Aluminum phosphide (ALP), also known in Iran as rice tablets, is one of the most effective rodenticides used to protect stored grain. However, ALP poisoning regularly causes mortality in humans. The aim of this study was to evaluate the characteristics and predictive factors of mortality from ALP poisoning.3 levels, and PCO2 . Differences between the survivors and non-survivors of ALP poisoning were analyzed using univariate logistic regression and multivariate analysis.This study evaluated all patients with ALP poisoning referred to Imam Khomeini Hospital in Kermanshah Province, Iran from 2014 to 2015. For each patient, the following information was recorded: age, sex, the number of tablets consumed, the number of suicide attempts, the time elapsed from consumption to treatment, blood pressure, blood pH, HCOIn this study, 48 patients were male and 29 patients were female . The average age of the survivors and non-survivors was 28.7 and 31.3 years, respectively. All cases (100%) of ALP poisoning were intentional, with the goal of committing suicide. The main predictive variables of mortality from ALP poisoning were blood pressure, blood pH, and time elapsed from consumption to treatment.The likelihood of mortality in patients with ALP poisoning can be predicted using blood pressure, blood pH, and time elapsed from consumption to treatment. These findings may help healthcare providers take more effective measures to treat patients with ALP poisoning. Poisoning is one of the main causes of disability and death throughout the world. Poisoning has been reported to account for 1.0-2.0 and 1.3% of deaths in developed countries and Iran, respectively . ALP is The symptoms of poisoning start within a few minutes after ingestion, after phosphine gas is released through the contact of the ALP tablet with stomach acid. ALP poisoning has several distinct symptoms, including vomiting, abdominal pain, agitation, tachycardia, tachypnea, acidosis, and hypotension. The clinical course of ALP poisoning starts with nausea and vomiting and proceeds to multi-organ failure and death within 24 to 48 hours after poisoning ,17. The ALP poisoning most commonly occurs intentionally, with the goal of committing suicide, although some accidental cases of ALP poisoning occur through occupational exposure, and in rare cases, ALP poisoning is committed with criminal intentions. Most poisoning cases occur in young adults (20-30 years). Various factors affect the extent of ALP poisoning, including social, geographical, and psychological status and the availability of ALP .In studies that compared poisoning in different parts of Iran, it has been shown that poisoning with ALP accounted for between 25 and 45% of all poisoning cases ,20. In aThere is a high risk of death from ALP poisoning in Kermanshah Province because of its farmland and abundant grain production, which imply that rice tablets are abundantly available. Factors predicting mortality from ALP poisoning have not been investigated in any studies, and our hypothesis was that some factors, such as blood pH and blood pressure, could predict mortality in patients with ALP poisoning. Therefore, it was necessary to investigate the characteristics and predictive factors of mortality from ALP poisoning.3 levels, blood pH, and PCO2 at admission and after full recovery (or death) were gathered using a checklist. The patients at this center received the standard treatment for ALP poisoning applied by most medical centers in Iran  about the patient’s age, sex, the number of tablets consumed, the number of suicide attempts, and the time elapsed from consumption to treatment. Blood pressure, serum HCO in Iran , includiThe data were categorized as quantitative or qualitative. Patients were classified according to systolic blood pressure (SBP). Patients with a SBP of at least 90 mmHg were considered not to be in shock, while those with a SBP less than 90 mmHg were considered to be in shock. Variables with an abnormal and highly skewed distribution were used as qualitative inputs into the logistic regression analysis. In the univariate analysis method, each variable was separately entered into the regression table. In the multivariate analysis method, first, all variables were analyzed in the logistic regression analysis using the backward stepwise and forward stepwise methods, and then the variables with a p< 0.2 from the univariate analysis were included in the multivariate analysis using those 2 methods. SPSS version 16  was used for the statistical analysis.This study was received permission from the ethics committee of the university .Seventy-seven patients had ALP poisoning. The average age of the survivors and non-survivors was 28.7 and 31.3 years, respectively. The oldest and youngest cases of poisoning were 68.0 and 16.0 years old, respectively. Twenty-nine patients (37.7%) were female and 48 (62.3%) were male. All cases of ALP poisoning (100.0%) were suicide attempts . Forty-one patients were not in shock, while 36 patients were in shock. The majority of patients (61.0%) had vomited.3 level was 19.1± 4.8 and 12.0± 3.8 mEq/L, and the average PCO2 was 32.8± 8.4 and 33.8± 13.7 mmHg in the survivors and nonsurvivors, respectively. More details are presented in The average values of the studied variables for the survivors and non-survivors were as follows: the number of tablets consumed was 1.7 ± 1.0 and 2.6 ± 1.9, the time elapsed from consumption to treatment was 1.3± 0.7 and 2.0± 1.4 hours, the number of suicide attempts was 1.1± 0.3 and 1.2± 0.8 times, the average blood pH was 7.4± 0.1 and 7.1± 0.2, the average serum HCO3 (p< 0.05). Additionally, the variable of time elapsed from consumption to treatment had a p< 0.2, and was therefore also entered into the multivariate analysis. More details are presented in The univariate analysis found that mortality had a statistically significant relationship with clinical signs, the number of tablets consumed, having vomited, and serum HCOIn the multivariate logistic regression, the backward stepwise and forward stepwise methods led to the same results, both with all variables and when limited to variables with p< 0.2 in the univariate analysis .The multivariate analysis showed that blood pressure, pH, and time elapsed from consumption to treatment were the most important predictive variables of mortality from ALP poisoning. Blood pressure predicted approximately 59.4% of mortality in cases of poisoning. The combination of blood pressure and blood pH predicted 71.5% of mortality. The combination of blood pressure, blood pH, and time elapsed from consumption to treatment predicted almost 77.3% of mortality in cases of ALP poisoning .This cross-sectional study investigated the characteristics and predictive factors of mortality from ALP. All cases of ALP poisoning from 2014 to 2015 were referred to the Imam Khomeini Hospital, which is the only referral center for poisonings in Kermanshah Province, and were included in this study. Blood pressure, blood pH, and time elapsed from consumption to treatment were found to be the most important determinants of death in these individuals.The aim of this study was to determine the factors predicting mortality from ALP poisoning. The average age of the survivors and non-survivors of ALP poisoning was 28.7 and 31.3 years, respectively. Taramsary et al.  similarl3 level was 19.1± 4.8 and 12.0± 3.8 mEq/L for survivors and non-survivors, respectively. Mehrpour et al. [In this study, most of the reported cases of ALP poisoning were in male patients, consistent with the studies of Khodabandeh et al.  and Sahar et al.  reported3 level (p< 0.05), and time elapsed from consumption to treatment (p< 0.2) based on univariate logistic regression. Multivariate logistic regression showed that blood pressure alone could predict roughly 60% of mortality in the poisoned patients. Furthermore, 71.5 and 77.3% of mortality was predicted by using combinations of 2 (blood pressure and blood pH) and 3  variables, respectively. Similarly, Rahbar Taramsary et al. [3 levels. They showed that the mortality rate of ALP poisoning was higher in patients with a blood pressure below 90 mmHg, a blood pH < 7.2, or an HCO3 level<15.0, who took over half of a rice tablet, or for whom more than half an hour elapsed from consumption to treatment.The mortality rate from ALP poisoning showed a statistically significant relationship with variables including blood pressure, the number of tablets consumed, having vomited, the pH level, the HCOy et al.  showed tThe results of the multivariate analysis indicated that the likelihood of dying increased by about 59 and 12 times if patient was in shock or had experienced an elapsed time of more than 1 hour to reach treatment after ALP poisoning, respectively. Moreover, the likelihood of dying decreased by about two times with each unit (1 mmHg) increase in blood pH. Therefore, accelerating the transport of poisoned individuals to treatment centers, followed by careful attention to blood pressure and blood pH at the time of treatment, would be expected to reduce the risk of mortality in cases of ALP poisoning.One of the strengths of this study is that all cases of ALP in Kermanshah Province during the study period were evaluated, meaning that this study has good generalizability. Furthermore, appropriate analytical methods were used in this study, unlike similar studies in this field.The main limitation of this study is that some of the variables were measured indirectly , but since this issue occurred to the same extent for all cases, any resulting information bias is expected to be non-differential regarding outcomes.The results of this study showed that mortality can be predicted in patients with ALP poisoning based on their blood pressure, blood pH, and time elapsed from consumption to treatment. These findings may help healthcare providers take more effective measures to treat patients with ALP poisoning.


