elevated supine systolic BP was linked to higher cardiovascular mortality (HR = 1.57, 95% CI: 1.40–1.75, p<0.05). Heart Failure: Three studies demonstrated a strong, consistent association between supine hypertension and heart failure (HR = 1.83, 95% CI: 1.72–1.95, p<0.05). Mortality: Eight studies showed a modest but significant increase in all-cause mortality (HR = 1.23, 95% CI: 1.02–1.45, p<0.05). Stroke: Three studies revealed significantly increased stroke risk in individuals with supine hypertension versus standing hypotension (HR = 1.69, 95% CI: 1.41–1.97, p<0.05). Conclusion: Supine hypertension was significantly associated with increased risks of CVD events, cardiovascular mortality, stroke, heart failure, and all-cause mortality. These findings highlight the need to consider supine blood pressure patterns in clinical evaluations to improve risk detection and guide preventive care strategies.

Background: Hypertension is a major contributor to global cardiovascular morbidity and mortality. Despite a wide range of pharmacologic treatments, many patients continue to have uncontrolled blood pressure. Recent research highlights the gut microbiota as a modifiable factor in blood pressure regulation through mechanisms involving systemic inflammation, microbial metabolites such as short-chain fatty acids, and angiotensin-converting enzyme modulation. Probiotic and prebiotic supplementation has gained interest as an adjunct strategy, yet existing reviews are limited in scope and often lack robust subgroup analysis. Objective: To systematically evaluate the effect of probiotic and prebiotic supplementation on blood pressure in adults with hypertension or elevated blood pressure, with an emphasis on gut microbiota modulation. Methods: We conducted a systematic search of PubMed, Scopus, Cochrane CENTRAL, and ScienceDirect for articles published from May 1, 2015, to April 30, 2025. ClinicalTrials.gov and PROSPERO were also searched. Eligible studies were randomized controlled trials in English involving adults 19-44 years with hypertension or pre-hypertension, comparing probiotic or prebiotic interventions with placebo, no treatment, or standard care. The primary outcome were changes in systolic and diastolic blood pressure; secondary outcomes included gut microbiota composition, inflammatory markers, endothelial function, and adverse effects. Two independent reviewers screened studies and assessed quality using the Cochrane Risk of Bias Tool 2.0. Results: Of 601 records screened, 23 trials met inclusion criteria. Most studies showed modest reductions in systolic and diastolic blood pressure with probiotic or prebiotic use. Mechanistic insights included improved gut barrier integrity, reduced inflammation, and increased beneficial metabolites. Subgroup analyses suggested efficacy varied by strain type, dosage, duration, and delivery method. Secondary outcomes showed improvements in lipid profiles, insulin resistance, and abundance of Bifidobacterium. Conclusion: Modulation of gut microbiota shows potential as an adjunct approach in managing hypertension.. While short-term benefits are observed, variability across studies limits generalizability. Larger trials with standardized methods are needed to confirm long-term clinical relevance. Keywords: Hypertension, Blood Pressure, Gut Microbiota, Probiotics, Prebiotics, Randomized Controlled Trials, Systematic Review

