P < .001) and prolonged postoperative length of stay . Patients with postoperative complications had a higher frequency of intensive care admission (44.1% vs 15.3%), major postoperative interventions (6.6% vs 0%), and 30-day readmission (5.0% vs 0.7%). Systolic blood pressure fluctuations during resuscitation have an independent impact on postoperative complications and postoperative length of stay following meningioma surgery.It is unclear whether blood pressure variability in the post-anesthesia care unit is associated with postoperative complications. This study aims to characterize the impact of blood pressure fluctuations on postoperative complications and postoperative length of stay after meningioma surgery. Adult meningioma patients undergoing general anesthesia were retrospectively recruited. The principal exposure was blood pressure variability in the post-anesthesia care unit, calculated by noninvasive blood pressure measurements. The primary outcome was major postoperative complications, defined as II or higher in the Clavien-Dindo classification grades. Secondary outcomes included healthcare resource utilization parameters among patients. Multivariable logistic regression was used and adjusted for potential confounding variables. Data sensitivity analyses were performed via different variable transformations and propensity score matching analyses. A total of 578 patients qualified for the study, and 161 (27.9%) cases experienced postoperative complications. The multivariable analysis found that increased systolic blood pressure variability in the post-anesthesia care unit was associated with postoperative complications (adjusted odds ratio [aOR] = 1.15; 95% confidence interval [CI], 1.09–1.22,  Although meningiomas are highly prevalent as a primary benign disease, surgical resection remains a critical treatment paradigm. Evidence shows that, like other neurosurgical procedures, meningiomas are frequently associated with poor prognoses such as focal neurological deficits, seizures, and decreased quality of life. Several studies have explored the risk factors related to postoperative complications (POCs) in meningiomas, with varying incidence estimates among different surgical populations (15–35.8%).–5 POCs of meningiomas after general anesthesia deserves greater attention because of their association with more complex postoperative medical care, prolonged postoperative length of stay, long-term disability, and mortality of patients.Meningiomas are the most common primary intracranial tumor, comprising 36.6% of all primary central nervous system tumors in the USA. The prognosis of surgical procedures is significantly correlated to the management of perioperative anesthesia and the degree of circulatory stability. Liu et al demonstrated that one of the leading causes of rebleeding after a craniotomy was the increased incidence of postoperative blood pressure fluctuations. In prior studies, blood pressure fluctuations were often assessed based on mean values or a specific threshold range without considering the intrinsic dynamics.–11As demonstrated in previous literature, abnormal blood pressure changes lead to varying levels of target organ damage.,13 However, little attention has been paid to the blood pressure changes in the post-anesthesia care unit (PACU) after general anesthesia. The relationship between postoperative blood pressure fluctuations and postoperative outcomes for patients after meningioma resection has not been reported previously. Therefore, we conducted a retrospective cohort study to determine whether increased blood pressure fluctuations in the PACU demonstrate increased risks of POCs and prolonged postoperative length of stay (PLOS) following meningioma surgery.Evidence shows that persistent, significant intraoperative blood pressure fluctuation affects the outcome of critically ill and surgical patients.Meningioma resection was determined according to the international ICD-9 code and a retrospective cohort study was conducted on adult meningioma surgery patients following general anesthesia between January 2019 and June 2020. The study was approved on January 21, 2022 by the Ethics Committee of the Jinling Hospital, affiliated with the Medical School of Nanjing University (no. 2022NZKY-010-01), with a waiver of informed consent. The study was conducted in accordance with the principles set forth in the Helsinki Declaration. The primary outcomes and sensitivity analyses were defined and established before the initiation of the study design. We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Patients aged 18 years or older at the time of inclusion and who had been diagnosed with meningioma were eligible for this study. The exclusion criteria included no admission to the PACU for recovery, incomplete blood pressure data in the PACU, other intracranial lesion resections during the meningioma procedure, or a pathological diagnosis of the meningioma as a different tumor type. The missingness of data was assumed to be at random. After the patient’s admission to the PACU, arterial blood pressure was measured continuously at 5-minute intervals using an oscillometric upper-arm cuffs and recorded. Two researchers performed a rigorous screening and exclusion process for blood pressure data during resuscitation, including the removal of obviously erroneous blood pressure values and a final consistency test, which preserved the true blood pressure values of the patients. Data pertaining to demographic characteristics were obtained from the Jinling Hospital institution’s Electronic Medical Records. Recorded variables included sex, age, comorbidities, World Health Organization (WHO) tumor grade, and other tumor characteristics. Perioperative data included the date and duration of surgery, fluid management strategies, intraoperative blood transfusions, intraoperative hypertension, whether the patient received tracheal extubation in the PACU, and resuscitation time (defined as the time from when the patient entered to exited the PACU). These variables were all retrieved from the Surgical Anesthesia Information Records. Specific postoperative complications were summarized with reference to the authoritative literature and based on the international ICD-9 code. We collected specific postoperative complications from the Electronic Medical Records, including intracerebral hemorrhage and edema, intracranial infection, cerebrospinal fluid leakage, pulmonary infections, etc.The principal exposure, blood pressure variability in the PACU, was defined as the magnitude of the coefficient of variation (CV). Blood pressure variability was calculated using the CV = standard deviations/mean formula. Secondary outcomes included following healthcare resource utilization (HCRU) parameters, such as duration of Neurosurgical Intensive Care Unit, needs for major postoperative interventions, and 30-day readmission. We defined 30-day readmission as all-cause hospitalizations within 30 days of discharge and were limited to readmission to our hospital.The primary outcome was the incidence of major POCs, which are defined as any deviation from the ordinary postoperative course requiring pharmacological treatment or interventional procedures, rated as II or higher in the Clavien-Dindo classification (CDC) grades.Several sensitivity analyses were performed, including different variable classifications and definitions, the order in which variables are entered into the model, and subgroup analyses and interactions between variables. Additional adjustments for confounding variates were used to minimize bias, such as propensity score matching (PSM). We performed a one-to-one matching without replacement using the nearest-neighbor matching algorithm with caliper widths equal to 0.1. The matching effect of PSM was measured by the covariate-balanced plot.Since no prior data were available on the primary outcome measure, we performed a post hoc power calculation. Assuming the incidence of in-hospital POCs of 15.5% of patients with lower systolic pressure variability (SBPV), as seen in the first-year data, increased SBPV increases the risk of in-hospital POCs by an absolute 8%. The study would provide a power of 0.80 to detect this difference at a two-sided significance level of 0.05. Considering an exclusion rate of 5%, the current required sample size was estimated at 536 patients.t tests and Mann–Whitney U tests were used to assess the differences in numerical data between groups, and the χ2 tests for comparisons between categorical variables.Continuous variables were summarized as means (standard deviation) or medians (interquartile ranges) and categorical variables as frequencies and proportions. Student  Potentially risk factors were adopted and adjusted from preliminary evidence that might affect in-hospital POCs.–5,17 Subgroup analysis of in-hospital POCs stratifying the cohort was conducted as a post hoc study. The effect of blood pressure variability on PLOS was summarized using a univariable and multivariable generalized linear model with an adjusted β valve and 95% CIs. The fitted model used a gamma distribution and fully accounted for variable multicollinearity. Restricted cubic splines were applied to delineate the curve of associations. Secondary outcomes were considered exploratory.The relationship between blood pressure variability and in-hospital POCs was assessed using adjusted odds ratios (aORs) with 95% confidence intervals (CIs). For all analyses, we required a minimum of 10 events per predictor to avoid overfit models.A series of sensitivity analyses were performed. Multivariable logistic regression models were used to evaluate associations between all confounding variables with and without SBPV and in-hospital POCs. The fitted model discrimination was described by the area under receiver operating characteristics curves. The SBPV values were a natural log transformed to reduce the influence of extreme values, as both continuous variables and quartiles. A PSM cohort was carried out at a ratio of 1:1 by logistic regression to reduce the effects of confounders and selection bias.P value < 0.05 was considered statistically significant.All analyses were performed using IBM SPSS Statistics for Windows, Version 26.0 . A two-sided http://links.lww.com/MD/I113).A total of 606 patients with meningioma were initially included, and 3 patients who were not admitted to PACU for recovery, 8 patients who underwent concurrent resection of other intracranial lesions, 13 patients with pathological diagnosis of other tumors, 1 endoscopic procedure, and 3 patients with incomplete blood pressure data in PACU were excluded. Finally, 578 patients were included for analysis  when added to the regression model. For the sensitivity analysis, the inclusion of SBPV in the regression model did not qualitatively change estimates of other covariates; however, improved the model’s prediction accuracy (Table P < .001), and the results were also similar when analyzed as quartile variables . The association between increased SBPV and CDC grades was presented in Figure http://links.lww.com/MD/I117).An analysis of perioperative factors predicting POCs were preoperative comorbidities, WHO classification Ⅲ, operation time ≥ 3 hours, more intraoperative fluid administration, and tracheal unextubation in the PACU Table . Increascy Table . MeanwhiP = .004), and the results were similar in sensitivity analyses . The restricted cubic spline described a monotonic increase in PLOS with increased SBPV values, as shown in Figure In the adjusted generalized linear model, the association between increased SBPV in the PACU and prolonged PLOS was statistically significant . However, the 95% CI limits for these adjusted associations were maybe less precise in the reduced sample size.Following propensity score matching, 212 patients were incorporated into the final analysis. The significant associations between systolic blood pressure fluctuations and the postoperative outcomes were validated in both the PSM and the entire cohort Table . Baselin The robustness of the results was further demonstrated by a series of sensitivity analyses.Our findings reveal that among patients having meningioma surgery, increased systolic blood pressure fluctuations during resuscitation were significantly associated with increased risks of postoperative complications and prolonged postoperative length of stay. Based on the CDC grades, the incidence of POCs was 27.9%, and is comparable to the previous study by Zhao et al in 2018. To avoid ambiguity, we defined severities of postoperative complications rated as II or higher by the CDC grades. In a prospective study, Woodfield et al found that approximately one-third of complications occur between hospital discharge and 30 days postoperatively. Since only in-hospital POCs were considered, as reported in other studies,,22 our results might have underestimated the incidence of POCs. In addition to the hemodynamic variability observed in the PACU, our risk factors for POCs after meningioma surgery were largely congruent with those previously reported in the literature: preoperative comorbidities, higher WHO classification, longer operation time, and more intraoperative fluid administration.