The hypertension care cascade has been characterized worldwide, yet it has not been quantified how far above the blood pressure control threshold people with uncontrolled treated hypertension are. We summarized the mean systolic blood pressure  in people treated for hypertension but SBP not <130/80.We did a cross-sectional analysis of 55 WHO STEPS Surveys , comprising six world regions ; we only included the most recent survey by country regardless of when it was conducted. Adults, men and women, aged between 25 and 69 years, with self-reported hypertension receiving antihypertensive medication and whose blood pressure was >130/80 mmHg were included. We quantified the mean SBP overall and by socio-demographic  and cardiometabolic  risk factors.The lowest SBP was observed in Kuwait  and the highest in Libya . In 29 countries, the SBP was higher in men, and SBP tended to be higher in older groups except in six countries. In 17 countries, the SBP was higher in rural than in urban sites, for example in Turkmenistan the SBP was 162.3 (95% CI: 158.4–166.2) mmHg in rural versus 151.6 (95% CI: 148.7–154.4) mmHg in urban areas. In 25 countries, the SBP was higher in adults with no education, for example in Benin the SBP in people without formal education was 175.3 (95% CI: 168.8–181.9) mmHg versus 156.4 (95% CI: 148.8–164.0) mmHg in people with higher education.Stronger interventions to improve and secure access to effective management are needed in most countries and specific groups, to reach hypertension control in people with hypertension already receiving antihypertensive medication.10.13039/100010269Wellcome Trust International Training Fellowship (214185/Z/18/Z).The  We searched PubMed on January 4th 2023 using the terms: ((hypertension[tiab] AND ((medication OR treatment) AND control) and blood pressure[tiab]) AND national[tiab]). There were 224 reports, many informing about the hypertension care cascade and its determinants in different national populations. To the best of our knowledge, there were no reports about the gap between the mean blood pressure and the target blood pressure in people with uncontrolled hypertension.The global evidence on the hypertension care cascade has been well-described including trends since 1990 for all countries in 2021 by the NCD-RisC. The hypertension care cascade comprises three steps: awareness ; treatment ; and control . Nonetheless, knowing the control rate  tells us half of the story, with the other half being: Leveraging on 55 national health surveys in which blood pressure was measured with standard methods, we identified people with self-reported hypertension receiving antihypertensive medication yet whose blood pressure was still above 130/80 mmHg (herein defined as blood pressure control threshold). In such group, we quantified the mean systolic blood pressure and described how far above the control blood pressure threshold the mean was. In so doing, we advanced the global evidence on the hypertension care cascade showing the magnitude of the task ahead to bring people with treated uncontrolled hypertension below the blood pressure control threshold. Arguably, when the goal seems far away, stronger or multiple tasks are needed to reach the goal; conversely, when the goal appears easy to achieve, fewer efforts may suffice to reach the goal. For example, a country where the mean systolic blood pressure in people with treated uncontrolled hypertension was 1 mmHg above the blood pressure control threshold would need, possibly, fewer efforts than a country where the gap is 10 mmHg.The global evidence on hypertension care cascade mapped where treatment and control rates were not optimal. Our work advanced this evidence by showing that the task to bring patients with treated uncontrolled hypertension below the control threshold is daunting; we observed that the mean systolic blood pressure was 16 mmHg above the control threshold in the best-case scenario. This work provides a new metric to complement the care cascade, currently only including awareness, treatment, and control.,1). Unfortunately, the antihypertensive treatment coverage and the blood pressure control rates in people with hypertension vary globally,,,Despite available treatments and interventions,Cross-sectional empirical analysis of a pooled dataset of WHO STEPS Surveys.We pooled individual-level data of all surveys and excluded observations with implausible values in all three blood pressure measurements : DBP <50The WHO STEPS Surveys are freely available online through the official data repository. The WHO STEPS Surveys are available for independent reanalysis and do not contain personal identifiers. We deemed this