Background: Early detection and prediction of arterial hypertension (HTN) are vital to reduce cardiovascular morbidity and mortality. AI has enhanced ECG diagnostic capabilities, enabling detection of latent cardiovascular abnormalities. Aims: This systematic review evaluates current evidence on AI-enhanced ECG for detection and prediction of HTN in in both clinical and subclinical populations. Methods: A search was conducted on April 28, 2025, in PubMed, Scopus, and Web of Science. Gray literature and study reference lists, plus the first 10 pages of Google Scholar, were screened. The review followed PRISMA 2020 guidelines. Bias risk was assessed using PROBAST (for prediction models) and QUADAS-2 (for diagnostic studies). Two reviewers independently performed study selection and data extraction after pilot training. Results: A total of 26 studies were included: 16 focused on detection and 10 on prediction of HTN using AI-enhanced ECG. Overall, 96% reported successful outcomes, underscoring the strong diagnostic and prognostic potential of this approach. Among detection studies, 94% successfully identified hypertensive individuals, classified blood pressure (BP) levels, or evaluated cardiovascular risk. Most were retrospective in design (75%), with internal validation in 44% and external validation in 19%. Sample sizes ranged from 100 to over 120,000, including healthy and cardiovascular patients. Commonly used algorithms included deep Learning, random forest, and ensemble methods, often using single-lead ECG data, highlighting the feasibility of wearable technologies. QUADAS-2 identified 56% of studies had low risk of bias. All prediction studies achieved accurate estimation of systolic/diastolic BP or predicted future HTN onset. Designs were 40% experimental and 50% retrospective. All studies reported internal validation, and 50% included external validation. AI models such as CNNs, ResNet-LSTM, and U-Net were used across clinical and community-based populations, with follow-up periods of up to 6.8 years. Populations were predominantly normotensive or mixed. PROBAST assessments showed 60% low and 40% moderate risk of bias. Conclusion: AI-enhanced ECG is a promising, non-invasive tool for early detection and prediction of HTN. However, external validation and clinical trials are needed to support integration and generalizability.

Abstract Aims Endogenous endophthalmitis (EE) is a rarely reported complication of infective endocarditis (IE). In an international series, we sought to determine the clinical and microbiological profile, treatment, and outcome of patients presenting with IE-related EE. Methods and results Cases recorded from 2014 to 2023 in nine centres in Europe and the United States were collected. Results were compared to a matched control group. Conclusion Sixty-six patients with EE were reported, mean age of 65.2 ± 14.9 years, 71% (n = 47) male. Blood cultures were positive in 97% (64 cases) of patients, with a predominance of streptococci (46%, n = 30). As compared with the control group (n = 264), the EE group presented with more frequent diabetes (35% vs. 21%, P = 0.02), history of cirrhosis (9% vs. 3%, P = 0.04), glomerulonephritis (15% vs. 0.4%, P &lt; 0.001), embolism before admission (92% vs. 55%, P &lt; 0.001), and Janeway lesions (9% vs. 1%, P = 0.002). Streptococcal infection (46% vs. 26%, P = 0.001) was more frequent and Enterococcal infection (0% vs. 18%, P &lt; 0.001) less frequent in the EE group. The main ocular symptoms were a decrease in visual acuity (96%), red eye (55%), and ocular pain (55%). Treatment of EE consisted of intravitreal antibiotic injection in 55 (83%) patients and vitrectomy in 17 (26%). Improvement of visual acuity was observed in 36 (55%) patients. Conclusion EE is a serious complication of IE with severe residual vision impairment. Patients with IE should be evaluated for ocular complications, since early detection of EE is crucial to prevent delays in management and to preserve visual function.

Abstract Toxicology testing for drugs associated with scenarios such as recreational use or substance use disorder can be performed in support of the emergency department (ED) for specific patient populations such as pediatrics and trauma. These compounds were historically referred to as drugs of abuse (DOA); although the word “abuse” is recognized as potentially stigmatizing, no replacement terminology for DOA has emerged in current guidelines. This document refers to these compounds as drugs or substances of misuse, and acknowledges the need for less-stigmatizing language that more fully encompasses the range of uses for these drugs. This literature-driven, consensus guidance document provides recommendations primarily targeted to US hospital-based laboratories performing urine drug testing (UDT) in support of the ED. Indications for ordering UDT and related testing in both pediatric and adult populations are summarized. Further, recommendations are made for testing that should be available at all facilities with rapid turnaround, and how to perform and report testing. The advantages and disadvantages of immunoassays and mass spectrometry, as well as common challenges, are reviewed. Indications for mass-spectrometry assays and more extensive testing (e.g., novel psychoactive substances) are also provided. Future directions for improvements in laboratory technology to improve the utility of this testing are outlined. All laboratories should collaborate with ED leadership, medical toxicologists and poison control centers to optimize and update test menus to reflect local drug use patterns, ensure test methodologies and results meet clinical needs, and educate clinical staff regarding assay limitations and accurate test interpretation.