–5,17 The consistency of our findings further supports the validity of the multivariable regression models.The Clavien-Dindo classification is a common method used to classify complications.,9 blood pressure fluctuations were evaluated as changes beyond a specific threshold range. In the study by Liu et al blood pressure fluctuations were considered the absolute difference between two consecutive measurements. Furthermore, a 2019 prospective cohort study defined blood pressure fluctuation as the difference between the highest and lowest mean arterial pressure (MAP). Blood pressure assessments focusing on a single value may introduce potential bias. The parameter CV used in our data differs from a recent study by Hirsch et al, which quantified blood pressure fluctuations during surgery as the variance of blood pressure. Our data incorporated the blood pressure means into the calculation and considered the variance. Therefore, it may be more scientific to include blood pressure variability as a risk predictor rather than a threshold for change or an absolute difference.We selected blood pressure as the clinical biomarker due to its ease of measurement and clinical applicability. Our variability calculation included increases and decreases in blood pressure, which were not comprehensively considered in previous studies. In two randomized studies,,14,24,25 showed a relationship between persistent blood pressure fluctuations and adverse outcomes, including increased mortality. However, some observations were not limited to brain surgeries. Our data showed an apparent postoperative fluctuation of systolic blood pressure among patients with POCs following meningioma surgery. Some studies have reported that blood pressure fluctuations were related to cerebral hemorrhage after a craniectomy or enlargements of the hemorrhage hematoma. Early stabilization of blood pressure could significantly inhibit hematoma enlargement and improve the prognosis of these patients. Furthermore, prior studies have confirmed dramatic fluctuations in MAP as an independent predictor of poor neurological prognosis.–29 The exact role of blood pressure fluctuations is less well described. In 2014, two studies both showed that higher magnitudes of MAP above the upper threshold of cerebral autoregulation are associated with a higher risk of complications.,31 They proposed that blood pressure variability above the vasomotor constraints of autoregulation might lead to endothelial damage and a compromised blood-brain barrier. In addition, ischemia-reperfusion injury caused by sustained blood pressure fluctuations may also contribute to the development of POCs. Accordingly, optimizing the magnitude of blood pressure fluctuations during resuscitation to remain within the cerebrovascular autoregulation range might provide a possible strategy for modifying the risk for POCs and reducing PLOS.Our current findings and previous studies Patient-related factors: history of hypertension, advanced age, comorbid endocrine disorders, etc.; Anesthetic-related factors: chills, postoperative pain, hypoxia and CO2 accumulation, inadequate depth of sedation; and Medical intervention-related factors: suctioning operations, extubation stimulation, etc. In our cohort, both postoperative systolic and diastolic blood pressure variabilities were evaluated. In a 2019 retrospective study, Liu et al noted that greater postoperative fluctuation of systolic blood pressure was related to increased neurological and overall complications among glioblastoma patients. Our results affirmed the role of increased systolic blood pressure fluctuation rather than diastolic blood pressure for POCs and prolonged PLOS, which is consistent with Liu’s and Muntner’s findings.,34 These might suggest that fluctuations of systolic blood pressure in the PACU deserve more attention. Moreover, the underlying mechanisms as well as the causality of this relationship remain to be elucidated at the blood pressure levels observed in the present study.Some possible reasons for blood pressure fluctuations were summarized as:–37 Consistent with previous studies, we found that increased systolic blood pressure fluctuations prolonged postoperative length of stays, increasing medical care in such patient populations. In contrast, the postoperative event data in our cohort was considered more comprehensively including hospital readmissions and complicated postoperative medical needs, such as the need for secondary surgery reinterventions, postoperative blood transfusions, and tracheotomies. Thus, our findings are complementary to prior studies.The current study also provides evidence of HCRU. During the postoperative period, patients who developed POCs were admitted to the Neurosurgical Intensive Care Unit more frequently. Several studies highlighted medical resource care for POCs after meningioma surgery.There are several limitations to this study. Firstly, as this was a retrospective review, stratification analysis of the severity and duration of blood pressure in the PACU was not performed. Secondly, we could not provide causation evidence about those associations in this observational study. Meanwhile, the external validity of the results needs to be confirmed in different patient populations. Thirdly, this study included a heterogeneous population regarding different baseline and perioperative characteristics, for which PSM and a series of sensitivity analyses could not offset all biases.In summary, under the actual data from meningioma surgery, we present evidence that increased systolic blood pressure fluctuations during resuscitation have an independent and significant impact on POCs and prolonged PLOS. Further studies are warranted to identify possible causal mechanisms underlying this association.www.aimieditor.com) for English language editing and review services.The authors thank AiMi Academic Services (Conceptualization: Dong Xue Luo, Manlin Duan.Data curation: Zi Chuan Yue.Formal analysis: Dong Xue Luo, Zi Chuan Yue, Jie Jie Zhou.Funding acquisition: Manlin Duan.Investigation: Dong Xue Luo, Min Shi.Methodology: Dong Xue Luo.Resources: Manlin Duan.Software: Dong Xue Luo, Xing Jie Guo, Ya Qing Zhou, Jie Jie Zhou, Li Xiang Yu.Supervision: Lu Yi Shao, Miao Miao Xu, Manlin Duan.Validation: Ya Qing Zhou, Miao Miao Xu, Li Xiang Yu.Visualization: Min Shi, Xing Jie Guo.Writing – original draft: Dong Xue Luo, Zi Chuan Yue.Writing – review & editing: Lu Yi Shao, Manlin Duan.


After controlling for confounding variables, melatonin administration reduced MMP-9 levels to 90 ng/mL (95% CI 77.3–102.6). Conclusions: This pilot study demonstrated that compared to placebo, melatonin administration was associated with better outcomes in AMI patients undergoing primary percutaneous coronary intervention.Background: Matrix metalloproteinase-9 (MMP-9) is crucial in tissue remodeling after an adverse cardiac event. In experimental studies, melatonin has been found to attenuate MMP-9 activation. The present study assessed the effects of systemic melatonin administration on the prognosis of patients with acute myocardial infarction (AMI) successfully treated with primary percutaneous coronary intervention, and to examine the effects on MMP-9 levels. Methods: We conducted a randomized controlled trial, enrolling patients who underwent primary percutaneous coronary intervention due to AMI. They were assigned to two groups for melatonin or placebo. The primary endpoint was a combined event of mortality and heart failure readmission at 2 years. The secondary endpoint was the levels of MMP-9 after the percutaneous coronary intervention. Results: Ninety-four patients were enrolled, 45 in the melatonin group and 49 in the control group. At 2 years of follow-up, 13 (13.8%) patients suffered the primary endpoint (3 deaths and 10 readmissions due to heart failure), 3 patients in the melatonin group and 10 in the placebo group. The difference in the restricted mean survival time was 87.5 days ( The past 35 years have seen intense research to find drugs to reduce myocardial ischemia-reperfusion injury (IRI) . SeveralThe IRI causes numerous collateral reactions in tissues which culminate in the alteration of essential molecules and organelles in a number of cells, including components of the coronary endothelium and myocardium, with the recruitment of circulating blood elements such as leukocytes and platelets. During transient ischemia and the reperfusion period, many cells produce oxygen by-products that are toxic to the heart. In fact, partially reduced oxygen metabolites and the enhanced activation of matrix metalloproteinases (MMP) cause much of the cardiac damage that is sustained during IRI .Solid evidence exists that melatonin influences the cardiovascular system ,5,6,7. A−2), hepatic failure (Child–Pugh class B or C), known malignancy, ventricular fibrillation, cardiac arrest, cardiogenic shock as presenting symptom, previous myocardial infarction. The protocol was approved by the institutional review board and was implemented in accordance with the Declaration of Helsinki. All patients provided informed consent.Prospective, randomized, open-label study conducted in patients presenting with ST-segment elevation AMI who received successful primary percutaneous coronary intervention from September 2017 until December 2018. As per protocol, melatonin had to be initiated within 3 h of symptom onset. Main exclusion criteria were: age ≤ 18 or ≥ 85 years, severe renal failure  or intravenous melatonin 0.24 mg/mL (12 mg in 50 mL). The treatment with placebo or melatonin was delivered as an intravenous infusion for 60 min, starting immediately before primary percutaneous coronary intervention. Of the total cohort, all the patients received solely drug-eluting stents. In addition, antiplatelet drugs, beta-blockers, anticoagulants, statin therapy, and angiotensin-converting enzyme inhibitors were prescribed for all eligible patients as recommended by recent guidelines .Follow-up data were collected using hospital source data as well as all medical records. Contact with patient or family and physicians from other centers was performed when needed.Blood samples were drawn just after completion of the primary percutaneous coronary intervention. Serum samples for MMP-9 levels