work as of minimal risk and did not seek approval by an Institutional Review Board.1. These selection criteria led to a substantial sample size reduction because we are studying a small fraction of the population  because this age band was consistent across surveys  . We onlypulation : people ,,We summarized the mean SBP at the country level and stratified by socio-demographic determinants and cardiometabolic risk factors. Of note, throughout the manuscript where we refer to mean SBP, such mean is based on the average of the last two of three blood pressure measurements. The results focused on SBP only because the association between SBP and cardiovascular diseases may be stronger than for DBP and cardiovascular diseasesWe stratified the mean SBP by socio-demographic determinants: i) age, collapsed in three groups ; ii) sex (men and women); iii) urban/rural location as collected and defined by each WHO STEPS Survey; and iv) level of education, collected with questionnaires and collapsed in four levels . We also stratified the mean SBP by cardiometabolic risk factors: i) current smoking, collected with questionnaires (no versus yes); and ii) self-reported diabetes diagnosis, collected with questionnaires (no versus yes).statistically significant differences between groups or countries. Whenever we argue there was a strong or substantial difference between two groups , it is because the 95% CI did not overlap. Results are presented with figures and the underlying exact numbers are provided as Supplementary Materials. Countries were grouped into geographic regions according to the classification by the World Health Organization; likewise, countries were clustered according to income group based on the World Bank classification.This is a descriptive analysis conducted with R (version 4.1.2). We summarized the mean SBP at the country level and stratified by all levels of the socio-demographic determinants and cardiometabolic risk factors. The mean SBP is presented alongside the 95% confidence intervals (95% CI). The results account for the complex sampling design of each survey and are therefore informative at the general population level in each country. This is a descriptive work to summarise the mean SBP and we did not aim to claim The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. RMC-L and WCG-V had full access to the data and conducted the statistical analyses, and they are the guarantors of the study and vouch for the accuracy of the results. RMC-L had final responsibility for the decision to submit for publication.The analysis included surveys from 55 countries and 10,658 records met the selection criteria . The oldOverall , and accIn 29/55 countries the mean SBP was higher in men than in women, and in Qatar (Eastern Mediterranean) the mean SBP was virtually the same between men  and women . The mean SBP in countries in the Americas was either higher in men or similar between men and women ; for theIn general, the mean SBP increased with age, yet there were six countries where the opposite pattern was observed . In ArmeIn 25/55 (45%) countries, the mean SBP was highest in adults with no formal education . AlthougIn 17/25 (68%) countries with urban/rural location information, the mean SBP was higher in rural than in urban sites . The larIn 26/54 (48%) surveys with information about current smoking status, the mean SBP was higher in people that currently smoked at the time of the survey than in people who did not smoke . The larIn 35/54 (65%) surveys with information about self-reported diabetes, the mean SBP was higher in people with self-reported diabetes than in their otherwise healthy counterparts . The lar1); conversely, in the worst-performing country the mean SBP was 41 mmHg higher than the SBP control threshold. There was an heterogenous sex pattern whereby in 29/55 countries the mean SBP seemed to be higher in men than in women. As expected, the mean SBP tended to be higher with older age, though there were six countries where the mean SBP appeared to be highest in the youngest age group. In 25/55 countries, the mean SBP seemed to be highest in people with no formal education; similarly, in 17/25 countries, the mean SBP seemed to be higher in people living in rural than urban areas. Finally, in 26/54 countries, the mean SBP appeared to be higher in current smokers, and in 35/54 countries, the mean SBP seemed be higher in people with self-reported diabetes.Leveraging on 55 national health surveys we quantified the mean SBP in people with uncontrolled treated hypertension. At the country level, in the best-performing country, the mean SBP was 16 mmHg higher than the SBP control threshold .1) we used to