Abstract Few medical decisions have a greater impact on the life of patients affected by either long QT syndrome (LQTS) or catecholaminergic polymorphic ventricular tachycardia (CPVT) as the one to recommend an implantable cardioverter defibrillator (ICD) or not. If the decision is correct, a life might be saved or a litany of ICD-related complications might be avoided. If it is wrong, well you can fill in the blanks. Many physicians take the fastest and simplest road by recommending an ICD which represents ‘double protection’: for the patients and for themselves. Our opinion is that this requires a very careful consideration about the pros and cons and should be taken neither lightly nor quickly. Moreover, there is another side to this moon, which also requires more thought than usually assumed. As to LQTS and CPVT, the current data strongly indicate that when high risk patients are treated with either combination drug therapy comprising beta blockers and mexiletine (LQTS) or beta blockers and flecainide (CPVT) or triple therapy with left cardiac sympathetic denervation as the treatment intensifier, mortality is close to zero and most patients have no life-threatening events. Thus, we stand by our view that most patients still do not need and should not receive an ICD. However, sometimes patients are desperately worried for the fear of dying suddenly and ask for an ICD despite being at low risk. Their request should be listened to, respected, and considered with empathy because immortality cannot be guaranteed. We believe that both expertise and compassion are quintessential to practicing the science and art of medicine.

Background: In younger patients (<60 years) with cryptogenic stroke (CS) presumed to be patent foramen ovale (PFO)-related, the standard approach involves transcatheter PFO closure combined with antithrombotic therapy. However, due to their exclusion from randomized clinical trials (RCTs), no formal recommendations exist for patients ⩾60 years. This study had two objectives (1) to compare the efficacy and safety of PFO closure versus antithrombotic therapy alone (ATA) exclusively in older patients (⩾60 years) and (2) to assess the outcomes of PFO closure in patients ⩾ 60 years versus < 60 years. Methods: We searched PubMed, Embase, Web of Science, and ScienceDirect databases to obtain articles in all languages from January 2004 until July 2025. The primary outcome was risk of recurrent stroke during follow-up. Secondary outcomes were risk of new-onset atrial fibrillation (AF), all-cause mortality, and in-hospital complications. PROSPERO registration ID: CRD420250652870. Results: Only one RCT (post hoc evaluation of the DEFENSE-PFO trial) and 11 observational studies were included. In patients aged ⩾ 60 years, risk of recurrent stroke was lower when PFO was closed compared with ATA (5.48% vs 10.05%, respectively, hazard ratio (HR) = 0.56, 95% confidence interval (CI) = 0.45–0.80, p < 0.001, I 2 = 45.6%). All-cause mortality was also lower for PFO closure versus ATA (1.73% vs 7.59%, respectively, HR = 0.41; 95% CI = 0.19–0.90, p = 0.02; I 2 = 43.8%). There was no difference between PFO closure and ATA in risk of new-onset AF (HR = 1.13, 95% CI = 0.53–2.44, p = 0.74). Compared with patients < 60 years, individuals ⩾ 60 years who underwent PFO closure had a higher risk of recurrent stroke (2.94% vs 1.04%, respectively, HR = 3.47; 95% CI = 1.61–7.48; p = 0.001), new-onset AF (4.86% vs 1.01%, respectively, HR = 4.12; 95% CI = 1.90–8.95; p < 0.001), and all-cause mortality during follow-up (8.32% vs 0.39%, respectively, HR = 8.24; 95% CI = 3.49–19.46; p < 0.0001). In-hospital complications after PFO closure were comparable between two age groups. Due to insufficient data, we were not able to perform a subgroup analysis based on anatomic features of PFO, antithrombotic regimen, or occluder devices. Conclusion: Based on available data, which is predominantly derived from observational studies, PFO closure is associated with a reduced risk of recurrent stroke compared to ATA in patients over 60 years. However, these findings are subjected to limitations, including the potential for selection bias, unmeasured confounding, and insufficient long-term follow-up. Furthermore, long-term randomized trials are essential to definitively confirm efficacy and establish clinical guidelines for PFO closure in this older population.