assessment were collected and aliquoted into several tubes and stored at −80 °C until analysis. Sandwich enzyme immunoassay was performed for measuring concentrations of serum MMP-9 using commercially available kit with monoclonal antibody against the substance , accordiPrimary endpoint was the incidence of death or readmission due to heart failure (defined as worsening of heart failure symptoms that required admission) at 2 years of follow-up. Secondary endpoint was levels of MMP-9 after the primary percutaneous coronary intervention.t-test for equal or unequal variances. Variances were compared using the robust Levene test. Skewed variables were compared using the nonparametric Mann–Whitney U test. Categorical variables were compared using the Fisher exact test except for variables with several categories that could be ordered. For this last case, the trend test was used.Quantitative variables that had a normal distribution were presented as mean ± SD; others were presented as median (interquartile range). To test if quantitative variables had a normal distribution, Shapiro–Wilk test and Q-Q plots were used. We compared quantitative variables with normal distribution using For analyzing the primary end-point , we used the restricted mean survival time (RMST), which does not depend on number of events or proportionality of hazards. The RMST is the average time free from an event up until a milestone time point, a numeric expression of the area under the Kaplan–Meier survival curve. RMST of both groups can be compared, allowing the estimation of the difference of time without the event between arms. For example, a difference in RMST of 10 days would indicate that the treatment group lived on average 10 days longer than the control group ,13. SurvFor the secondary end-point, MMP-9 levels were directly compared between both groups. Despite randomization, some baseline characteristics were different between groups. As sensitivity analysis, we controlled for all baseline variables that were statistically different between arms. To do that, we created a multivariate linear regression model where MMP-9 was the dependent variable, melatonin/placebo was the exposure variable, and the independent variables were those that had statistically significant differences between both groups. Diagnostics of the model were tested. We presented the coefficient with the 95% confidence intervals (CI). Data was analyzed according to the ‘intention to treat’ principle.Ninety-four patients were randomized to melatonin (45) or placebo (49) .Median age was 62.4 (55.7–75.9) and 43 (45.7%) were women. There was no crossover between treatments. All patient characteristics are shown in p = 0.02). HR = 0.3 . Controlling for hemoglobin and number of diseased vessels, the model showed HR = 0.27 . Log-rank test 0.04. Kaplan–Meier survival curves are shown in No patient was lost to follow-up. All censored observations reached 2 years of follow-up. During the two years of follow-up, 13 patients (13.8%) exhibited the combined event (3 deaths and 10 readmissions due to heart failure). Three patients in the melatonin group and 10 in the placebo group manifested these events. The mean time until a clinical outcome event occurred was 699.2 days and 611.8 days for the melatonin and placebo group respectively. RMST difference was 87.5 days (p < 0.001). The distribution of this molecule between groups can be observed in Compared with the placebo, MMP-9 levels were reduced in the melatonin group (248 ng/mL (211–259) vs. 142 ng/mL (130–161) The results of this pilot study indicate that treatment with intravenous melatonin in patients with AMI undergoing primary percutaneous coronary intervention is associated with a reduced incidence of death or readmission due to heart failure. This effect was accompanied by a substantial treatment-related difference in MMP-9 levels, a marker of AMI remodeling response.MMP are a family of zinc-dependent endopeptidases (collagenase type IV) which are synthesized as zymogens. Of particular interest in the heart is MMP-9, which is found in cardiac myocyte, cardiac fibroblasts, and endocardial cells . MMP-9 iAMI is one of the biggest challenges for the health systems of western countries. Survival from myocardial infarction has improved considerably because of early, effective treatment, but myocardial infarction leads to chronic heart failure in many cases, exerting a huge global healthcare burden on a country’s economic resources. Despite timely reperfusion with primary percutaneous coronary intervention, mortality and morbidity following AMI remain significant, with 7% death and 22% hospitalization for heart failure at one year . The socRecently, preclinical or clinical data regarding the role of melatonin in myocardial IRI has been reported in two meta-analyses ,17. Mao The limitations of this study should be recognized. First, the MMP-9 activity is a time-dependent process which increases significantly at 2 to 24 h after reperfusion . In our


Anesthetic management for patients of pseudomyxoma peritonei (PMP) is challenging. This case report describes a patient of PMP with high intra-abdominal pressure. Intubation was performed in lateral position; the intraabdominal pressure was relieved slowly to prevent significant hemodynamic changes. Additionally, positive pressure ventilation was performed to reduce the risk of re-expansion pulmonary edema. During the operation, transfusion and infusion therapy was performed with target-mediated fluid therapy according to stroke volume variation (SVV) and cardiac index (CI) and blood gas analysis. Pseudomyxoma peritonei (PMP) is a rare clinical syndrome. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a safe and effective treatment for PMP . The sur2: 31.1 mmHg, PaO2: 83.6 mmHg, lactate: 1.74 mmol/L, potassium: 4.74 mmol/L, sodium: 132 mmol/L, calcium: 1.14 mmol/L, FiO2: 21%, and SpO2: 96.7%.A 62-year-old woman  was admitted to the hospital because of a 3-month history of increased abdominal circumference, shortness of breath and disable of lay down. The patient was diagnosed as PMP by pathology of ascites. We have got the patient's written informed consent to publish the case report. The patient had a history of hypertension for 11 years, paroxysmal atrial fibrillation for about one month. The blood pressure was controlled by nifedipine. Before the operation, the patient feels dyspnea and must have the passive position of left lateral and reverse Trendelenburg. The abdominal circumference was high to 115 cm . Chest c2, and bispectral index were monitored. A radial artery catheter was placed, intra-arterial blood pressure (IBP), CI, and SVV by using FloTrac vigileo system were monitored. Arterial blood pressure was 148/82 mmHg, heart rate was 97 beats /minute, and SpO2 was 96%. Arterial blood gas analysis showed the following: pH: 7.34, PaCO2: 34 mmHg, PaO2: 80mmHg, lactate: 0.9 mmol/L, potassium: 4.6 mmol/L, sodium: 138 mmol/L, calcium: 1.14 mmol/L, hemoglobin (Hb) 9.6 g/dl, FiO2: 21%, and SpO2: 94.9%. Before anesthesia, 40 μg of dexmedetomidine was infused within 10 min and gastric contents were suction through a gastric tube. The patient was preoxygenated with 100% oxygen at 6 L/minute for 5–10 min. Anesthesia induction was performed with 20 mg of etomidate, 20 μg of sufentanil, and 50 mg of rocuronium. A 7.0 endotracheal tube was inserted with the help of a video assisted device at the first position, and ventilation was performed. The tidal volume was set at 6 to 8 ml/kg, the respiratory rate was 13 to 15 breaths/minute, and the inhalation: expiration ratio was 1:2. Propofol, remifentanil, and sevoflurane were used to maintain anesthesia. Maintenance anesthesia was performed by static inhalation compound anesthesia with propofol 4–8 mg/kg/h, remifentanil 4–8 ug/kg/h, and inhaled sevoflurane 1%–2%, and the depth of anesthesia was adjusted according to the BIS value  to maintain the BIS at 40–60. After the intubation, the patient was slowly put in the supine position and there were no significant changes in blood pressure and heart rate. Then a right internal jugular venous catheter was placed guided by ultrasound and the central venous pressure and oropharyngeal temperature was monitored.The patient was in the passive position of left lateral and reverse Trendelenburg when she was in the operation room. The patient's electrocardiogram, blood pressure, SpO2O at the beginning of the operation to 21 cmH2O, the CI increased from 1.8 L/min.m2to 2.2 L/min.m2, SVV decreased from 13 to 2, central venous pressure (CVP) decreased from 23.3 cm H2O to 15.7 cmH2O. There were no significant changes in blood pressure and heart rate. After ascites drainage, we performed blood gas analysis before the start of the main steps of CRS. Arterial blood gas analysis showed the following: pH: 7.25, PaCO2: 42 mmHg, PaO2: 205 mmHg, lactate: 0.9 mmol/L, potassium: 4.8 mmol/L, sodium: 135 mmol/L, calcium: 1.18 mmol/L, Hb 8.2 g/dl, bases excess (BE) −7.8,FiO2: 60%, and SpO2: 97.0%. The respiratory rate was adjusted to 10 to 12 breaths/minute, the positive end-expiratory pressure was set at 5 cmH2O, FiO2 was adjusted from 1.0 to 0.4.The surgeon created a small incision for paracentesis. 11,000 ml of ascitic fluid was drained in 30 min . In thisCRS was continued for about 3.5 h and about 5 kg of diseased or metastasized tissues were removed . During HIPEC was performed after CRS in a closed-loop manner: after the latex drainage tubes were put in the pelvic and bilateral upper abdomen, the skin was closed and the latex drainage tubes were fixed by continuous suture. The circulation was controlled at the speed of 800 ∼1,000 ml/min. The temperature was set to 41 °C. Mitomycin (MMC) 30 mg and Cisplatin (DDP) 60 mg were dissolved in 4,000 ml of normal saline. HIPEC was continued for 60 min. In this period, the oropharyngeal temperature was increased to 37°C. Torsemide 5 mg was given during this period and another 800 ml of urine was excreted.2and 5–16. Lac was decreased from 0.9 mmol/L at the beginning to 0.6 mmol/L at the end of the surgery. Hb was decreased from 9.6 g/dl at the beginning to 8.5 g/dl at the end of the surgery.The patient was transferred to intensive care unit (ICU) after the operation. x-Ray of Chest revealed the elevated diaphragm was descended at a normal position . These increase the risk of aspiration and rapid desoxysaturation during anesthesia induction, so the airway was carefully evaluated before surgery and prepared for a difficult airway if necessary. To prevent the chance of aspiration, we performed full attraction to the gastric contents before the anesthesia induction. Because of the passive position, we performed the anesthesia induction and intubation at this position after 5–10 min of preoxygen. The patient was slowly put in the supine position and the hemodynamics changes were monitored for avoiding the rapid decrease in return blood volume caused by the huge abdominal pressure compressing the inferior vena cava after rapid supine position, and the decrease will result in great hemodynamic fluctuations. In the operation, we created a small incision for paracentesis to avoid a significant hemodynamic change due to the rapid decrease of intraabdominal pressure and it was proved effective in this patient.Low intravascular volume is very common during CRS due to ascites drainage and blood loss. A large amount of fluid transfusion will be needed. The study of Schmidt showed that all patients were supplemented with 4900m1on average of crystal fluid and 2,500 ml on average of colloidal fluid. Treatment with open fluid to supplement the intraoperative loss of body fluids is at risk of volume overload, tissue edema, and severe abdominal complications , 4. AfteHigh intra-abdominal pressure (IAP) at the level of 18–22 mmHg during HIPEC is feasible and safe in patients diagnosed with PMP . But theCytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy operation is complicated, with a huge incision, completely opened peritoneal cavity, and large fluid loss, especially in HIPEC stage, which can induce significant changes in hemodynamics, high temperature and coagulation dysfunction . Anesthe