define the study population may be seen as an aggressive target, which is difficult to achieve even in high-income countries with solid health systems.We acknowledge that the blood pressure control threshold  be enough to improve treatment for people with uncontrolled yet treated hypertension? What new interventions to boost antihypertensive medication adherence are warranted in diverse settings and populations? These questions deserve careful consideration by high-quality research.Our work has several strengths. We analysed individual-level data from 55 surveys conducted in a national sample. Our results for blood pressure were based on the gold standard: the average of the last two out of three measurements. Moreover, the results accounted for the complex sampling design of each survey. Altogether, our results provide strong evidence to inform policies, strategies, and interventions to improve blood pressure control in people with uncontrolled treated hypertension in 55 countries across the globe.1). In this line, the sample size for some countries included much more women than men or vice versa. The results should be interpreted accounting for this sex imbalance. As such, using our results deserve careful consideration examining the sample size, sex-imbalance, and year when they survey was conducted. The small sample size in some countries may compromise the representativeness of the results for the underlying general population in the country; however, the results may still be informative for the underlying population. Future work should verify our findings with a much larger sample size, possibly by pooling several surveys per country or by using national registries of patients with hypertension. Second, because of data availability we included few socio-demographic determinants and cardiometabolic risk factors. Had we included other cardiometabolic risk factors, such as obesity or high cholesterol, the sample size would have been smaller (after accounting for missing observations in these variables and because blood biomarkers were collected in some WHO STEPS Surveys only). Third, this is a descriptive analysis whereby we summarized the mean SBP in a relevant population (people with uncontrolled treated hypertension) stratified by key socio-demographic and clinical determinants. Analysing the association  between the socio-demographic determinants or cardiometabolic risk factors with SBP was beyond the scope of this work. This, because the role of these socio-demographic determinants and cardiometabolic risk factors in the epidemiology of hypertension has been well studied in the past.,,statistically significant differences between countries or groups . The reason was because we aimed to characterize the mean SBP in people with uncontrolled treated hypertension in diverse populations, rather than to claim the mean SBP was statistically higher/lower in one country than the other(s). The results without statistical comparisons provide solid evidence for policy makers and public health officers in these 55 countries, who now have data to support the formulation of stronger interventions to achieve substantial SBP reductions overall and in some subgroups. Moreover, from a presentation standpoint, comparisons across countries will deliver 1486 p-values . These p-values would need to be summarized in a very busy table compromising its readability, interpretability, and appeal to the readers. Fifth, we used self-reported information about antihypertensive treatment which did not incorporate evidence about adherence as it is common practice in global analyses.Notwithstanding, there are limitations we must highlight to improve the interpretation of the methods and results. First, for some countries there was a rather small sample size because we studied a fraction of the population (i.e., people with hypertension receiving antihypertensive medication and whose SBP/DBP was >130/80 mmHg,The global hypertension care cascade has been characterized,RMC-L conceived the idea. RMC-L and WCG-V downloaded and pooled the data. RMC-L and WCG-V conducted the statistical analysis and verified the underlying data. RMC-L and ABO drafted the manuscript with support from all co-authors. All co-authors edited and provided critical input to improve the manuscript through several rounds of revisions. All authors approved the submitted version.https://extranet.who.int/ncdsmicrodata/index.php/home. Access to the data requires personal login credentials, we therefore cannot share the data with the manuscript.Data can be freely accessed and downloaded from the World Health Organization NCD Repository at All authors declare no competing interests.