The Korean Society of Hypertension guideline defines hypertension as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, where the effectiveness of pharmacological treatment has been established. It is confirmed that higher blood pressure levels are associated with increased risk of cardiovascular disease and mortality also in the Korean population. About one third of Korean adults aged 30 years or older are estimated to have hypertension, and the prevalence of hypertension gradually increases as the age increases. The awareness, treatment, and control rates of hypertension are generally improving in Korea, but more efforts are required to increase awareness and treatment among younger patients with hypertension and to improve lifestyle modification compliance at all ages. More studies are required to determine the magnitude and impact of white coat hypertension and masked hypertension in the Korean population. This guideline defines ‘hypertension (HTN)’ as a blood pressure (BP) above the threshold value for which the effectiveness of pharmacological treatment has been proved by randomized clinical trials and also classifies BP values lower than the threshold value based on cardiovascular (CV) risk for using lifestyle modifications to lower BP and prevent HTN. Therefore, based on the available evidence from clinical trials, HTN is defined as systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. HTN is further classified into grade 1 and grade 2 HTN depending on the higher SBP or DBP value. ‘Normal BP’ is defined only as both SBP below 120 mmHg and DBP below 80 mmHg. Normal BP defines the optimal condition with the lowest CV risk and is used as a reference when assessing the risks of higher BP . In. In12]. It is known that reducing salt intake can lower BP. The daily intake of salt in Koreans is estimated to be over 10 g, so it is important to reduce salt intake to prevent HTN . AccordiUsing the criteria for abdominal obesity as a waist circumference of greater than 90 cm for men and 80 cm for women, the prevalence of metabolic syndrome was 24.1% in the 1998–2005 KNHANES . Among tIt is important to monitor the rates of awareness, treatment, and control of HTN, as these are the key indicators of the quality of HTN management. The awareness rate is defined as the proportion of the subjects who are aware of their physician-diagnosed HTN among all of the subjects with HTN. The treatment rate is defined as the proportion of the subjects taking antihypertensive drugs at the time of the survey among all of the subjects with HTN. The control rate is defined as the proportion of the subjects with SBP/DBP controlled below 140/90 mmHg among the subjects taking antihypertensive drugs or among all subjects with HTN.The awareness, treatment, and control rates of hypertension in South Korea are generally improving. According to the data from KNHANES, the awareness rate among HTN patients aged 30 years or older increased from 25% in 1998 to 65% in 2016. The treatment rate also improved significantly from 22% in 1998 to 61% in 2016. During the same period, the control rate increased from 5 to 44% among all patients with HTN, and from 24 to 71% among patients taking antihypertensive drugs  was only 38.2% among patients with HTN aged 40 years or older. More efforts are required to improve lifestyle modification compliance.‘White coat HTN’ is diagnosed when the patient’s BP in the doctor’s office is 140/90 mmHg or above but the daytime ambulatory BP or home BP is less than 135/85 mmHg. If the BP is high both in and out of the office, the patient is considered to have persistent HTN. According to the registry data for ambulatory BP monitoring (ABPM) in secondary or tertiary referral centers supported by the Korean Society of Hypertension (KorABP registry), 14.9% of 1916 subjects who underwent ABPM for the diagnosis of HTN were found to have white coat HTN. In a single-center study from a domestic tertiary hospital, white coat HTN occurred more frequently in women and in men with a low body mass index (BMI) . Accordi‘Masked HTN’ is defined as the condition in which the office BP is less than 140/90 mmHg and the daytime ambulatory BP or home BP is 135/85 mmHg or higher. According to the KorABP registry data, masked HTN was observed in 17.6% of patients who underwent ABPM for the diagnosis of HTN. Masked HTN was also observed in 13.8% of patients taking antihypertensive medication and in 35.1% of subjects with controlled office BP .. In a KThere is no available data on white coat HTN and masked HTN in the general Korean population. According to data from other countries, patients with white coat HTN have a relatively good short-term clinical course. However, white coat HTN can develop into persistent HTN and increase the risk of CVD in the long-term, therefore, patients with white coat HTN should be monitored regularly . In fore


The aim of present study was to determine the safety and efficacy of a new renal artery denervation system for treatment of hypertensive patients. Hypertensive patients with mean office systolic blood pressure ≥150mmHg and ≤180mmHg or an average of 24-hour ambulatory systolic blood pressure ≥145mmHg and ≤170mmHg after stopping hypertensive medications for 2 weeks or more were enrolled to undergo renal denervation (RDN) using a new RDN system. Changes in office blood pressure and mean 24-hour ambulatory blood pressure and safety were assessed after 6 months. Fifteen patients underwent RDN and followed up for 6 months. At the 6-month follow-up, office systolic blood pressure decreased 11.5±9.9mmHg (P<0.01) and office diastolic blood pressure decreased 6.9±4.8mmHg (P<0.01); mean 24-hour ambulatory systolic blood pressure decreased 7.5±7.7mmHg (P<0.05) and mean 24-hour diastolic blood pressure decreased 3.3±4.7mmHg (P>0.05) compared to baseline values. There were no serious RDN-related adverse events during follow-up.ChiCTR1800017815. Our results demonstrate that the new RDN system is safe and could significantly reduce blood pressure in hypertensive patients in the absence of antihypertensive medications. This trial is registered with  Hyperactivity of the sympathetic nervous system contributes an important role in the pathophysiology of hypertension. Renal denervation (RDN) is a new interventional treatment for resistant hypertension in recent years –4. RecenChiCTR1800017814. All enrolled patients signed informed consent.Inclusion criteria are (1) age >18 and ≤75 years; (2) mean office systolic blood pressure ≥150mmHg and ≤180mmHg; or an average of 24-hour ambulatory systolic blood pressure ≥145mmHg and ≤170mmHg after stopping hypertensive medications for 2 weeks or more; (3) renal artery length ≥20mm. Exclusion criteria are (1) secondary hypertension; (2) glomerular filtration rate(GFR) <40mL/min; (3) unilateral or bilateral renal artery anatomy; (4) office SBP >180mmHg and/or diastolic blood pressure >110 mmHg after stopping hypertensive medication during the enrollment period. The study was approved by the Zhongda Hospital Ethics Committee of Southeast University . NCT no. is RDN was performed by using the newly developed RDN system (GL-06E15WA ablator and GL-6W ablation catheter) developed by Shanghai Golden Leaf Medtech Company, Shanghai, China. The major features of this RND system are as follows: this system is easy to handle and supplies a 360° circular ablation with 6 electrodes, without affecting renal artery blood flow and the impact of respiratory movement on ablation is minimal. RDN procedure was performed as previously described . PatientStudy Endpoints. Mean office blood pressure and 24-hour ambulatory blood pressure, remote blood pressure monitoring data, and complications at 6 months were followed up. Safety: the occurrence of study-related adverse events during the trial, especially renal function indicators and renal artery complications. Adverse events or serious adverse events that may occur during or after the procedure: renal artery stenosis, renal artery dissection, thromboembolism, artery puncture site complications, arteriovenous fistula, sepsis, and other possible adverse reactions during the period [The continuous data were expressed as mean±standard deviation. Differences from baseline to the 6-month follow-up assessment were tested with the use of paired t-tests. P <0.05 was considered as statistically significant.A total of 15 patients  underwent RDN and all finished the 6-month follow-up. The mean age was 39.0±7.0 years, average heart rate was 70±2.6 beats/min, and the average GFR was 127.8±24.5 mL/min.The office systolic blood pressure was 158.2±6.4mmHg at baseline, 146.7±11.6mmHg at 6 months after RDN. The office diastolic blood pressure was 100.3±8.8mmHg at baseline and 93.4±7.2mmHg at 6 months after RDN. Office systolic blood pressure decreased 11.5±9.9mmHg (P<0.01) and diastolic blood pressure decreased 6.9±4.8mmHg (P<0.01) at 6 months post RDN compared to baseline levels .The mean 24-hour ambulatory systolic blood pressure was 154.5±10.7mmHg at baseline and 147.0±12.0 at 6 months after RDN . The mean 24-hour ambulatory diastolic blood pressure at baseline was 97.5±8.1mmHg and 94.2±9.2 mmHg at 6 months after RDN .Renal function and the average heart rate were similar between baseline and 6-month follow-up. No complications such as renal artery stenosis and renal artery dissection were observed during the 6-month follow-up in this patient cohort.RDN is an interventional method used for the treatment of refractory hypertension, but the real world and clinical trial efficacy remains controversial. The study of SIMPLICITY HTN-1 and simplicity HTN-2 using SIMPLICITY™ catheter ablation showed that RDN is safe and effective for refractory hypertension, 7, but The Symplicity™ catheter system is a widely used RDN system in clinical practice now, but this system has several limitations: (1) the catheter has only one electrode, which leads to long ablation time; (2) the selection of vascular ablation site by unipolar electrode is relatively difficult; (3) it is difficult to ablate deep renal sympathetic nerve, since this catheter only possesses low radio frequency power and limited penetration depth. So these deficiencies are likely to be responsible for the uncertainty of clinical trial results. In order to solve the core problem of RND, the latest SPYRAL HTN-OFF MED study used a different innovative Symplicity Spyral multielectrode catheter, which has 4 electrodes, and can ablate 4 locations at the same time from different locations, and preliminary results showed that RDN with this catheter can significantly reduce blood pressure in hypertensive patients in the absence of antihypertensive medications , 14.The RDN in our study is achieved through a 6-point reticular electrodes catheter ablation system, which is simple in operation and easy to locate due to the 360° annular ablation design. Its basket-shaped design also guaranteed the impact on renal arterial blood flow, and it was suitable for ablating vessels with different morphologies and sizes. The real time impedance measurement function and temperature monitoring function during RDN procedure are also available to assist the operator to control the efficacy and quality of RDN process .In conclusion, our preliminary study results show that the new RDN system used in this study is safe and can effectively reduce the blood pressure in primary hypertensive patients in the absence of antihypertensive medication.