The primary endpoints were safety by assessment of adverse events. Secondary endpoints included assessment of kidney graft function, immunological and histological changes related to AMR activity and chronicity assessed by conventional microscopy and molecular transcripts. A total of 3 patients were enrolled in the study before it was terminated prematurely because of adverse events. We found that AMR did not improve in any of the patients after treatment with MSCs. In addition, serious adverse events were observed in one case when autologous MSCs therapy was administered in the late phase after kidney transplantation, which requires further elucidation.Mesenchymal stem cell (MSCs) therapy has already been studied in kidney transplant recipients (KTRs), and the available data showed that it is safe and well tolerated. The aim of this study was to evaluate the safety and efficacy of autologous MSCs in combination with standard therapy in KTRs with biopsy-proven chronic active antibody-mediated rejection (AMR). Patients with biopsy-proven chronic active AMR received treatment with autologous bone marrow-derived MSCs (3 × 10  Chronic antibody-mediated rejection (AMR) is a major challenge to long-term graft survival in kidney transplant recipients (KTRs) . New tec. With the exception of few studies using third-party MSCs  have attracted much interest due to their immunomodulatory properties . In kidnrty MSCs , 14–16, rty MSCs , recentlrty MSCs , 18.in vivo generation of regulatory T cells and suppression of T cell proliferation in response to autoantigens and alloantigens in a non-MHC-linked manner , which was discontinued due to serious adverse events, including kidney graft loss in one patient (published elsewhere)  therapy at a late stage after kidney transplantation. Patients were enrolled in the study protocol (sewhere) .ClinicalTrials.gov, NCT03585855.This was a prospective, investigator-initiated, interventional, single-center clinical study. The study was approved by the National Medical Ethics Committee of the Republic of Slovenia (permit number 0120-215/2018-4) and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. The inclusion and exclusion criteria are presented in the 6 cells/kg 1 week apart . The protocol was developed based on data from studies in experimental animal models, clinical data on previously experimental MSC treatment of renal pathologies, and treatment results of graft-versus-host disease in allogeneic stem cell transplant setting. Our center’s extensive experience with various experimental stem cell treatments also influenced the development of study design. During the follow-up period of up to 12 months, patients were monitored for adverse events according to CTCAE 5.0; estimated glomerular filtration rate (eGFR) was determined according to the Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) monthly for the first 6 months and once every 3 months thereafter; excreted creatinine clearance (ECC) before and after 12 months; kidney transplant Doppler ultrasound at 0, 6, and 12 months; anti-HLA DSAs, antibodies to angiotensin receptor type 1 (anti-ATR1), and anti-endothelin 1 type A receptor antibodies (anti-ETAR) at 0, 6, and 12 months; immunophenotyping of peripheral blood T-cell populations and selected miRNA expression at 0, 1, 3, 6, 9, and 12 months; kidney biopsies including analysis of molecular transcripts by MMDx before and 12 months after MSCs application.The study design is shown in MSCs were prepared and cultured as described in the Kidney function was assessed by eGFR, calculated using the CKD-EPI study formula with serum creatinine (s-Cr), and by 24-hour urine collection and measurement of ECC.Scoring of kidney biopsies and histological diagnosis of AMR were performed in a blinded fashion by a renal pathologist, using the 2019 Banff classification . ImmunohExpression of selected miRNAs was determined by Quantitative real-time polymerase chain reaction (qPCR). The details are provided in the Details of HLA, anti-ETAR, and anti-ATR1 antibodies, peripheral blood lymphocyte populations, and serum cytokine analyses are provided in the Primary outcome measures were safety of MSC therapy assessed by adverse events at 12 months. Secondary outcome measures included changes in kidney graft function, histology, MMDx scores, and miRNA expression during the 12-month follow-up.All the analyses in the study were descriptive and all graphs were created using Microsoft Excel 2021.Baseline and end of follow-up characteristics of patients are presented in 6/kg at 1-week intervals. He reported no adverse events. Histologic assesment before therapy revealed focal glomerulitis and 30% moderate peritubular capillaritis without tubulitis, double contour formation (transplant glomerulopathy) in 10 of 21 glomeruli, 20% interstitial fibrosis/tubular atrophy, and a lymphocytic interstitial infiltrate in areas of interstitial fibrosis (i-IFTA2). A very sparse lymphocytic interstitial infiltrate consisting of CD3+T lymphocytes, scarce CD68+ macrophages, and few CD79a+B lymphocytes was present in another 20% of the preserved renal cortex. Immunofluorescence for C4d in the peritubular capillaries was negative. Electron microscopy showed peritubular capillary basement membrane multilayering (ptcml1), see Patient #1 was a 53-year-old man with end stage kidney disease due to ADPKD who received the first deceased donor kidney transplant 9 years before enrollment in the study. After histological diagnosis of chronic active AMR, patient received SOC therapy, followed by MSCs 3 × 10+ lymphocytes, CD79a+ lymphocytes, and CD68+ macrophages was similar to the biopsy before MSCs administration. MMDx analysis 12 months after MSCs therapy showed persistence of fully developed AMR with molecular classifiers of inflammation and fibrosis in the range of highly elevated values.During follow-up, patient experienced a continuous decrease in kidney function and an increase in proteinuria. The MFI values of DSAs decreased after standard and MSC therapy and remained stable thereafter. Surveillance kidney biopsy at 12 months showed similar histologic features to the previous biopsy, with a decrease in peritubular capilaritis (from 30% to 15%) and an increase in chronicity . The number of CD3+CD4+ and cytotoxic CD3+CD8+ T lymphocytes increased. The proportion of activated CD3+HLA-DR+ lymphocytes increased, whereas the absolute number and proportion of CD4+CD25++ T lymphocytes within the total CD4+ population decreased. CD4+CD25++ T lymphocytes were still suppressed 12 months after MSCs infusion. NK (CD16+CD56+) and B lymphocyte (CD19+) concentrations were consistent with patient age and stable throughout the follow-up period. MSC therapy had no effect on memory T cells. Evaluation of timely expression of miRNA associated with AMR showed no significant changes in expression profiles during the observation period , tubular atrophy (from 10% to 30%), and peritubular capillary basement membrane multilayering (from ptcml 1 to ptcml3), see + lymphocytes, CD79a+ lymphocytes, and CD68+ macrophages were similar to those obtained by biopsy before MSCs were administered. MMDx 12 months after MSC treatment showed molecular classifiers indicative of microvascular inflammation and fibrosis associated with persistent chronic active AMR. Expression of miRNA associated with AMR also showed no significant changes in expression profiles during the observation period  according to the study protocol.Patient #3 was a 26-year-old man with end stage kidney disease due to IgA nephropathy. He received a deceased kidney transplant 4 years before participation in the study. Two years after transplantation, he was diagnosed with mixed T-cell rejection (Banff 4/IB) and AMR treated with high-dose steroids, plasmapheresis, antithymocyte globulin, and rituximab. After 3 years of stable kidney function, s-Cr and proteinuria increased in the last months before enrollment. Graft biopsy revealed chronic active AMR. Because he had a history of childhood acute lymphoblastic leukemia, we performed a bone marrow aspiration before entering the study, which showed mild reactive changes. After completion of SOC therapy, he received MSCs (3 × 102) and kidney graft explantation had to be performed 2 months after the MSCs administration. The full course and temporal evolution of the adverse reaction including histopathological changes have been described in detail previously  or ectopic tissue infiltrates, which would indicate transdifferentiation of infused MSCs, were found in the biopsy specimens. Molecular analysis of the kidney biopsy before and after treatment showed that the classifiers of fully developed severe AMR, including g-, cg-, and ptc-related molecular features, persisted. Previously, we identified miRNAs  which are typically expressed in patients with AMR  during the observation period. MSC therapy had no effect on the number of NK cells and B lymphocytes. Despite an increased percentage of activated T lymphocytes in the peripheral blood, we observed no increase in interstitial inflammation, peritubular capillaritis, or other signs of activity in the renal transplant biopsies compared with the biopsies before MSCs were administered in patient#1 and #2. However, in patient# 3, severe glomerular and tubular damage with endarteritis and thrombotic microangiopathy were noted, as we reported previously. The results suggest that MSC therapy does not alleviate rejection by enhancing the regulatory immune cell component. Rather, it may be responsible for a transient activation of the T-lymphocyte response, which in some cases may enhance the rejection process. The results of our immune monitoring do not coincide with the general knowledge regarding MSCs function both in vivo and in vitro. For example, Carrion et al . The impact of above-mentioned factors on outcome in our patients is difficult to assess, but given the data from preclinical studies in similar cases , decreased MSC function might be expected.Although we currently have limited data related to the results of AMR treatment with MSCs, the largest research to datelignancy , 38. MSClignancy . SimilarTaken together, the administration of autologous MSCs in the three patients with chronic active AMR did not improve kidney graft function and had no protective effect on histological and molecular indicators of AMR activity. From an immunological perspective, treatment with autologous MSCs, when given in the late posttransplant period, could further activate the T-lymphocyte response, which may enhance the rejection process. The safety of MSC treatment in patients after solid organ transplantation should be closely monitored for the occurrence of as-yet unexplained adverse reactions. Further studies with prolonged follow-up are needed before continuing MSCs administration to patients in the late period after transplantation.The main limitation of the study is the small sample size, as the study was terminated prematurely due to serious adverse events in one of the patients. As a result, the originally planned comparison cohort of patients treated with SOC alone was not included. Another shortcoming that may have affected the treatment outcome is that we used a slightly modified protocol for bone marrow isolation and MSCs preparation in patient#2 to ensure a less invasive bone marrow collection.