In cardiorenal syndrome (CRS) type 1, acute cardiac failure or acute decompensation of chronic heart failure causes acute kidney injury (AKI). Every individual AKI episode increases the risk for chronic kidney disease (CKD) in the long term. In this study, we aimed to evaluate epidemiological characteristics and outcome variables of CRS type 1 individuals from the nephrologist’s perspective.The study was performed in a retrospective, observational manner. All AKI patients treated at the Brandenburg Hospital of the Medical School of Brandenburg between January and December 2019 were screened for diagnostic criteria of CRS type 1. Endpoints were in-hospital death, need for dialysis, and renal recovery.During the screening, 198 out of 1189 (16.6%) AKI subjects were assigned to the diagnosis CRS type 1. The overall in-hospital mortality was 19.2%; 9.6% of the patients required dialysis due to AKI. Complete recovery of kidney function was observed in 86 individuals (43.4%); incomplete recovery occurred in 55 patients (27.8%). Mortality-predictive variables were AKIN stage 2, longer ICU treatment, and insulin-dependent diabetes. Regarding dialysis, AKIN stage 3 and higher potassium at the time of diagnosis were predictive. Subjects with longer in-hospital stay recovered more often from CRS type 1.The incidence of CRS type 1 is high  and the mortality is higher than the average mortality of AKI in general. At the same time, complete recovery of kidney function occurs less frequent. The kidney-related follow-up management of CRS type 1 needs to be significantly optimized to improve the long-term outcome of affected patients. In 2008, Ronco et al. introduced the concept of cardiorenal syndromes (CRS) . It diffIn CRS type 1, acute cardiac failure or acute decompensation of chronic heart failure impairs kidney function . ImpaireIt is being estimated that ∼25% of all subjects that are hospitalized due to acute decompensated heart failure develop acute kidney dysfunction or AKI of variable severity (CRS type 1) –14. LateThe study was conducted in a monocentric, retrospective, and observational manner. It was not required to obtain written consent due to the retrospective nature of the study. The study was formally approved by the ethics committee of the Medical School of Brandenburg (No.: E-01-20200602). The observational period lasted from January until December 2019. Based on an electronic algorithm which was implemented hospital-wide in summer 2018, every patient with an increase of serum creatinine according to criteria 1 or 2 of the KDIGO guideline from 2012  was screThe diagnosis of CRS type 1 was made if AKI according to the KDIGO guideline  occurredPrimary endpoint was in-hospital survival. Secondary endpoints were the need for dialysis and recovery of kidney function until demission . Complete renal recovery was diagnosed if the last eGFR was ≤ 10% the initial eGFR. If the last eGFR was higher than the lowest value during the treatment course but more than 10% lower as compared to the initial value, we diagnosed incomplete recovery.t test (two groups) or with ANOVA (three groups), not normally distributed data were compared with the Mann–Whitney test (two groups) or the Kruskal–Wallis test (three groups). For correlation analysis, we calculated the Spearman’s rank correlation coefficient. For the identification of endpoint risk factors, we performed multivariate logistic regression analysis. A p value of below 0.05 was stated as statistically significant. Results are either given in percent or as mean ± SD or SEM as indicated. For all statistical analyses, we employed the following application: Wizard 2 for MacOS, Version 2.0.5, developer: Evan Miller.Comparisons between two groups were performed with Chi-square test for categorical data. Numerical data were initially tested for normal distribution with the Kolmogorov–Smirnov test. Normally distributed data were compared with Student’s n = 136 (68.7%), stage 2 n = 38 (19.2%), and stage 3 n = 24 (12.1%). All further characteristics of included subjects are summarized in Table During the screening period between January and December 2019, a total number of 1,189 subjects were diagnosed with acute kidney injury according to KDIGO . One-hunn = 38). To identify surrogate parameters that were possibly associated with a higher risk for death, the following variables were defined: gender, age, duration of in-hospital treatment, initial eGFR and eGFR at demission , dialysis therapy at any time during hospital treatment, initial serum sodium and potassium, serum sodium and potassium at the time of AKI diagnosis (onset), initial and peak CRP, initial NT-proBNP, vasopressor therapy at any time during hospital treatment, ventilatory therapy at any time during hospital treatment (non-invasive and invasive), ICU treatment (categorized according to the length of stay at the ICU), coronary angiography, diabetes mellitus, pre-existing chronic kidney disease (CKD)/chronic heart failure (CHF)/coronary artery disease (CAD), obesity including the body mass index (BMI), hyperuricemia, and neoplasia (currently or in the past). The following differences