IntroductionPatients with congestive heart failure (CHF) readily present with electrolyte imbalance which commonly includes deficiencies of sodium, potassium, and magnesium. Hyponatremia occurs in advanced stages of CHF and is associated with adverse disease outcome-longer hospital stay, severity of CHF, and increased risk of mortality.MethodsIn this observational, single-center, prospective, case-control study adult patients admitted with clinical diagnosis of CHF were included after informed consent. Their demographic, clinical, and biochemical profile was attained. Patients with low serum sodium (hyponatremia) were grouped as "cases" and patients with normal serum sodium profile (normonatremia) were grouped as "controls". Factors associated with both groups and their hospital outcome were compared. SPSS for Windows version 16  was utilized.ResultsHyponatremia (serum sodium <135 mmol/L) was present in 58/189 (30.7%) patients admitted with CHF. Younger patients with non-ischemic CHF, and history of previous diagnosis, treatment, and hospitalization due to CHF were more likely to be affected. Diabetic nephropathy, chronic kidney disease, salt-restricted diet, drugs including furosemide, spironolactone, and angiotensin-converting enzyme inhibitors, low serum potassium, and reduced GFR were also related to hyponatremia. Hyponatremic CHF patients showed adverse hospital outcome on all parameters including higher death rate (12% vs. 0.8%), longer duration of hospital day, and deranged blood pressures and severe CHF at the time of discharge.ConclusionHyponatremic CHF patients are associated with prolonged hospital stay, more severe form of CHF, and deranged blood pressures. Overall, hyponatremia is an indirect clinical indicator of circulatory dysfunction and should guide a clinician for closer observation as outcomes could be poor. These patients also have higher in-hospital mortality risk. Congestive heart failure (CHF) is a clinical syndrome with functional as well as structural disruptions in the myocardium. In earlier stages, ventricular filling is preserved, however, as the disease progresses, there is impairment of ventricular filling (reduced ejection fraction). Myocardial ischemia remains the most common cause of CHF. Other causes include dysfunction of the pericardium, myocardium, endocardium, heart valves, or great vessels alone or in combination .Patients with CHF readily present with electrolyte imbalance both in the outpatient and the inpatient department. This may be due to activation of neurohumoral mechanism due to heart failure state  or it may occur as an unwanted effect of certain drugs such as diuretics, cardiac glycosides, and angiotensin-converting enzyme inhibitors (ACEi). The common electrolyte imbalance seen in these patients include deficiencies of sodium, potassium, and magnesium. Deficiencies of magnesium and potassium pose a serious risk of cardiac arrhythmias . HyponatReduced serum sodium concentrations have been associated with adverse disease outcome-longer hospital stay, severity of CHF on New York Heart Association (NYHA) functional class, predisposition to fall and fractures, and increased risk of mortality -4. The aThis observational, prospective, and case-control study was conducted in Civil Hospital located in Larkana, Pakistan. The study was conducted in the department of internal medicine from January to December 2018. The study was approved by the Institutional Review Board. In this study, patients of age ≥ 18 years, of both genders, admitted with the clinical diagnosis of CHF of all etiologies were included after attaining informed consent. CHF was diagnosed according to Framingham Criteria. Major criteria include paroxysmal nocturnal dyspnea or orthopnea, neck-vein distention, rales, cardiomegaly, acute pulmonary edema, S3 gallop, increased venous pressure >16 cm of water, circulation time ≥25 seconds, and hepatojugular reflux. Minor criteria include ankle edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion, vital capacity ↓ ⅓ from maximum, and tachycardia (rate of ≥ 120/min). Major or minor criterion includes weight loss ≥4.5 kg in 5 days in response to treatment. Two major criteria or one major and two minor criteria are needed for diagnosis of CHF [A semi-structured questionnaire was constructed for data collection. First section of the questionnaire included demographic, clinical, and biochemical characteristics. Demographic characteristics comprised of gender and age. Past medical history included co-morbidities, previous hospital admissions, and drug history. Thorough clinical examination was done for diagnosis of CHF. Severity of CHF was assessed using NYHA functional class .Relevant biochemical data comprised of serum creatinine, blood urea nitrogen, serum sodium, and serum potassium. Second part of the questionnaire was filled at the time of discharge to assess hospital outcome. It included alive/dead status, duration of hospital stay, blood pressure at the time of discharge, and CHF severity based on NYHA Classification.For the purpose of analysis, patients of serum sodium level (at the time of admission) <135 mmol/L (hyponatremia) were categorized as "cases" and patients with serum sodium 135-145 mmol/L (normonatremia) were grouped as "controls". Glomerular filtration rate (GFR) was calculated for all patients . All cliData were assessed for cleanliness, completeness, and consistency. It was then entered for analysis in SPSS for Windows version 16 . Continuous variables were presented as mean and standard deviation (SD). Categorical variables were presented as frequencies and percentages. For the purpose of analysis, data were divided into two categories based on serum sodium concentration (“≥135 mmol/L” and “<135 mmol/L”). Independent sample t-test was applied to find the correlation between continuous variables. Chi-square test was applied to correlate categorical variables. Risk was presented as odds ratio (ORs) and confidence interval (CI). P value ≤0.05 was taken as significant.In this study, 189 patients with CHF were included. There were more women than men (56.1% vs. 43.9%). The mean age of the study sample was 53 ± 7 years (range: 47-68 years). There were 72 (38.1%) referred from other smaller cities, 38 (20.1%) belonged to the outskirts of the city, and 98 (51.8%) patients were illiterate or only had primary education.In 46% patients, CHF was due to ischemia and in the remaining 54% patients, causes included hypertension , valvular disorders , dilated/restrictive cardiomyopathies , and others  had been previously diagnosed in 36%, treated in 30%, and 26% had been previously hospitalized due to HF. At the time of admission, all patients had dyspnea on exertion, 93.1% (n=176) had dyspnea on rest, 88.9% (n=168) had orthopnea, and 87.8% (n=166) had paroxysmal nocturnal dyspnea. A large majority of 89.9% (n=170) presented with Class IV NYHA and remaining with Class III HF. Mean serum potassium level of the study sample at the time of presentation was 4.56 ± 1.03 mmol/L, GFR was 96.5 ± 48.8 (mL/minute/1.73 m2), and serum sodium level was 132.25 ± 6.14 mmol/L/. There were 131 (69.3%) patients with serum sodium ≥135 mmol/L (normonatremia) and 58 (30.7%) patients with serum sodium <135 mmol/L (hyponatremia).Demographic and disease-related characteristics of the study samples categorized according to their serum sodium concentrations are shown in table Patients with hyponatremia showed adverse hospital outcome on all parameters as shown in table Being one of the most common electrolyte imbalance, hyponatremia is readily suspected in hospitalized patients with cardiological, neurological, and/or endocrinological diseases. CHF may be chronic, acute, or acute on chronic. Younger patients, with non-ischemic CHF, and history of previous diagnosis, treatment, and hospitalization due to CHF should be considered high risk for hyponatremia. Diabetic nephropathy, chronic kidney disease, salt-restricted diet, use of drugs including furosemide, spironolactone and ACEi, low serum potassium, and reduced GFR are also related to hyponatremia. These patients have adverse outcome including higher mortality rate and longer duration of the hospital day.Although this study is crucial in highlighting the importance of hyponatremia in CHF patients, it has its limitations too. It was a single-center study. Only at-discharge outcomes were analyzed and patients couldn’t be followed up to evaluate the long-term impact. The study also included patients with adverse renal function (diabetic nephropathy and chronic kidney disease patients) which may have caused biasness in the results. Most patients belonged to smaller cities or outskirts and were of low education status, hence, the results cannot be generalized to the entire population.CHF patients have been previously evaluated for hyponatremia in Pakistan -10. HypoHyponatremia was associated with 31% of patients presenting with CHF without any other clause. However, this finding must be interpreted closely as other variables such as medications, cause of the CHF, presence of diabetes, chronic and disease might alter the levels of sodium and hence the interpretation of this study. The incidence is slightly higher than that reported in the global data. Japanese Acute Decompensated Heart Failure Syndromes (ATTEND) Registry reported 11.6% hyponatremics, Korean heart failure Registry (KorHF) reported 18%, Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) reported 19.7%, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheter Effectiveness (ESCAPE) trial reported 24%, and Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) trial reported 27% hyponatremia .ATTEND Registry reported that there were fewer men in the hyponatremia group, they had more previous HF-related hospitalizations and higher rates of all-cause mortality as well as cardiac mortality . SimilarAt the time of discharge, the hyponatremic CHF patients in our study had significantly lower blood pressures as compared to the normonatremic group. These findings are strengthened by another study where hyponatremic patients were discharged at lower blood pressures. More hyponatremic patients belonged to NYHA class III-IV in their study and had a longer duration of hospital stay. The mortality rate was significantly less in the normonatremic group  . A similCHF patients should be readily monitored for electrolyte imbalance. These patients are frequently seen to have a deficiency of serum sodium which predisposes them to signs of agitation and irritation. Hyponatremia also affects the outcome of CHF patients. Hyponatremic CHF patients have prolonged hospital stay, a more severe form of CHF, and deranged blood pressures. As compared to normonatremic patients, hyponatremic CHF patients also have higher in-hospital mortality risk.