Evidence regarding blood pressure (BP) variability (BPV) and its independent association with adverse outcomes has grown. Diabetic patients might have increased BPV, but there is still an evidence gap regarding relation between BPV and type 2 diabetes beyond mean values of BP. D) and nondiabetics (ND), and to explore BPV relation with estimated glomerular filtration rate (eGFR), and pulse wave velocity (PWV) as indicators of target organ lesion.  To examine the relationship between 24 h ambulatory BP monitoring  and visit-to-visit in-office BPV , in diabetics (D and ND adjusted for clinical variables. Pearson's correlation was performed to evaluate relation of BPV with eGFR and PWV.  We conducted a single-center cross-sectional study in an outpatient BP unit, including adult patients consecutively admitted from 1999 to 2019. Multivariate was performed to compare BPV between D than in ND. Measurements of OBPV did not differ between groups. Of ABPM BPV, the coefficient of variation and standard deviation for daytime systolic BP were higher in D compared to ND, but only in ND did BPV correlated with both eGFR and PWV.  A total of 1123 patients with ABPM and OBP measurements were included. Values of eGFR and PWV were worse in  We found that diabetes is associated with higher variability of daytime BP than nondiabetics along with worse damage of vascular and renal function. However, in contrast to nondiabetics, in diabetics eGFR and PWV may not be dependent on BP variability, suggesting that other mechanisms might explain more rigorously the greater damage of target organ lesion markers.  High blood pressure (BP) is a well-known risk factor for cardiovascular mortality and morbidity, and the main contributor to global disease burden . In addiBPV can be classified into short-term, mid-term, and long-term variability. Seriated office BP (OBP) over the months and years might be considered as long-term BPV, seriated home BP measurement (HBPM) over a week as mid-term BPV, and (ABPM) as short-term BPV, and all have been related to cardiovascular adverse outcomes , 4.In diabetic patients, both DMT1 and DMT2, atherosclerosis, and microvascular diseases, such as nephropathy, are signs of a poorly managed condition , 6. HypeThus, our aim was to examine the relationship of short-term and long-term BPV with diabetes and interaction of target organ lesion indicators (estimated glomerular filtration rate (eGFR) and pulse wave velocity) in this relationship.We performed a cross-sectional study in the outpatient clinic of Blood Pressure Unit, Hospital Pedro Hispano, Matosinhos, Portugal, an Excellence Center of the European Society of Hypertension . The stuPatients underwent demographic and clinical baseline data collection either by questionnaire in the first appointment or from clinical files: age, gender, weight and height, family history of cardiovascular risk and adverse outcomes, and calculated body mass index (BMI). Clinical analysis, collected within 3 months from first appointment included glycated hemoglobin (HbA1C), fasting plasma glucose (FPG), and 24 h urinary sodium and potassium, and as indicators of target organ lesion: estimated glomerular function according to MDRD formula (eGFR) and pulse wave velocity (PWV). Patients were excluded if they had a significant inflammatory disease, if they had a change in their ongoing therapy in the last 3 months, or if they were pregnant, critically ill, or had a life expectancy under 3 months. Patients were examined under their stable chronic therapies and habitual dietary and physical activity habits.Diabetes mellitus was defined by two fasting plasma glucose ≥ 126 mg/dl, 2 h post-load plasma glucose ≥ 200 mg/dL, HbA1C ≥ 6.5%, or use of antidiabetic agents or personal history of diabetes . Pulse wSeriated OBP and in-office heart rate  measurements were collected in 3 consecutive clinical appointments in the unit, within a 6-month interval from each other. ABPM and OBP measurements were taken as reported in our previous work and performed according to the American Heart Association 2018 recommendations , 8. ABPMBPV was measured by the following parameters: delta systolic/diastolic blood pressure ; coefficient of variation ; standard deviation (SD); average real variability (ARV), computed as the average of the absolute differences between consecutive BP, reflecting reading-to-reading, within-subject variability in BP or pulse levels; and “weighted” 24-hour SD ; other BPV variables were right-skewed. To compare between nondiabetic (ND) patients and diabetic (D) patients a significance level (α) of 0.05 was considered and Pearson's chi-square and Mann–Whitney rank sum tests were applied. We then performed generalized linear regression analysis  for BPV variables that were significantly correlated with diabetes . Most of the continuous variables assumed a non-normal distribution. After visual analysis and the Kolmogorov–Smirnov test, only age, 24 h urinary sodium, daytime/night-time/24H pulse rate, in-office SD DBP, night-time SD DBP, daytime DBP, and eGFR presented a normal distribution  were significantly higher in diabetics vs. nondiabetics, but no differences were found for mean diastolic blood pressure values.A total of 1123 patients (851 nondiabetics and 272 diabetics) were included. The demographic characteristics, previous medical history, family history, and clinical analysis are presented in As shown in P-value 0.003), with the double prevalence of reverse dipper profile in diabetic patients: 37 (14%) of diabetics were reverse dippers vs. 57 (7%) of nondiabetics  . After adjustment, only 24-hours delta SBP and daytime systolic BPV variables (SD and CVS) were independently correlated with diabetes (P=0.040) .P < 0.001) were observed between age and both PWV (Rs for PWV = 0.51) and eGFR (Rs = − 0.49). PWV and eGFR were negatively correlated with each other . Daytime systolic SD and CVS were significantly correlated with both PWV  and eGFR .In the overall population, significant correlations (P=0.04).Age was significantly correlated with all systolic BPV variables, with moderate correlations for daytime BPV, weak for 24 h BPV and negligible for night-time BPV. In The relationship between daytime systolic SD and CVS with target organ lesion indicators (estimated a glomerular filtration rate and pulse wave velocity), by groups are plotted in In the present study, we assessed BP variability in nondiabetics and diabetic patients with 24 h-ABPM and seriated OBP . We applied different formulas of assessment of variability to evaluate the association of BPV with diabetes and, also, the association of BPV with vascular, renal, and target organ lesion indicators . Our population of diabetics was older, weighted more, and had worse clinical conditions than nondiabetics as expressed by higher PWV and lower eGFR. Although no differences in long-term BP variability were observed between groups, variability of daytime systolic BP was higher in diabetics than nondiabetics, even after adjustment for other significant clinical variables, as expected ; in univPrevious evidence suggested that increasing values of long-term BPV predict the development and progression of diabetes organ target lesions, such as nephropathy, including correlation with PWV and urinary albumin excretion, another indicator of kidney lesion , 12. YetRegarding short-term BPV (in 24 h-ABPM): at the moment, there is no standard way of measuring BPV, being one of the strengths of our study the use of different parameters to measure it, allowing for a more comprehensive evaluation of BPV and comparison with further research .The prevalence of reverse dippers was significantly higher in diabetics vs. nondiabetics. This circadian pattern has been related to increased cardiovascular risk, and this association with diabetes has been already explored before .Independently of the measurement, systolic BPV has been increasingly associated with cardiovascular outcomes in diabetic and nondiabetic patients, an impact that might go beyond that of BP , 14. ChiIn our study, short-term BPV was higher in diabetics than in nondiabetics. However, short-term BPV was indeed significantly correlated, in nondiabetics, with increased PWV and lower eGFR, but in diabetics there was no correlation of these markers of target organ lesions and BPV. Looking closer at the results of Chiriacò et al. significant heterogeneity across studies was present, and adverse outcomes were composite measures rather than specific assessments, such as PWV and eGFR, as an estimation of creatinine clearance . Thus, iBPV may indeed be a marker of vascular aging, which may be accelerated in diabetics, but other factors may contribute in a larger scale to it adverse outcomes . In our This cross-sectional study's strengths include a large cohort of patients with and without type 2 diabetes. The comparison between diabetics and nondiabetics allowed for a distinction of the BPV impact beyond diabetes. Although subgroup analysis of patients on BP lowering drugs within diabetic population has already been reported , most ofThe main limitation of our study is its observational cross-sectional nature and the fact it was conducted in a single center. Although we have considered several potential confounders, other characteristics, such as diabetes duration disease, anti-hypertensive drugs, and diabetes treatment could be considered. We have performed complete-case analysis, considering that missing data were not differential between diabetics and nondiabetics. PWV was only available for 37.9% of patients. Considering this is a cross-sectional study, dealing with observational data collected from patients' clinical registries, missing data imputations was not performed . For GLMIn conclusion, we found that diabetes is associated with higher variability of daytime BP than nondiabetics, along with worse damage of vascular and renal function. However, in contrast to nondiabetics, in diabetics eGFR and PWV may be not dependent of BP variability, suggesting that other mechanisms might explain more rigorously the greater damage of target organ lesion markers.