were identified: the in-hospital treatment time was longer in surviving subjects, AKIN stages 2 and 3 were diagnosed more often in non-survivors, and both, the minimal eGFR and the eGFR at the time of demission were lower in non-survivors. Dialysis was performed more often in non-survivors, serum potassium at the time of AKI onset was lower in survivors, and comparable differences were found for peak CRP and NT-proBNP. Vasopressor therapy was initiated more frequently in non-survivors; the latter also required (non-invasive and invasive) ventilation more often. ICU therapy became mandatory in fewer survivors; in addition, coronary angiography was performed less frequently in surviving individuals. Finally, the average weight was higher in surviving subjects. Since the differences seen between survivors and non-survivors may not be proposed as mortality risk factors per se, additional multivariate logistic regression analysis included the following variables: age, male gender, in-hospital stay, AKIN stage 2, minimal EGFR, peak CRP, NT-proBNP, ICU treatment for longer than 10 days, insulin-dependent diabetes, the absence of CKD or CHF, BMI, and a negative history neoplasia. Three variables were identified as positive predictors of survival: in-hospital-stay, BMI, and negative history of neoplasia; three variables however were negatively predictive: AKIN stage 2, ICU treatment for more than 10 days, and insulin-dependent diabetes. Tables p values of the multivariate analysis.The overall in-hospital mortality was 19.2% n = 8. To idep = 0.001). For risk analysis, we employed the same variables as in the previous section. Table A total number of 19 (9.6%) patients required dialysis therapy due to CRS type 1-associated AKI. Forty-seven 47.4) % of the patients did not survive as opposed to 16.2% of individuals without dialysis  occurred in 86 individuals 43.4%), incomplete recovery (IR) was diagnosed in 55 patients 27.8%). Fifty-seven patients (28.8%) did not recover at all (NR). Patients with versus without recovery differed in the following variables: the in-hospital treatment time was longer in CR/IR as opposed to NR patients. Vasopressor therapy was performed less frequent in patients with complete or incomplete recovery. Finally, coronary angiography was performed more often in subjects without recovery. Multivariate logistic regression analysis included the same variables as mentioned under the ‘Dialysis’ section. Two variables were predictive: in-hospital stay (positive) and AKIN stage 3 (negative)  demission letters did not contain any cardiorenal diagnosis at all. ‘AKI’ alone was documented in 3 letters (1.5%), ‘AKI + HF’ (HF–heart failure) was named 60 times (30.3%), ‘CKD + HF’ was documented in 57 (28.8%) letters, and the exclusive diagnosis of ‘CKD’ was documented 8 times (4%). Finally, only 6 distinctive letters (3%) contained the diagnosis ‘CRS’.Follow-up recommendations were given in only 14 patients (8%).The current study reports on epidemiology and outcome of CRS type 1 patients treated at a cardiorenal unit over the year 2019. We particularly intended to evaluate outcome variable from the nephrologist’s perspective. One-hundred ninety-eight (198) out of 1189 AKI patients were diagnosed with CRS 1 (16.2%).n = 38). Mortality data in CRS type 1 are available from both, retrospective and prospective trials. In a 2012 published, retrospective study, AKI was diagnosed according to the RIFLE criteria [Mortality. The primary endpoint  was reached in 19.2%  significantly more often. Only a few articles on RRT in CRS type 1 have been published. Most studies related to RRT in CRS evaluated peritoneal dialysis instead of hemodialysis/hemodiafiltration. In a 2017 published prospective trial, Ponce et al.  includedRecovery of kidney function. Only a few data are available on CRS type 1 and recovery of kidney function until demission. This particular aspect is highly important. AKI in general has been identified as risk factor for CKD, which on the other hand dramatically worsens the long-term prognosis of respective patients. Since the landmark study be Go et al. published in 2004 , CKD hasThe final aspect to be discussed is related to the follow-up management. Both, the final documentation of any type of cardiorenal diagnosis in demission letters and more so, respective follow-up recommendations for the monitoring of kidney function were performed/given inadequately . In 2020, Ransley et al.  reported