Ascites is a major complication of decompensated liver cirrhosis. Intraabdominal hypertension and structural alterations of parenchyma involve decisive changes in hepatosplanchnic blood flow. Clearance of indo-cyanine green (ICG) is mainly dependent on hepatic perfusion and hepatocellular function. As a consequence, plasma disappearance rate of ICG (ICG-PDR) is rated as a useful dynamic parameter of liver function. This study primarily evaluates the impact of large-volume paracentesis (LVP) on ICG-PDR in critically ill patients with decompensated cirrhosis. Additionally, it describes influences on intraabdominal pressure (IAP), abdominal perfusion pressure (APP), hepatic blood flow, hemodynamic and respiratory function.® Medical Systems; Maquet Getinge Group), and hepatic blood flow was analyzed by color-coded duplex sonography.We analyzed LVP in 22 patients with decompensated liver cirrhosis. ICG-PDR was assessed by using noninvasive LiMON technology (Pulsionp < 0.001). Concomitantly, we observed a raise in “ICG-Clearance” from 99 (73.5–124.5) to 104 (91–143.5) mL/min/m2 (p = 0.005), while circulating blood volume index was unchanged . Sonography revealed a significant impact of paracentesis on hepatic blood flow: Hepatic artery resistance index dropped from 0.74 (0.68–0.75) to 0.68 (0.65–0.71) (p < 0.001) and maximum flow velocity in hepatic vein increased from 24 (17–30) to 30 (22–36) cm/s (p < 0.001). Consistent with previous studies, paracentesis caused significant decreases in IAP from 19.0 (15.0–20.3) to 11.0 (8.8–12.3) mmHg (p < 0.001) and central venous pressure from 22.5 (17.8–29.0) to 17.5 (12.8–24.0) mmHg (p < 0.001) with inverse increases in APP from 63.0 (56.8–69.5) to 71.0 (65.5–78.5) mmHg (p < 0.001). Changes in ICG-PDR were concomitant with changes in IAP (r = − 0.602) and APP (r = 0.576). Moreover, we found a substantial improvement in respiratory function. By contrast, hemodynamic parameters assessed by transpulmonary thermodilution, serum bilirubin and international normalized ratio did not change after paracentesis.Paracentesis of a median volume of 3450 mL ascites evoked significant increases of ICG-PDR from 3.6 (2.8–4.6) to 5.1 (3.9–6.2)%/min (Critically ill patients with decompensated cirrhosis and elevated IAP showed dramatically impaired ICG-PDR. Paracentesis evoked an improvement in ICG-PDR in parallel with a decreased IAP and an increased APP, while conventional parameters of liver function did not change. This effect on ICG-PDR is mainly referable to a relief of intraabdominal hypertension and changes in hepatosplanchnic blood flow. Decompensated liver cirrhosis implies serious consequences for affected patients. Ascites is one major and highly frequently emerging complication , 2. IntrFurthermore, advanced cirrhosis is accompanied by structural alterations leading to increased intrahepatic vascular resistance , 12. ResFinally, end-stage liver disease is associated with progressive loss of functional liver capacity. Conventional laboratory assessment of liver function is mainly based on liver enzymes, bilirubin and the coagulation parameter international normalized ratio (INR) . DynamicThe accumulation of ascites is a typical complication of decompensated cirrhosis with elevated IAP and restricted organ perfusion , 10. TheThis observational study was approved by the institutional review board , and informed consent was obtained by all patients.Between April 2016 and July 2017, a total of 29 critically ill patients with decompensated liver cirrhosis on our university hospital general ICU were screened for the feasibility of LVP, analyses of ICG-PDR, IAP and hemodynamic monitoring via transpulmonary thermodilution. LVP was performed irrespective of the study based on the indication made by the treating ICU physician. We released a maximum of mobilizable ascites in each individual case of LVP; laboratory analyses of ascites revealed a cell count < 500/μL and polymorphonuclear neutrophils < 250/μL in every single patient. Due to potential influences on hepatosplanchnic blood flow, analysis was considered feasible only in patients without terlipressin treatment, portal vein thrombosis or transjugular intrahepatic portosystemic stent shunt. Therefore, 6 patients with terlipressin-treatment, 1 patient with portal vein thrombosis and 2 patients with portosystemic stent were restrained from the study. Finally, we analyzed a total of 22 critically ill patients with decompensated liver cirrhosis and tense ascites.® Medical Systems; Maquet Getinge Group) via a disposable finger color sensor as previously described [ICG-PDR, circulating blood volume index (BVI) and “ICG-Clearance” (CBI) were analyzed immediately before and after paracentesis by using noninvasive LiMON technology  were analyzed once a day—corresponding to current standard in our intensive care unit. Overall time interval between blood sampling was 24 h.LVP was performed ultrasound guided after bringing the patient in supine position . IAP wasdyn) and fraction of inspired oxygen (FiO2) were recorded at baseline and at the end of LVP. PaO2 and PaCO2 were derived from a fully automatic blood gas analysis device . Blood gas analysis and ventilatory parameters were used for calculation of Horowitz-index (PaO2/FiO2) and oxygenation index (OI = FiO2 * mean airway pressure * 100/PaO2) [Patients with spontaneous breathing received a demand-based application of oxygen. Mechanical ventilation was performed using the routine ventilator device EVITA XL of our ICU . Parameters were set according to current ARDSNet recommendations, especially regarding positive end-expiratory pressure (PEEP) . Ventila00/PaO2) .® Medical Systems; Maquet Getinge Group) inserted through a femoral artery and a hemodynamic monitor  served to derive and analyze the thermodilution curve after injection of a cold indicator bolus  through a jugular central venous catheter. Measurements were done in triplicate, averaged and automatically indexed according to manufacturer’s recommendations.With the exception of only a single subject, all patients were under hemodynamic monitoring irrespective of the study, by using transpulmonary thermodilution with the PiCCO-2-device  as described previously : A 5 Fr Transabdominal ultrasound examination was accomplished noninvasively at the bedside in a supine position of the patients. All analyses were performed by a single physician with 6 years of institutional experience in the field of abdominal ultrasound. We used the mobile ultrasound scanner ACUSON X300  and a convex 3.5 MHz transducer with color Doppler capacity. The transducer was placed in the right intercostal space due to the intraabdominal fluid accumulation. Doppler-analyses of blood flow were performed of the portal vein, hepatic artery and right hepatic vein; middle hepatic vein was chosen only when analysis of right hepatic vein was insufficient .Clinical and laboratory parameters for the calculation of APACHE II-, SOFA-, MELD- and Child–Pugh scores were recorded on the day of paracentesis. Measurements of ICG-PDR, BVI and CBI were done immediately before and after LVP, with a median time interval of 210 (180–255) min. Ventilatory parameters, hemodynamic profiles as well as IAP-assessment and ultrasound examinations were performed immediately before as well as after the maximal mobilizable release of ascites.r and linear regressions using the coefficient R2. Continuous variables are expressed as median and interquartile range (IQR). Categorical variables are expressed as percentages. To compare continuous variables, we used nonparametric Wilcoxon test for paired samples. Significance was assumed at a p value < 0.05.For primary outcome analysis, we investigated ICG-PDR at the end of LVP compared to baseline. All analyses and graphs were generated using GraphPad Prism 7.0 . Correlations were calculated using Pearson`s correlation coefficient Patients’ baseline characteristics and clinical scores are presented in Table We performed LVP procedures in a total of 22 patients  with decompensated liver cirrhosis and tense ascites. APACHE-, SOFA-, MELD- and Child–Pugh scores are explainable by advanced hepatic impairment and critical illness. The etiology of cirrhosis was predominantly alcoholic-toxic. About 75% of patients were mechanically ventilated and about 25% were spontaneously breathing. Regarding mechanically ventilated patients, PEEP-setting was unchanged during LVP and study measurements./μL in all patients), with polymorphonuclear neutrophils < 250/μL in each patient to exclude spontaneous bacterial peritonitis and to justify a release of a maximum of mobilizable ascites volume.Twenty-two LVP procedures with a median volume of 3450 (3075–4700) mL removed ascites (≥ 3000 mL for every paracentesis) were analyzed. We noticed a median ascitic cell count of 180 (100–310)/μL (≤ 500p < 0.001) %/min compatible with dramatic hepatic impairment of advanced liver cirrhosis. LVP provoked a significant increase of ICG-PDR to 5.1 (3.9–6.2)%/min  increased from 99 (73.5–124.5) to 104 (91–143.5) mL/min/m2 (p = 0.005)  was unchanged after LVP [2412 (1983–3025) before paracentesis vs. 2409 (1997–2805) mL/mIn comparison, main laboratory tests of liver function showed no significant changes after an overall time interval of 24 h: Parameter of liver excretion function bilirubin as well as plasmatic coagulation parameter INR remained stable (Table p < 0.001). Grading of IAH before and after LVP is listed in Table Paracentesis caused a distinct relief of IAH: At the end of LVP, pressure levels of IAP had lowered from 19.0 15.0–20.3) to 11.0 (8.8–12.3) mmHg ( to 11.0 p < 0.001). Pressure levels of IAP and APP are depicted in Fig. p = 0.001).Consecutively, we noticed a marked improvement of APP from 63.0 (56.8–69.5) to 71.0 (65.5–78.5) mmHg (Median changes in IAP (delta IAP) and APP (delta APP) caused by paracentesis were -8.0 (− 5.0 to − 10.0) mmHg and 8.5 (5.8–10.3) mmHg, respectively. Furthermore, LVP provoked a median change in CVP (delta CVP) of − 5.0 (− 3.0 to − 7.0) mmHg.r = − 0.602, p = 0.003). In parallel, delta ICG-PDR correlated significantly with delta APP . In contrast, delta ICG-PDR was not significantly associated with evacuated ascites volume . Concerning concomitant changes of IAP and CVP after LVP, correlation analyses outlined an association of delta IAP and delta CVP .Analyses according to Pearson as well as linear regressions are illustrated in Fig. p < 0.001). This reduction was mainly reflected in an increase of diastolic hepatic arterial flow velocity, while systolic arterial flow velocity was steady. Furthermore, LVP provoked an increase of maximum hepatic vein flow velocity. In contrast, maximum flow velocity in portal vein was mainly unaffected by paracentesis  to 0.68 (0.65–0.71) (aO2/FiO2) increased and oxygenation index (OI) improved. Furthermore, we registered a significant raise in TV and Cdyn. We also recorded a decrease in respiratory rate and PaCO2, but results were not statistically significant.Respiratory function improved by paracentesis without changes of PEEP-level, outlined in Table Hemodynamic assessment by transpulmonary thermodilution and pulse contour analysis revealed overall unchanged parameters of hemodynamic function after LVP: Mean arterial pressure MAP, cardiac Index CI, cardiac output CO, global end-diastolic volume index GEDVI, extravascular lung water index EVLWI and systemic vascular resistance index SVRI did not change significantly Table .Table 6PThe present study shows that large-volume paracentesis (LVP) induced an improvement in ICG-PDR in critically ill patients with decompensated liver cirrhosis. This effect comes along with a relief of intraabdominal hypertension (IAH) reflected in a decrease in intraabdominal pressure (IAP) and an inverse raise of abdominal perfusion pressure (APP).ICG-PDR represents a useful dynamic liver test in addition to conventional laboratory parameters . On the This dramatic impairment of ICG-PDR in case of end-stage liver disease is confirmed in our study. Median baseline ICG-PDR was reduced markedly to 3.6%/min. Large-volume paracentesis (LVP) provoked a significant increase in ICG-PDR. Additionally, we noticed an increase in “ICG-Clearance” in contrast to unchanged circulating blood volume index, but data on the relevance of these parameters are rare so far. As opposed to this, paracentesis had no influence on main laboratory parameters of hepatic function. In this context, it should be pointed out that an earlier study found no correlation between ICG-PDR and standard laboratory liver tests .The improvement in ICG-PDR is in parallel with a decline of IAP after evacuation of ascites. Correlation analyses revealed a statistically significant association of changes in ICG-PDR with changes in IAP. Previously, a few studies described a relationship between ICG-PDR and IAP. Some of them focused on the effect of prone positioning on IAP and ICG-PDR in patients with respiratory failure , 40, 41.The results of our study reaffirmed previous trials concerning a significant and immediate drop of IAP after LVP in patients with decompensated cirrhosis and tense ascites , 30, 43.Considered as secondary endpoints of this study, we analyzed the impact of LVP on respiratory and circulatory function in case of decompensated cirrhosis. We registered an overall beneficial effect on parameters of oxygenation and ventilation. Several studies underlined that respiratory improvement was particularly attributable to decreases in IAP, enhanced ventilatory mechanics with increased compliance as well as alveolar recruitment with increased end-expiratory lung volume , 49–51. Altogether, the present study emphasizes the inverse correlation of ICG-PDR with IAP and the far-reaching effects of IAH in critically ill patients with decompensated cirrhosis. Hydropic decompensation evokes harmful increases of IAP with negative effects on abdominal perfusion and liver blood flow. LVP immediately lowers IAP in combination with an increase in ICG-PDR. According to ultrasound examination, this beneficial effect on ICG-PDR is mainly referable to improved arterial liver perfusion and decreased hepatic vascular resistance. By implication, our study to some extent questions the significance of ICG-PDR for an exclusive evaluation of hepatocellular function in case of IAH.To our knowledge, this is the first study evaluating the effects of LVP on ICG-PDR in a characterized population of critically ill patients with decompensated cirrhosis and tense ascites. The study combines ICG-PDR with assessments of IAP and APP, ultrasound examinations as well as respiratory and advanced hemodynamic monitoring. Despite the overall modest beneficial effect of paracentesis on ICG-PDR, the results are conclusive with high levels of statistical significance.However, this is a single-center study with consecutively a very limited number of patients. Paracentesis was performed with a maximum release of mobilizable ascites instead of a stepwise release of predefined fluid amounts. Therefore, our data allowed only the calculation of an “overall” abdominal compliance with limited validity considering its evolution during progressive, stepwise evacuation of ascites . MoreoveDecompensated cirrhosis is associated with a marked decrease of dynamic liver test ICG-PDR, reflecting reduced hepatocellular capacity as well as impaired hepatosplanchnic blood flow. LVP evokes a modest but significant improvement in ICG-PDR, primarily referable to a decline in IAP and an inverse increase in APP. While conventional laboratory parameters of liver function did not change, the increase in ICG-PDR is mainly attributable to changes in hepatic perfusion.Moreover, LVP induced substantial improvement in respiratory parameters, while hemodynamic profiles remained stable.