Kidney transplantation is the best renal replacement therapy  for eligible patients with end-stage kidney disease. Studies in some French regions and in other countries suggest a lower access to the kidney transplant waiting listing and also to kidney transplantation, once waitlisted, for women. Using a mixed methods approach, this study aims to precisely understand these potential sex disparities and their causes. The quantitative study will explore the geographic disparities, compare the determinants of access to the waiting list and to kidney transplantation, and compare the reasons and duration of inactive status on the waiting list in women and men at different scales . The qualitative study will allow describing and comparing women’s and men’s views about their disease and transplantation, as well as nephrologists’ practices relative to the French national guidelines on waiting list registration. This type of study is important in the current societal context in which the reduction of sex/gender-based inequalities is a major social expectation. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines define kidney disease as the presence of functional and/or structural abnormalities of the kidney with implications for health . ChronicPrevious studies have identified several medical and non-medical factors that limit access to kidney transplantation at each step of the process. Patients’ characteristics, such as comorbidities ,25,26,27Sex/gender disparities in the access to renal transplantation could be explained partly by the higher rate of immunization linked to pregnancies ,32 that In 2015, the French Haute Autorité de Santé (HAS) published national recommendations for placement on the waiting list  to develTo better investigate the kidney transplantation access potential disparities between women and men in France, this research used a mixed methods approach that combines a quantitative study and a qualitative study . The quaSeveral ways of mixing quantitative and qualitative methods have been described ,56,57,58We hypothesized that access to kidney transplantation is not homogeneous in France. Specifically, access to kidney transplantation is not homogenous between women and men in some French territories (regions and departments) and the underlying reasons may differ among territories. We also hypothesized that the determinants of access to the waiting list and to transplantation as well as the reasons and duration of inactive status on the waiting list may be different between men and women.The objectives of the quantitative study were: (i) to identify geographical disparities of access to kidney transplantation between men and women; (ii) to identify and compare the factors associated with placement on the waiting list and access to kidney transplantation between men and women; and (iii) to compare the reasons and duration of inactive status on the waiting list between men and women.All 18 to 85-year-old patients with ESKD who started RRT in France in 2017, 2018 and 2019 were included and followed until 31 December 2021. Data will be extracted from the REIN registry. This registry was started in 2002 and includes all patients with ESKD treated by RRT in France ,53,59. SAs this research focuses on the access to the first transplantation, patients who are considered for re-transplantation will not be included in the study.Concerning the occupational status at RRT initiation, the REIN registry classifies patients as inactive  and active . Consequently, this variable does not fully represent the patients’ socio-professional situation. As the REIN registry does not contain other data on the patients’ socio-economic status , to overcome this limitation, the neighborhood socio-economic deprivation level at the census-block level  will be integrated using the European Deprivation Index (EDI) as a covariate .t-test (quantitative variables).First, the patients’ baseline characteristics will be described and compared between women and men using the Chi-squared test  and p-value of <0.05 in multivariate analyses will be considered as significant.Then, access to kidney transplantation (living or deceased donor) will be studied through the probability of occurrence of three events of interest: access to the kidney transplant waiting list, access to kidney transplantation after waitlisting, and access to kidney transplantation after dialysis starts. Associations between patients’ characteristics, including sex, and these three events of interest will be analyzed using Cox proportional hazard models  and alsoMoreover, the factors associated with access to transplantation will be thoroughly investigated by integrating a spatial accessibility approach  using, aFor better understanding of the potential disparities in the access to kidney transplantation between women and men, we decided to trace back the patients’ care trajectory, and to determine the patients’ views and expectations about their disease and its management, particularly kidney transplantation. We will cross these data with the nephrologists’ practices regarding the HAS recommendations.not only the potential physiological development of an illness but also the work involved in its management, the impact of illness, and the changes in the lives of the ill and their families that in turn affect their management of the illness itself” [must resolve the dilemma of receiving a gift–vital–without being able to thank the donor, give, or symbolically pay back”, which can lead to some forms of culpability [The approach of our qualitative study is anchored in the interactionist movement  and spec itself” . The pro itself” . Therefo itself” . In the pability ,80. PatiThe qualitative study will include patients with ESKD who started replacement therapy in 2021 and also nephrologists. Without seeking exhaustiveness, which is not feasible in a qualitative study, participants will be chosen using a purposive sampling methodology  based on2, oxygen-dependent) will not be included [For the qualitative study, 40 patients (20 women and 20 men) and 15 nephrologists will be included in each region. Patients with contraindication to kidney transplantation according to the HAS recommendations  and combines two methodological approaches with different paradigms to improve knowledge on the access to kidney transplantation in France. To our knowledge, this is the first study using mixed methods to assess access to kidney transplantation in France with a special focus on the differences between men and women.The mixed methods approach that combines quantitative and qualitative studies is becoming more frequent in scientific publications  and in nthe tendency to present oneself and one’s social context in a way that is perceived to be socially acceptable, but not wholly reflective of one’s reality” [With a qualitative approach, researchers can study phenomena in their natural settings, and can try to make sense of or interpret them in terms of the meanings people give to them . Howeverreality” . Althougreality” , includiThis is the first mixed methods study on the potential association between sex/gender and access to kidney transplantation in France. The results will be presented at various working groups of the operational health agencies (HAS and Agence de la Biomédecine). This will help to produce robust evidence-based and relevant recommendations to enhance the access to kidney transplantation. The results will also be presented at meetings with regional health agency officials and healthcare professionals involved in kidney transplantation. This will contribute to develop more precise and efficient interventions, adapted to the local specificities of each region/department, to improve access to kidney transplantation, for example by encouraging waitlisting practices or reviewing policies on placement on temporary inactive status. Moreover, we will reach out to patients’ advocacy groups and will participate in patients meetings organized by these groups to inform patients on the results of our project, including the barriers to kidney transplantation access, and to promote discussion on this subject.Finally, this type of project is important in the current societal context in which sex/gender inequalities persist in many areas and their reduction is a major social expectation and political issue.This research protocol describes the use of a mixed methods approach to explore potential sex/gender disparities in kidney transplantation access.


Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive.All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups.Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI.The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age. Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological event with a mortality of 30% after 3 months ” study. This study was approved by the local institutional ethical review board. The study was registered in ClinicalTrials.gov with the number NCT04785976. Written informed consent for clinical analyses was obtained from the patients or their surrogates. The article adhered to the applicable Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards for observational studies.Adult patients with emergent admission for surgical clipping due to aSAH were enrolled in this study. The initial clinical severity of aSAH was accessed immediately upon admission. SAH was documented by angiography and confirmed by computed tomography or lumbar puncture. The exclusion criteria were as follows: (1) treatment by both surgical clipping and endovascular coiling; (2) other neurological diseases ; (3) history of neurosurgery prior to rupture; and (4) incomplete perioperative data.Two independent researchers reviewed the electronic medical records and extracted postoperative data. Differences were resolved by a senior investigator. Baseline data included demographic and morphometric characteristics, American Society of Anesthesiologists physical status, coexisting medical condition, pre-operative medication, and neurological function scales, including the Glasgow Coma Scale, the Hunt and Hess Scale, the World Federation of Neurosurgical Societies Scale, and the modified Rankin Scale, which were assessed based on guidelines  to 6 (dead). Poor clinical outcomes were defined by the mRS score of 3–6.Intraoperative blood pressure data were extracted from our Anesthesia Information Management System . Most of the patients had arterial catheters inserted into the dorsal pedis or the radial artery with transducers positioned at the level of the right atrium. The invasive blood pressure measurement system included a built-in filter for artifacts that reduced the resonant effects of the tubing system, in which the blood pressure was recorded at 10-s intervals. Non-invasive blood pressure was monitored with a brachial cuff-based oscillometric method at 5-min intervals.Blood pressure data were excluded using a previously reported method adjusted with our data if (1) invasive data during the initial first 5-min corresponded to the “flushing, leveling and zeroing the transducer” segment; (2) data showed sudden changes of more than 30 mmHg in adjacent invasive pressure values without any annotation identifying clinical causes  or transcranial Doppler (TCD) may also be used.Delayed cerebral ischemia (DCI) was defined as the development of new focal neurological deficits or a decrease in ≥2 points on the Glasgow Coma Scale score for a duration ≥1 h in conscious patients, with the exclusion of any other explanation for the deterioration, such as infection with an associated decrease in consciousness level, rebleeding, edema (increasing) hydrocephalus, hypoglycemia or hyponatremia or hypotension, or any other possible cause for deterioration as judged by the treating physician  and analyzed using a two-tailed chi-square test with continuity correction or the Fisher exact test. The continuous variable is presented as the mean and standard deviation (SD) or the median and inter-quartile range (IQR) and compared with Student's We used logistic regression to identify change points that are indicative of a harm threshold as reported by previous researchers .The results are presented as odds ratios (OR) or adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Model diagnostics were also reported, including the Hosmer–Lemeshow goodness-of-fit test and the area under the receiver operating characteristic curve. The interaction was detected using interaction terms in the regression model, and a variance inflation factor of < 5 was considered as an absence of multicollinearity. For all outcomes, a P < 0.05), a modified Fisher Scale score of 3 to 4 , and the WFNS Scale of Grade 4 to 5  was significantly higher in patients with DCI than those without. Aneurysm characteristics including whether there are multiple aneurysms, the size of the aneurysm, and the locations of ruptured aneurysms did not significantly differ between groups.Of the 629 patients who underwent emergent surgical clipping between January 2015 and December 2020, 534 patients were enrolled . A totalIntraoperative anesthetic-related parameters were compared . The meaP = 0.001), extended hospital stay , and higher medical cost . In addition, patients who experienced DCI had a lower incidence of a favorable outcome at discharge , time-weighted average MAP , or AUC–MAP  between patients with DCI and those without DCI was found. The same trend existed with the other two thresholds   adjustedIn the current study, we included 534 patients who underwent surgical clipping after aneurysmal subarachnoid hemorrhage, out of whom 164 (30.7%) patients showed delayed cerebral ischemia. The duration of intraoperative MAP lower than different thresholds was almost similar in patients who had DCI or not. Furthermore, MAP below 105 mmHg for 30 min did not significantly associate with DCI adjusted by the baseline severity of aSAH and age.In the present study, the incidence of delayed cerebral ischemia was 30.7% (164 out of 524) after surgical clipping ruptured aneurysm, consistent with those of previous studies (Lawton and Vates, Maintaining adequate blood pressure is essential for patients under general anesthesia to treat the aneurysm, avoiding hypotension-related cerebral ischemia (Suarez et al., Lowering blood pressure may attenuate hematoma progression and hemorrhagic transformation in patients with aSAH; in contrast, increased blood pressure could avoid secondary cerebral ischemic damage related to hypotension (Akkermans et al., The study has several limitations. First, the information on intraoperative blood pressure was not prospectively collected, which might lead to a measurement bias. Second, we did not perform a pre-estimation of the sample size, and the relatively limited sample size might contribute to the negative association between the blood pressure threshold and DCI. Third, brain CT was not routinely performed, leading to the exclusion of those patients for whom it was uncertain if the primary endpoint, cerebral infarction, was reached. Finally, we did not relate the MAP threshold to the surgical procedure, that is, the target blood pressure for maintaining cerebral perfusion pressure differs before clipping and after clipping. Weiss et al.  found thIn summary, the presence of DCI was diagnosed in ~30% of the patients with SAH with aneurysm rupture, and baseline SAH severity and age over 70 years old were independent risk factors. Although an association between intraoperative hypotension and the occurrence of postoperative DCI was not found, further prospective research is worth considering with a trial of hypotension avoidance in patients with aSAH.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by Beijing Tiantan Hospital, Capital Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JW, RL, SL, TM, XZ, and YR performed material preparation, data collection, and analysis. JW wrote the first draft of the manuscript. YP and XC designed the research project and revised the manuscript. All authors contributed to the study's conception and design, commented on previous versions of the manuscript, read, and approved the final manuscript.