To describe clinical complications related to colonoscopy in inpatients with multiple diseases. Among the known complications, acute kidney injury was the primary focus.This was an observational retrospective study of 97 inpatients. Data relating to age; gender; comorbidities; current medication; blood tests ; length of hospital stay; indication, results, and complications of colonoscopies; and time to the development of kidney injury were collected between June 2011 to February 2012.A total of 108 colonoscopies (9 screening and 88 diagnostic) were conducted in 97 patients. Renal injury occurred in 41.2% of the patients. The univariate analysis revealed that kidney injury was related to the use of diuretics, statins, calcium channel blockers, and angiotensin converting enzyme inhibitor; however, the multivariate analysis showed that only the use of diuretics was associated with kidney injury. The occurrence of kidney injury and the time to its development were independent of the previous glomerular filtration rate as calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.The use of diuretics was the only independent variable associated with the development of kidney injury in inpatients with multiple comorbidities who underwent colonoscopy. The occurrence of kidney injury and the time to its development were independent of previous CKD-EPI-based assessments of renal function. These results highlight the increased risk of colonoscopy in such patients, and its indication should be balanced strictly and perhaps avoided as a screening test. Colorectal cancer is the second most common cancer worldwide among women and the third among men Many tests are available for screening purposes; these tests include stool-based tests , radiologic tests , and endoscopy-based tests  Sedation during colonoscopy may lead to hypoxemia, bradycardia, hypotension, cardiac arrhythmias, or cerebrovascular events Studies have compared screening strategies for colorectal cancer This is an observational, retrospective cross-sectional study. Data were collected from the medical records of patients who underwent colonoscopy between June 2011 and February 2012 at an internal medicine ward at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, in São Paulo, Brazil. The study was approved by the local Ethics Committee for Research Project Analysis - Cappesq (#13208/2015). Because this was a retrospective study with no patient identifiers, informed consent from the patients was not required by the ethics committee.Population: All patients hospitalized in the internal medicine ward for screening or diagnostic colonoscopy during the study period were included. Colonoscopy preparation using bisacodyl and mannitol was the same for all the patients.The Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo is the largest hospital in Latin America. It is a tertiary and quaternary public teaching hospital where undergraduate medical students and medical residents work daily. The internal medicine ward has 48 beds, and physicians in this ward treat patients with multiple comorbidities using polypharmacy to diagnose and manage unstable chronic diseases. The most frequent patient comorbidities are hypertension, diabetes mellitus, chronic pulmonary disease, cardiac failure, systemic lupus, rheumatoid arthritis, and chronic renal failure. Patients undergoing maintenance dialysis were excluded from this study.Patients were divided in groups according to colonoscopy indication (screening and diagnostic) and renal function (creatinine clearance above or below 30 mL/min). The demographic and clinical data collected were age, comorbidities, medication use 48h before colonoscopy, blood tests , indication for colonoscopy, length of hospital stay, the results and complications of colonoscopies, and time until the development of kidney injury (if it occurred).Kidney injury was defined as a 0.3-mg/dL absolute increase in creatinine at 48 h (KDIGO 1), a 1.5- to 1.9-fold increase in basal creatinine within 7 days (KDIGO 1), a 2- to 2.9-fold increase in basal creatinine within 7 days (KDIGO 2), or a >3-fold increase in basal creatinine within 7 days (KDIGO 3) according to the KDIGO 2012 criteria p-value <0.05 was considered statistically significant. For statistical analysis, SPSS 20 software  was used.Continuous variables are expressed as either the mean ± standard deviation or the median  according to their distribution. Normality was tested with the Kolmogorov-Smirnov test and homogeneity with Levene's test. Categorical variables were expressed as proportions, and the association between kidney injury and comorbidities or medication use was tested with the chi-square test. The covariates of patients divided according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) glomerular filtration rate were analysed. An unpaired t test or a Mann-Whitney test were used to compare changes in the variables between the screening and diagnostic groups as appropriate. Multivariate relationships between the diagnosis of AKI and independent variables were also examined with logistic regression. A two-tailed During the study period, 97 in patients underwent colonoscopy (88 diagnostic and 9 screening). A total of 108 colonoscopies were performed in 97 patients (eleven patients underwent another colonoscopy due to inadequate preparation). Most patients (77.8%) who underwent a screening colonoscopy presented clinical complications; six presented renal injury, two had inadequate bowel preparation and one had hypoglycaemia. Among the patients in the diagnostic group, almost half presented clinical complications, most of which were due to renal injury. Inadequate bowel preparation, sepsis, hypotension, cardiovascular complications , nausea or intestinal sub-occlusion were also present but were less frequent. In the diagnostic group, two patients could not complete their exam due to intestinal sub-occlusion .versus 1.27±1.52 days, respectively, p=0.924). The incidence of colon tumours was approximately 1/3 of the studied population, but malignant cancer was rare and found solely in patients in the diagnostic group ; blood glucose (p=0.304); LDL cholesterol (p=0.428); comorbidities such as diabetes (p=0.110), cerebrovascular disease (p=0.471), or cardiac diseases (p=0.289); length of hospital stay (p=0.543); use of aspirin (p=0.390), insulin (p=0.108), or beta blockers (p=0.105); and anatomopathological findings as cancer (p=0.716), low grade adenoma (p=0.141), intermediate grade adenoma (p=0.928), or high grade adenoma (p=0.226).There was no association between kidney injury and age (p=0.032), diuretics (p<0.001), calcium channel blockers (p=0.043) and statins (p=0.05) for all the patients. The associations were not tested separately for the screening and diagnostic groups due to the small size of the screening group.The univariate analysis revealed that kidney injury was associated with the use of angiotensin converting enzyme inhibitors (ACEIs) (p=0.011) .The multivariate analysis only included covariates that were associated with kidney injury in the univariate analysis: the use of diuretics, statins, calcium channel blockers, and ACEIs. Age and diabetes were also included in the multivariate analysis due to their clinical relevance. Only the use of diuretics was associated with kidney injury (2) and analysed for continuous covariates. Only 5 patients had EPI <30 mL/min/1.73 m2 and were excluded from the analysis. The length of hospital stay, blood glucose, LDL and time to AKI were similar among the CKD-EPI groups , change in bowel habits (2), anaemia (1), and blood loss (1). In this group, only the screening patient presented any complications (kidney injury). After we excluded these 5 patients, we compared the incidence of kidney injury and the time to AKI development between patients with CKD-EPI ≥60 and patients with CKD-EPI 30-59. The analysis showed that the occurrence of kidney injury and time to its development were independent of previous CKD-EPI glomerular filtration rate .The indications for colonoscopy of the five patients who presented a CKD-EPI glomerular filtration rate lower than 30 mL/min/1.73 mThis study highlights three main points: the most important factor in the development of kidney injury in inpatients presenting multiple comorbidities who undergo colonoscopy is the use of diuretics; kidney injury is an early event after the exam and the occurrence of kidney injury and the time to its development were independent of the previous CKD-EPI glomerular filtration rate.The internal medicine ward at Hospital das Clínicas is a tertiary university institution where most patients are hospitalized for diagnostic investigation or treatment of unstable chronic diseases. These individuals usually present multiple comorbidities such as hypertension, diabetes mellitus, chronic pulmonary disease, cardiac failure, systemic lupus, rheumatoid arthritis, and chronic renal failure and engage in polypharmacy . Therefore, the risk of complications in this population was expected to be higher than that observed in screening studies for colon cancer in asymptomatic patients in an outpatient setting Some results were unexpected. Age and comorbidities such as cardiac diseases, cerebrovascular diseases, and LDL cholesterol levels were similar between the groups, but the screening group had a higher prevalence of diabetes and use of statins, ACEIs, diuretics and insulin, suggesting that these individuals have comorbidities at more advanced stages. The results of the laboratory tests indicate that creatinine and glomerular filtration rate (as measured by CKD-EPI) were similar between the groups both before and after colonoscopy.Regarding clinical complications, AKI was the most prevalent and occurred more frequently in the screening population. The higher prevalence of diabetes in the screening group may have contributed to this difference. The higher incidence of complications in the screening group highlights their susceptibility to adverse events, and this should be noted before indicating a screening colonoscopy in older patients with multiple diseases who engage in polypharmacy. Due to their profile, this population should be hospitalized prior to undergoing screening colonoscopy, and our data suggest that doctors should carefully balance the risks and benefits of this procedure before indicating hospitalization for colonoscopy or not indicating it at all.Bowel preparation was the same for all the patients, and none of them received oral sodium phosphate, which has been associated with AKI The time to kidney risk or injury was similar between the screening and diagnostic groups independent of previous renal function (EPI ≥60 or EPI 30-59) and was an early event approximately 1 day after the start of bowel preparation. The literature notes that renal failure due to hypovolemia may develop within 24h or several days after colonoscopy depending on the blood volume and renal perfusion Our study has some limitations. It is an observational and retrospective study that does not allow causality. We did not assess the use of other types of medications such as non-steroidal anti-inflammatory drugs or anticoagulants, which might have influenced any bleeding complications. External generalizability is limited due to the single-centre design of this study. Additionally, the entire study cohort underwent screening or diagnostic colonoscopy while hospitalized, which may reflect a population with a more severe clinical profile; thus, our results may not be suitable for an outpatient procedure. This could have introduced selection bias to our study. Finally, the small size of the screening group requires that comparisons be interpreted carefully.However, despite the limitations, this study highlights some key points that should be considered before indicating colonoscopy to patients at tertiary or quaternary hospitals. There is an association between the use of diuretics and AKI after colonoscopy, which is probably due to exacerbated hypovolemia during bowel preparation, and anticipating renal injury in these patients may be crucial. The development of colonoscopy-related AKI occurred independent of previous renal function, which was not expected. The time to AKI development was similar in the diagnostic and screening groups and independent of previous renal function. These data support and reinforce the necessity of balancing the risk and benefits of colonoscopy in patients with multiple chronic metabolic diseases who engage polypharmacy and are older than 65 years. The decision for indicating colonoscopy as a diagnostic procedure should also be carefully considered, and the indication for screening perhaps should be avoided because the procedure may do more harm than good for these patients.The maintenance of adequate hydration with fluid administration and the suspension of diuretics may reduce renal complications related to colonoscopy. Performing daily weight checks during bowel preparation and after colonoscopy may be an efficient and inexpensive approach to assess proper hydration and mitigate complications related to the procedure.Ivanovic LF and Bueno-Garcia ML designed the study, analyzed the data and helped drafting the manuscript. Silva BC designed the study, analyzed the data and helped drafting the manuscript. Lichtenstein A and Paiva EF designed the study and helped drafting the manuscript.


Patients suffering from cardiovascular autonomic failure often develop neurogenic supine hypertension (nSH), i.e., high blood pressure (BP) in the supine position, which falls in the upright position owing to impaired autonomic regulation. A committee was formed to reach consensus among experts on the definition and diagnosis of nSH in the context of cardiovascular autonomic failure.As a first and preparatory step, a systematic search of PubMed-indexed literature on nSH up to January 2017 was performed. Available evidence derived from this search was discussed in a consensus expert round table meeting in Innsbruck on February 16, 2017. Statements originating from this meeting were further discussed by representatives of the American Autonomic Society and the European Federation of Autonomic Societies and are summarized in the document presented here. The final version received the endorsement of the European Academy of Neurology and the European Society of Hypertension.In patients with neurogenic orthostatic hypotension, nSH is defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, measured after at least 5 min of rest in the supine position. Three severity degrees are recommended: mild, moderate and severe. nSH may also be present during nocturnal sleep, with reduced-dipping, non-dipping or rising nocturnal BP profiles with respect to mean daytime BP values. Home BP monitoring and 24-h-ambulatory BP monitoring provide relevant information for a customized clinical management.The establishment of expert-based criteria to define nSH should standardize diagnosis and allow a better understanding of its epidemiology, prognosis and, ultimately, treatment. Primary cardiovascular autonomic failure develops in the context of inherited and sporadic neurodegenerative diseases affecting the autonomic nervous system. Secondary causes of cardiovascular autonomic failure include amyloidosis and metabolic or immune-mediated diseases inducing autonomic neuropathy .The main feature of cardiovascular autonomic failure is neurogenic orthostatic hypotension (nOH), defined in 2011 as a sustained reduction of systolic blood pressure (BP) of ≥ 20 mmHg (≥ 30 mmHg in patients with supine hypertension) or diastolic BP  of ≥  10 mmHg within 3 min of standing or head-up tilt of at least 60° –6.As yet, no consensus criteria have been established for the diagnosis of nSH, limiting current understanding of its epidemiology, prognostic significance and the development of appropriate management strategies.To address this shortcoming, a round table discussion with participants from the European Federation of Autonomic Societies (EFAS) and from the American Autonomic Society (AAS) was convened in Innsbruck on February 16, 2017 to establish clinical criteria for the diagnosis of nSH in the context of cardiovascular autonomic failure.Discussion points and statements originating from this meeting were subsequently examined and reviewed by representatives of both societies and are summarized in the document presented here. The final version was endorsed by the European Academy of Neurology (EAN) and by the European Society of Hypertension (ESH).In patients with proven nOH, nSH is defined as systolic BP of ≥ 140 mmHg and/or diastolic BP of ≥ 90 mmHg, measured after at least 5 min of rest in the supine position.Mild nSH: systolic BP values of 140–159 mmHg or diastolic BP values of 90–99 mmHg.Moderate nSH: systolic BP values of 160–179 mmHg or diastolic BP values of 100–109 mmHg.Severe nSH: systolic BP values of ≥ 180 mmHg or diastolic BP values of   ≥ 110 mmHg.We propose the following ranges to define the severity of nSH in autonomic failure:Reduced-dipping: characterized by a mean nocturnal BP reduction of < 10% with respect to mean daytime BP values.Non-dipping or rising: when the mean BP does not decrease or even increases during the night with respect to daytime , 8.Patients with cardiovascular autonomic failure frequently show nSH also during sleep, i.e. nocturnal hypertension, with loss of the physiological nocturnal BP fall at night of ≥ 10% while supine and asleep (dipping). Two main pathological nocturnal BP profiles are distinguished:Additional aspects are important for an appropriate interpretation of 24 h-ambulatory BP monitoring (24 h-ABPM) in patients with cardiovascular autonomic failure and are discussed in the section Neurogenic supine hypertension is mostly asymptomatic or induces only non-specific complaints, such as headache. The main, most clinically relevant and immediate consequence of nSH is an exacerbation of pressure natriuresis during sleep, causing nocturia, sleep disturbances, volume depletion overnight and worsening of nOH in the morning , 10.nSH could potentially result in hypertensive emergencies, with similar complications as in the general population, i.e. cerebral hemorrhage, ischemic stroke, acute pulmonary edema and myocardial infarction , althougThe long-term effects of cardiovascular autonomic failure have been studied in patients with Parkinson’s disease (PD) and multiple system atrophy (MSA). Current evidence suggests that early-onset cardiovascular autonomic failure is associated with a poor prognosis –20, deveAt present, it is uncertain how much of the increase in risk is related to the underlying disease causing autonomic failure and how much is directly related to the abnormality in BP regulation. It is also unclear whether nOH or nSH represents the actual negative prognostic factor in patients with cardiovascular autonomic failure—or whether it is the BP volatility induced by the combination of both .Keeping in mind the limitations due to inconsistences in the diagnostic criteria, nSH has been reported in 34–46% of patients with PD and 37% of patients with MSA . The freThe prevalence of nSH in pure autonomic failure (PAF) ranges from 48 to 70% , 47. An To date, no studies have addressed the epidemiology of nSH in diabetes, but a significant association has been reported between the presence of nOH and rising nocturnal BP profiles both in patients with type 1 and type 2 diabetes mellitus , 50.The prevalence of nSH in genetic and acquired amyloidosis, as well as in other kinds of autonomic neuropathies is unknown. Clinically, patients with acquired amyloidosis (AL) and nOH often present with relatively low supine BP measurements which may be related to cardiovascular amyloid deposition.Anti-hypotensive drugs used for the treatment of nOH may unmask or exacerbate nSH, thereby posing a management challenge. However, nSH can also develop in the absence of anti-hypotensive treatment, which reflects the likelihood that multiple factors contribute to nSH, including impairment of the afferent, central and efferent pathways of the arterial baroreflex arch, disruption of the renin–angiotensin–aldosterone axis and denervation supersensitivity at the level of the vascular adrenoceptors due to impaired sympathetic transmission , 51–53.Noradrenaline release from intact post-ganglionic sympathetic fibers in the setting of severe baroreflex impairment drives nSH in MSA, which is characterized in most cases by severe preganglionic sympathetic denervation, with sparing of the post-ganglionic sympathetic fibers to the heart and blood vessels .In contrast, mechanisms independent of the sympathetic autonomic nervous system are considered to contribute to the development of nSH in autonomic disorders with post-ganglionic sympathetic denervation and very low circulating noradrenaline levels, such as in PAF . ParadoxAll patients newly diagnosed with nOH should be screened for nSH at the time of diagnosis and at regular intervals afterwards, especially if they begin treatment with anti-hypotensive agents, increase their dosage, report multiple episodes of nocturia per night or develop ankle edema.Office screening should be performed by measuring supine BP as soon as the patient assumes the supine position and then again after the patient has been resting supine for at least 5 min. This can be combined with a standing test, by having the patient stand immobile to avoid engaging the muscle pumps in the lower limbs, or with a tilt table examination. A tilt table examination may be preferred in patients unable to stand for several minutes.It should be noted that the criteria outlined here to define nSH only apply for patients with proven nOH: if present, both conditions are usually verified during the same test. Exceptions to this rule may be due to the fact that nOH and nSH could manifest with different degrees of severity according to the time of the day, intravascular volume status and timing of the administration of anti-hypotensive drugs. Anti-hypotensive drugs may succeed in raising the standing BP and improving symptoms, but exacerbate nSH.A diagnosis of nSH should be also made independently from seated BP values, which may vary from hypertensive values to normo- or hypotensive values in patients with cardiovascular autonomic failure.In addition to office BP screening, home BP recordings performed by patients themselves are recommended to gather further insights into circadian BP control. Although no protocol for home BP self-monitoring has been validated in patients with cardiovascular autonomic failure, we recommend that the BP be recorded three times per day  in the supine, seated and standing position for 1 week at first diagnostic work-up. The same home BP protocol should be repeated after the initiation or adaptation of any treatment for nOH or nSH in order to monitor therapeutic effects and to detect potential side effects. Comparison of supine and seated BP values during the daytime is particularly valuable for choosing therapeutic strategies: patients with nSH may show normal BP values while seated, hence benefitting from a simple non-pharmacological approach such as avoiding the supine position during daytime.If office BP screening or home BP recordings suggest nSH, a 24 h-ABPM is recommended to ascertain the presence of nocturnal hypertension and document absolute BP levels reached overnight. 24 h-ABPM may also provide information on the severity of nOH during daily activity or after meals , thus sSeveral activities of daily life may cause severe drops in BP, which may be captured in the 24-h recordings. For an accurate interpretation of the 24 h-ABPM data, patients should be instructed to compile an activity diary on the examination day in which they report the times of medication intake , meals, physical activities and times of getting out of bed at night .Extreme drops in BP during daytime will reduce mean BP during the daytime, thereby resulting in an overestimation of the percentage of nocturnal BP rise. Conversely, nocturnal standing or bathroom visits may induce nocturnal BP falls, which may result in an underestimation of the BP rise overnight. For these reasons, both the percentage of nocturnal BP rise, as well as the absolute overnight BP values should be considered when diagnosing and tailoring treatment strategies for nSH. Whereas non-dipping and rising nocturnal patterns have been associated with long-term end-organ damage, absolute BP values reached while supine may be more relevant for the development of hypertensive emergencies.Sleeping with the bed 12° head-up tilted  creates an overnight gravitational stress and is an effective non-pharmacological strategy to manage nOH . SleepinPatients with cardiovascular autonomic failure, especially in the setting of PD and MSA, may suffer from sleep fragmentation or sleep disordered breathing, both of which have been associated with development of hypertension –61. If sNocturnal BP profiles may change over the short term with repeated 24 h-ABPM in 10–35% patients with essential hypertension , 63. RepAdditional considerations are required when interpreting 24 h-ABPM data of patients with cardiovascular autonomic failure:Finally, if a nocturnal BP rise is documented in a patient not known to suffer from any autonomic disorder, screening for nOH may be indicated. Similarly, if a patient is found to have elevated BP while supine—for example, in a hospital or acute care setting—they should also have the BP measured seated and, if the systolic difference exceeds 10 mmHg, standing as well. Otherwise, nSH might be mistaken for essential hypertension, and if treatment decisions are based on supine BP values alone, medications could potentially worsen unrecognized nOH.Current epidemiological data are not sufficient to define cut-offs for nSH based on its impact on end-organ damage or mortality. For this reason, the criteria proposed here for the diagnosis of nSH in the context of cardiovascular autonomic failure are based on the criteria for the diagnosis of essential hypertension and interpretation of 24 h-ABPM recordings in the general population , 8. Ther