Introduction: Ischemic colitis (IC) results from compromised blood flow to the colon. Risk factors include atrial fibrillation (A.Fib), peripheral artery disease (PAD), coronary artery disease (CAD), and congestive heart failure (CHF). However, few studies compared the mortality rate and colectomy between patients with IC with CHF and IC alone.Objective: We aim to investigate the possibility of worse outcomes in patients with IC and CHF compared to IC alone.Methodology: Using the National Inpatient Sample database from 2016 to 2019, we obtained baseline demographic data, total hospital charge, rate of colectomy, length of hospital stay (LOS), and in-hospital mortality. Data were compared using a t-test and chi-squared. Odds ratios for comorbidities including A.Fib, CAD, PAD, end-stage renal disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, diabetes, and cirrhosis were calculated.Results: 106,705 patients with IC were identified, among which 15,220 patients also had CHF. IC patients with CHF had a longer LOS , higher total hospital charge , higher mortality rate , and higher colectomy rate .Conclusion: CHF is associated with poor outcomes in patients with IC. Our study showed an increased risk of mortality and colectomy compared to patients with IC alone. The findings suggest it may be warranted to have a heightened clinical suspicion of IC in patients with CHF who present with bleeding per rectum. Ischemic colitis (IC) is a form of bowel ischemia resulting from hypoperfusion to the colon and is relatively common in the United States (US). The incidence of IC has been steadily increasing over the past four decades . Prior sCHF is a common condition that results when the heart fails to sustain the body's metabolic demands. In this setting, the colon, which relies heavily on vascular collaterals to maintain its blood supply is susceptible to low perfusion ischemic injury. In addition, CHF causes reduced cardiac output and, therefore, may be a risk factor in determining the severity of IC.Previous studies have concluded a higher risk of mortality and colectomy rates in patients with IC who also have significant comorbidities such as cirrhosis and chronic obstructive pulmonary disease (COPD) ,6. HowevData sourceOur study is a retrospective cohort study of patients admitted to hospitals with a primary diagnosis of IC in the United States between the years 2016 and 2019. The data were extracted from the Healthcare Cost and Utilization Project National Inpatient Sample (NIS) database. The NIS is sponsored by the Agency for Healthcare Research Quality (AHRQ) and is considered the largest publicly available inpatient health care database in the United States. The database includes data from at least 46 states and covers more than 97% of the US population [Study variablesBaseline demographic data, including age, gender, and race; hospital information, including region and region; comorbidities, including atrial fibrillation (A.Fib), coronary artery disease (CAD), peripheral arterial disease (PAD), end-stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), hyperlipidemia (HLD), hypertension (HTN), diabetes mellitus (DM), and cirrhosis; and outcome variables, including colectomy rate, in-hospital mortality rate, total hospital charge, and length of stay were collected. The data were compared using a t-test and chi-square.Statistical analysisThe statistical analysis was performed using STATA software, version 17.0 . The characteristics of patients with OSA alone and those who had both OSA and GERD were described using descriptive statistics. In this study, multivariate logistic regression analyses were performed to determine factors associated with in-hospital mortality. Variables that were not statistically significant  on univariate analysis were excluded from the multivariate analysis, except for PAD, as it is considered an important risk factor for IC. The odds ratio at 95% CI was used to describe the association between the study and outcome variables. Statistical significance was defined as a two-tailed p-value of <0.05.Patient and hospital characteristicsWe identified 106,705 patients with IC, among which 15,220 patients also had CHF diagnoses . In comparison to patients without CHF, patients with IC with CHF had an increased prevalence of males  and black race . Most patients were predominantly white females in both groups. The differences between hospital characteristics and insurance type were statistically significant  Table . A plot  Length of Stay and Total Hospital ChargesIn IC patients with CHF, the mean LOS was statistically significantly longer than in IC without CHF . Total hospital charges were also significantly higher in the IC and CHF group . Table ColectomyPatients with IC and CHF had an increased rate of in-hospital colectomy compared to patients with IC without CHF  Table . A plot This retrospective study is the first to evaluate the effect of CHF on outcomes in hospitalized patients with IC. Our results are concordant compared to similarly designed studies that examined COPD and cirrhosis instead of CHF ,6. FurthWhen adjusting for age, gender, race, and various comorbidities, we found that patients with IC and CHF had a nearly three-fold increase in mortality in patients with IC and coexisting CHF. Additionally, most of the other comorbidities included in the analysis, some of which are known risk factors for the development of IC, were associated with worse outcomes when combined with IC. This may reflect a reduced colonic vascular reserve in response to the hemodynamic derangements caused by CHF . OutcomeMortality in patients with IC may occur secondary to the complications of bowel necrosis, leading to sepsis and multiorgan failure, which in turn obligates one to undergo respective surgery. The adverse hemodynamic changes of CHF likely predispose the colon to such irreversible complications and, therefore, colectomy. We found that CHF increases the risk of undergoing colectomy in hospitalized patients with IC. Moreover, patients undergoing colectomy due to complications of IC face higher perioperative mortality with a co-diagnosis of CHF ,16.Although CHF per se is associated with high perioperative mortality in non-cardiac surgery , the degIn keeping with higher mortality rates and colectomy, we observed that those with IC and CHF had a longer LOS and higher hospital charges. This was likely directly related to increased rates of colectomy and the need for additional medical treatments or surgical interventions. The type of surgery used to perform the colectomy was not specified, which could have affected the results. Laparoscopic colectomies were associated with reduced hospital LOS compared to open colectomies in patients with IBD . FurtherThe population study was significantly skewed toward the female gender and slightly older adults. The older adults may have a lower physiologic reserve or other comorbidities unaccounted for by the study, resulting in worse outcomes. It remains unclear why the female gender or Black race was associated with worse outcomes. Perhaps this reflects inequities in healthcare delivery to specific populations. Greater age and male sex were independently associated with mortality in IC in a large population-based study , which wThis study has several limitations. The first is its retrospective nature. Specific details such as the severity of heart failure and specific heart failure syndrome  were not obtained. Additionally, the mortality rates associated with IC vary depending on the area of the colon involved, with right-sided IC and pan-colonic ischemia being worse than isolated left-sided IC -22. TherIn our study, the diagnosis of CHF and IC is associated with increased mortality (5.6%), length of stay (2.2 days), rates of colectomy (3.5%), and hospitalization costs  when compared to IC alone. Based on these findings, increasing the clinical suspicion and close observation of IC in patients with CHF who present with bleeding per rectum might be warranted. Furthermore, outcomes may vary with the degree of heart failure, anatomic area of colonic involvement, and presence of other comorbidities not included in our study, and we recommend further research in these areas regarding this topic. In addition, we advocate for exploration into race and gender as possible prognostic indicators for IC. Finally, hospitalization costs are significantly higher in patients with IC and CHF, and we further recommend that future studies focus on costs associated with comorbidities in the setting of IC to facilitate the development of healthcare policy.