Background and aim: Systemic lupus erythematosus (SLE) is associated with increased risk of cardiovascular disease (CVD). Among many mechanisms, accelerated atherosclerosis, endothelial dysfunction, and hypercoagulability play a main role. Here, we investigate whether inflammatory, serological and clinical markers of SLE determine and correlate with arterial stiffness in SLE patients. Materials and methods: Routine blood samples, inflammatory mediators, specific antibodies, and 24 h proteinuria were measured in 43 SLE patients and 43 age and sex-matched controls using routine laboratory assays. We also assessed arterial stiffness by measuring radial artery applanation tonometry-derived augmentation index (AI), normalized AI (AIx@75), aortic pulse pressure, central systolic, diastolic and peripheral blood pressure. Results: SLE patients showed a significantly greater arterial stiffness vs. controls, as demonstrated by the significantly higher AIx@75 and aortic pulse pressure. Interestingly, regression analysis showed that age, systolic pulse pressure, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), daily dose of glucocorticoids, and cumulative organ damage positively correlated with arterial stiffness. Conclusions: SLE patients show increased arterial stiffness which correlates with markers of inflammation, that is involved in early alterations in arterial walls. Applanation tonometry can be used to screen SLE patients for subclinical vascular damage to implement prevention strategies for CVD. Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease mainly affecting women of childbearing age . CardiovAlterations in arterial distensibility and compliance have been described in chronic inflammatory diseases . They maA total of 43 SLE patients  years) were enrolled at the Department of Translational Medical Sciences, Federico II University, Naples, between March 2018 and October 2018. All patients fulfilled the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria . Forty-tAt the time of the enrolment, 39 patients (90.7%) were on glucocorticoid therapy  mg). The median duration of the disease was 14 18) years. SLE disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score [ years. SThe median value of systolic blood pressure (SBP) was 120 (20) mmHg. Blood tests included total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, homocysteine, creatinine, acid uric, glucose lymphocytes, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen and lupus serology . 24-h proteinuria sample evaluated the urinary protein excretion. All the characteristics of the study population are shown in p = 0.03). SLE patients presented significantly higher values of AIx@75 (21.0 (17) vs. 9.0 (16); p < 0.001) .p < 0.05), SBP , CRP levels , ESR , daily dose of prednisone  and damage index . Moreover, patients who displayed organ damage, defined by a SLICC/ACR damage index score (SDI) ≥ 1, had significantly higher AoPP than those with a SDI = 0 (32 (9) vs. 28 (7), p = 0.03), as shown in In the univariate analysis , AoPP cop < 0.001), negative correlation with lymphocyte count . AIx directly correlated with age , inversely blood creatinine levels  and lymphocyte count .AIx@75 showed positive correlation with age  and active nephritis (p = 0.01 and p = 0.006) at the time of the study.Regarding the clinical manifestations, both AIx@75 and AIx resulted significantly higher in patients with clinical manifestations, especially in patients who had mucosal ulcers  0.20 to 0.89; p = 0.01), SBP , ESR . Both AIx@75 and AIx correlated with age .At the multiregression analysis , AoPP coCVD is an important factor for SLE mortality . ImportaPrevious work assessing arterial stiffness in SLE patients by means of applanation tonometry provided controversial results ,23,24,25Among other traditional cardiovascular risk factors, age showed the strongest correlation with all the parameters of arterial stiffness. This is coherent with what is known in the general population, as arterial stiffness increases with age ,38. AoPPOn the other hand, arterial stiffness did not show a significant correlation with disease activity, assessed with the SELENA-SLEDAI 2K tool. However, the parameters of arterial stiffness were significantly higher in patients with mucosal ulcers and active nephritis. Interestingly, an association between subclinical atherosclerosis and impaired renal function has been reported in some studies on SLE patients ,42.One of the most debated SLE-related factors contributing to vascular stiffness is represented by glucocorticoid therapy. In our analysis, AoPP showed a significant correlation with the dose of prednisone . The contribution of glucocorticoids to the CV risk in SLE patients is yet to be determined, but it has to be acknowledged that patients treated with higher glucocorticoids disease are usually those with the most severe clinical phenotype. Indeed, our results show that arterial stiffness correlates with cumulative organ damage, as assessed by the SLICC/ACR damage index (SDI). AoPP was significantly higher in patients with (SDI score ≥ 1) than in those with no organ damage . MoreoveThe impact of glucocorticoid therapy on cardiovascular risk is relevant also because of the metabolic alterations occurring with long-term treatment with steroids ,44. HoweIn our study we included 43 subjects older than 18 years who fulfilled the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria , treatedThe study was conducted in accordance with the principles of the 1975 Declaration of Helsinki and good clinical practice guidelines of the International Conference of Harmonization (ICH GCP). Informed consent was obtained from all patients before the procedure, and the study was approved by the local ethical committee of the University of Naples Federico II “Carlo Romano” (348/2018 approved 14 March 2018).Routine blood samples, inflammatory mediators, specific antibodies, and 24 h proteinuria were measured using routine laboratory assays. A detailed clinical history was collected, including current and cumulative use of glucocorticoids. Disease activity in the preceding 30 days was assessed with the use of the SELENA-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI-2K) . CumulatBrachial blood pressure was measured at the non-dominant arm with a sphygmomanometer. Parameters of arterial stiffness were derived by a high fidelity applanation tonometer . Measurements were performed in a quiet and controlled temperature room, after 10 min in supine position, with the patient fasting and refraining from alcohol and coffee assumption for at least 10 h. All measurements were made in duplicate by two trained operators  according to the international recommendations  and interpreted by a different operator (V.M.) who was blind to the clinical characteristics of the patients. Aortic pulse pressure (AoPP), Augmentation Index (AIx) and Augmentation Index normalized to heart rate of 75 bpm (AIx@75) were the parameters considered in order to evaluate arterial stiffness. In particular, AoPP was defined as the difference between the first peak of systolic blood pressure and the diastolic blood pressure; AIx was calculated as the ratio of late systolic pressure to early systolic pressure, expressed as a percentage of the sphygmic wave .p value ≤0.05 was considered as statistically significant.Continuous variables were expressed as median ± interquartile range; categorical variables were expressed as frequencies or percentages. The comparison between patients’ and controls’ data was performed by non-parametric Mann–Whitney U-test for independent samples. Factors associated with arterial stiffness, in SLE patients, were analyzed by the use of Pearson’s correlation coefficient or Spearman’s correlation  and multiple linear regression with OLS method . Variables correlated to stiffness with a p-value below 10% in univariate analysis were considered for the multivariate model. A Intra- and inter-observer variabilities for parameters of arterial stiffness were evaluated by means of intraclass correlation coefficients (10 random exams were preformed twice by an operator and compared with the results obtained by a second operator).Overall, our results support the concept that inflammation is a main determinant of cardiovascular complications in SLE. As highlighted by a recent meta-analysis, SLE patients have a higher carotid intima-media thickness and an increased prevalence of carotid plaques, supporting the evidence for an increased CVD risk .Our study has some limitations to be considered. The sample size is small and may lack statistical power to define additional factors correlated to arterial stiffness, especially concerning the results of the regression analysis. Moreover, a cause–effect relation cannot be inferred from a cross-sectional study. Nevertheless, our results suggest that a regular and careful serological and clinical assessment together with vascular investigations is useful to identify an early impairment of arterial stiffness in patients with SLE. Our data also support the use of non-invasive techniques such as applanation tonometry of the radial artery to assess the accelerated progression of atherosclerotic damage of the vessel wall in SLE patients. It is particularly important to stratify high-risk patients in order to plan an appropriate therapeutic approach for SLE patients and control traditional risk factors to avoid subclinical vascular impairment evolving into manifest cardiovascular events . Therefo