Suboptimal blood pressure control among people living with diabetes mellitus (DM) is one of the primary causes of cardiovascular complications and death in sub-Saharan Africa (SSA). However, there is a paucity of evidence on the prevalence and associated factors of suboptimal blood pressure control in SSA. Therefore, this review aimed to estimate its pooled prevalence and associated factors among people living with DM in SSA. I2 test, and small study effect was checked using Funnel plot symmetry and Egger’s statistical test at a 5% significant level. A random-effects model was used to estimate the pooled prevalence and associated factors of suboptimal blood pressure control at a 95% confidence interval (CI) and significance level of p < 0.05.We systematically searched PubMed, African Journals OnLine, HINARI, ScienceDirect, Google Scholar, and direct Google to access observational studies conducted in SSA. Microsoft Excel spreadsheet was used to extract the data, which was exported into STATA/MP version 16.0 for further analyses. Heterogeneity across studies was checked using Cochran’s Q test statistics and CI: 63.43, 76.25%). Poor adherence to antihypertensive treatment  and overweight  were significantly associated with suboptimal blood pressure control.Of the 7329 articles retrieved, 21 articles were eligible for the meta-analysis. After performing random-effects model, the pooled prevalence of suboptimal blood pressure control was 69.8% (95% The prevalence of suboptimal blood pressure control among diabetic patients in SSA was high, and poor adherence to antihypertensive treatment and overweight were significantly associated with suboptimal blood pressure control. Hence, there is an urgent need for initiatives to improve and control hypertension, and preventive measures should concentrate on modifiable risk factors.PROSPERO CRD42020187901.The online version contains supplementary material available at 10.1186/s13643-022-02090-4. Hypertension is the worldwide leading cause of cardiovascular diseases (CVD) and deaths  and accoTherefore, it is imperative to control CVD risk and mortality in diabetes patients, and the most effective and powerful intervention to reduce it is controlling blood pressure by integrated use of lifestyle modifications and appropriate regimen and dose of antihypertensive medications , 11. TheA meta-analysis has revealed that a 10-mm Hg reduction in systolic blood pressure reduced the risk of major cardiovascular disease events by 20%, coronary heart disease by 17%, stroke by 27%, heart failure by 28%, and all-cause mortality by 13% . LowerinEven though extensive efforts to develop interventional BP control strategies to decrease the risk of complications have been made in the past several decades, there is still a significant rise in the risk of complications in diabetic patients with hypertension, and the control of BP is suboptimal. To solve this problem and meet the blood pressure target, understanding the pooled prevalence and risk factors of blood pressure control particularly in SSA is important. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence and associated factors of suboptimal blood pressure control among people living with DM in SSA.By pooling the findings of 21 studies, this study determined the pooled prevalence and associated factors of suboptimal blood pressure control among DM patients which in turn may help clinicians and policymakers to design effective intervention strategies to improve blood pressure control among the diabetic population in the most affected region, SSA. Moreover, the result of this study will be a baseline for future studies that possibly determine other possible causes of the high prevalence of suboptimal blood pressure control.What is the estimated pooled prevalence of suboptimal blood pressure control among diabetes mellitus patients in sub-Saharan African countries?What are the associated factors of suboptimal blood pressure control among diabetes mellitus patients in sub-Saharan African countries?https://www.crd.york.ac.uk/PROSPERO/#myprospero. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines  studies that have reported the prevalence and/or associated factors of suboptimal blood pressure control among people living with type 1 or type 2 diabetes mellitus were included.Language: Studies written in the English language were included.SBP ≥ 140 mmHg and/or a DBP ≥ 80 mmHg, and (3) SBP ≥ 130 mmHg and/or DBP ≥ 80. The latest BP cut point to define suboptimal blood pressure control among DM patients is SBP ≥ 130 mmHg and/or DBP ≥ 80 [Outcome: The outcome variable of this study was suboptimal blood pressure. In the primary studies, the outcome variable was defined using different blood pressure cut points. Included studies defined suboptimal blood pressure control in diabetes as follows: (1) systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, (2) DBP ≥ 80 –33.Publication year: Studies published before July 20, 2020, were included.Studies that did not report the prevalence of suboptimal blood pressure control among type 1 or type 2 diabetes patients, case reports, case series, letters to the editors, and studies conducted on specific populations were excluded.PubMed, African Journals OnLine, HINARI, ScienceDirect, Google Scholar, and direct Google search were used to access relevant studies for this review. Moreover, reference lists of eligible studies were retrieved to account for the missed studies in the database searching. All studies reporting the proportion or prevalence of suboptimal blood pressure control among people living with DM (either T1DM or T2DM) in SSA countries were the target of this review.A search strategy was established for each database by combining MeSH  terms. Example of the search strategy for PubMed  OR (“Hypertension control”) OR (“blood pressure control”) OR (“management of hypertension”) OR (“Treatment of Hypertension”)) AND ((“Diabetes Mellitus”) OR (“Type 2 diabetes mellitus”) OR (“Type 1 diabetes mellitus”) OR (“Diabetes”)) AND ( (Angola) OR (Benin) OR (Botswana) OR (Burkina Faso) OR (Burundi) OR (Cameroon) OR (Cape Verde) OR  OR (Chad) OR (Comoros) OR (Congo) OR (Ivory Coast) OR (Democratic Republic of the Congo) OR (Djibouti) OR  OR (Eritrea) OR (Ethiopia) OR (Gabon) OR (Gambia) OR (Ghana) OR (Guinea) OR (Guinea-Bissau) OR (Kenya) OR (Lesotho) OR (Liberia) OR (Madagascar) OR  OR  OR (Mauritania) OR (Mauritius) OR (Mayotte) OR (Mozambique) OR (Namibia) OR (Nigeria) OR (Reunion) OR (Rwanda) OR (Saint Helena) OR (Sao tome) OR  OR (Seychelles) OR (Sierra Leone) OR  OR (South Africa) OR (South Sudan) OR (Swaziland) OR (Togo) OR (Uganda) OR (Tanzania)OR (Zambia) OR (Zimbabwe)).All studies retrieved using different electronic databases were exported into EndNote version X7. After excluding duplicated articles, titles of all articles were screened, and abstracts and their full texts were independently reviewed by two authors (YA and SAT). Disagreement between reviewers was resolved by further discussion and other reviewers (DAA and MG).Findings on the prevalence and associated factors of suboptimal blood pressure control among diabetic patients from each study were summarized by two authors (YA & YY) using the data extraction format which was prepared with the assistance of the Joanna Briggs Institute (JBI) data extraction tool for prevalence studies, and the extracted data were compared between the two authors (YA and YY). Discrepancies were resolved by consensus after discussion. For each study, the name of the first author, year of publication, study design, sample size, blood pressure cut point used , the prevalence of suboptimal blood pressure control, or the number of cases with suboptimal blood pressure control, and associated factor  estimates (odds ratio or the cases in each cell) with their standard error were extracted.The quality of included studies was assessed using the validated modified version of a quality assessment tool for prevalence studies . Two revQ-test and I2 statistics [The extracted data in Microsoft Excel were exported into STATA version 16.0 software for further analysis. The pooled estimate of the prevalence of suboptimal blood pressure control and its associated factors was determined by the random-effects model using DerSimonian-Laird weight . Statistatistics . To miniPublication bias  was checked using funnel plot and statistically by Egger’s test . Odds raWe retrieved 7329 records of journal articles in the electronic database search, and 974 duplicates were removed. After a scrupulous review of the titles and abstracts, we excluded 5794 articles. Five articles were excluded in the full-text review because of differences in the population under study , full teOf the 21 studies, 5 were from South Africa –45, 5 frCI: 63.43, 76.25%), and considerable heterogeneity was observed among studies  , indicating no publication bias  was significantly associated with suboptimal blood pressure control among people living with diabetes mellitus , I2 = 0.00%, p = 0.47) was significantly associated with suboptimal blood pressure control  was not significantly associated with suboptimal blood pressure control , which is in line with the study among diabetes patients in 11 sub-Saharan African countries (74.5%) [CI: 66.92, 88.39) which is in line with a LEADER trial study among type 2 diabetes patients in 32 countries (74%) [The pooled prevalence of suboptimal blood control in diabetes patients among 21 studies in SSA was 69.8% (95% es (74%) , a largees (74%) , a studyes (74%) . The higes (74%) . In addies (74%) , 69. Lowes (74%) . This hiHowever, the prevalence of suboptimal BP control in this review is higher than the finding of a review of 16 studies (64.8%) , a studyOn the contrary, the prevalence of suboptimal BP control among peoples living with diabetes in this review is lower than the prevalence of suboptimal blood pressure control in Spain (90.2%) . This vaCI: 61.9%, 78.08). A similar study that uses the same BP cut point to diagnose suboptimal blood pressure control in Saudi Arabia among 1178 diabetic reported a consistent finding (71.8%) [On the other nine studies of this review which used a BP cut point of 140/90, the pooled prevalence of suboptimal blood pressure control was 70.0% (95%  (71.8%) . In this (71.8%)  and Tanz (71.8%)  that useIn this review, diabetes patients with poor adherence to antihypertensive medications were more likely to have suboptimal blood pressure control. This finding is in agreement with existing literature showing a higher prevalence of suboptimal blood pressure control among patients with poor adherence . This is2 or greater was associated with suboptimal blood pressure control. Consistently, other studies reported that being obese is associated with suboptimal blood pressure control [In the current review, a BMI of 25 kg/m control , 87, 88. control . Insulin control . Moreove control , therebyFindings from the current review might be helpful for clinicians, programmers, and policymakers to design a strategy and take prompt interventions which would prevent complications and death due to uncontrolled hypertension in people living with diabetes and hypertension comorbidity.Though sensitivity, subgroup, and meta-regression analyses were conducted to minimize the effect of heterogeneity, the extent of heterogeneity among the included studies was high which might be due to the difference in the study area, methodology, study period, blood pressure cut point used to diagnose suboptimal blood pressure control, and other unexplained variations. Hence, clinicians and policymakers should consider these during the interpretations of results.It would be better if future efforts focused on identifying further causes of high prevalence of suboptimal blood pressure control among diabetes patients in SSA on a larger sample size. Moreover, clinicians and policymakers should concentrate on controlling modifiable risk factors of suboptimal blood pressure control.2 or greater and poor adherence to antihypertensive treatments were significantly associated with suboptimal blood pressure control. Preventive measures should concentrate on overweight patients and patients with poor adherence to antihypertensive medications. The pooled prevalence of suboptimal blood pressure control among people with diabetes was high. This high prevalence of suboptimal BP in hypertensive diabetic people highlights an urgent need for initiatives to improve and control hypertension. BMI of 25 kg/mAdditional file 1: S. Figure 1 Forest plot for meta-analysis of suboptimal blood pressure control sub-analyzed by blood pressure cut point used for diagnosis of suboptimal blood pressure control among diabetes patients in sub-Saharan Africa countries . S. Figure 2 Forest plot for meta-analysis of suboptimal blood pressure control among diabetes patients in sub-Saharan Africa countries sub-analyzed by Type of DM . S. Figure 3 Forest plot for meta-analysis of suboptimal blood pressure control among diabetes patients in sub-Saharan Africa countries sub-analyzed by sample size . S. Figure 4 Forest plot for meta-analysis of suboptimal blood pressure control among diabetes patients in sub-Saharan Africa countries sub-analyzed by publication year . S. Figure 5 Forest plot for meta-analysis of suboptimal blood pressure among diabetes patients in sub-Saharan Africa countries sub-analyzed by income .Additional file 2: Search strategies of data bases used for the systematic review and meta-analysis on prevalence and associated factors of suboptimal blood pressure control among diabetes mellitus patients in sub-Saharan Africa.