Some arthropods such as cockroaches can exacerbate asthma, but it is unknown is this is true of bed bugs.The objective of this work is to determine if bronchospastic diseases like asthma and chronic obstructive pulmonary disease (COPD) would be higher for ED patients who have bed bug infestation compared with patients who do not have bed bug infestation.A case–control study was performed with 332 adult emergency department (ED) patients with bed bug infestation and 4952 without infestation. Univariable and multivariable regression analysis was performed.P < 0.05). Infested patients receiving albuterol in the ED were more likely to be admitted to the hospital compared with uninfested patients receiving albuterol (P < 0.001). Patients with an ED or inpatient diagnosis of asthma or COPD and bed bugs (compared with those without bed bugs) had significantly more ED visits during the study (P < 0.03). Bed bug infestations may be associated with respiratory pathology, which requires further investigation.Patients with bed bug infestation were not more likely to have a past history of or an ED diagnosis of asthma or chronic obstructive pulmonary disease (COPD). However, bed bug infested patients were significantly more likely to undergo chest radiography, be admitted to the hospital, and receive albuterol in the ED ( CHFcongestive heart failureCOPDchronic obstructive pulmonary diseaseEDemergency departmentESIEmergency Severity IndexORodds ratioUHUniversity Hospitals1Cimex lectularius, the common bed bug, is a hematophagous human ectoparasite.C. lectularius contain a large amount of histamine, which is one of six known bed bug aggregation pheromones.P < 0.001), and these high levels persisted in the environment even after the house was heat treated.Histamine is a central mediator of asthma and allergic reactions. The cross‐linking of immunoglobulin E on mast cells causes degranulation and histamine release, and histamine is a central mediator of asthma and allergic reactions. Histamine causes bronchoconstriction, increased secretion of mucus, increased endothelial permeability, rhinorrhea, sinus congestion, and sneezing.Asthma is one of the most common chronic lung diseases in children. Allergens trigger asthma attacks in 60% to 90% of children and in 50% of adults, and about 80% of patients with asthma have positive results on allergen skin tests.The prevalence of cockroach allergy ranges between 17% and 41% in the United States, and about 85% of urban homes have detectable levels of cockroach allergens.With high numbers of bed bug infestations in some low‐income and urban communities, it is important to know whether bed bugs—by their feeding, detritus, histamine production, or a combination of factors—are associated with respiratory illness similar to what has been observed with cockroaches. The objective of this study was to determine if respiratory diagnoses, particularly bronchospastic diseases like asthma and chronic obstructive pulmonary disease (COPD), along with the use of albuterol would be higher for ED patients who have bed bug infestation compared with patients who do not have bed bug infestation.2International Classification of Diseases code for bed bugs. University Hospitals (UH) information technology (IT) created a bed bug data set by identifying patients ≥18 years of age seen in one of nine UH EDs between February 1, 2011, through February 1, 2017, that had the words “bedbug,” “bed bug,” “Cimex,” or “lectularius” written in their clinical notes during that clinical encounter. These medical encounter records were examined by a study investigator to identify those encounters where a bed bug was suspected by clinical staff based on reports of a home infestation by the patient or an insect was found on the patient in the ED. Only the first ED encounter where a bed bug was noted was used for patients that had multiple subsequent encounters where bed bugs were noted. A total of 332 bed bug‐infested patients were identified, and they were matched 1:5 to 4980 ED patients that had no documented bed bug infestation. Controls were matched on age (within 1 year at the ED visit), sex, and the ED where the encounter occurred. There were 28 patients in the control group that expired in the ED and were not included in the analysis. Only the first documented set of triage vital signs and laboratory tests from the ED were included in the analysis. Incomplete or missing data were not included in the analysis. All medications and diagnoses were provided in text format which was explored using Excel spreadsheet software (Microsoft Corporation). The study was approved by the UH institutional review board (IRB). Manuscripts have previously been published from this data set.There is no 2.1t test. Categorical variables were summarized as frequency (percentage) and analyzed with the Fisher exact test for (2 × 2) outcomes; otherwise, the Pearson χ2 test was used. Stepwise regression analysis assisted in identifying the clinical variables for which there was not less than 20% missing data for use in the multivariable regression. Unless otherwise stated, all multivariable regression models accounted for age; race (Black vs. other); current or past history of tobacco use (yes vs. no/unknown); location prior to ED arrival ; Emergency Severity Index (ESI) score (from 1 [most urgent] to 5 [least urgent]); ED disposition (admitted vs. discharged); method of ED arrival ; and use of chest radiography (yes vs. no). All tests were twosided, and P values of 0.05 or less were considered statistically significant. Statistical analysis was performed with JMP Pro 14 (SAS Institute Inc).Continuous variables were summarized as mean (SD), and they were analyzed with the independent 33.1P < 0.001), to require an ED ventilator (P < 0.001), and to require an ED or inpatient ventilator (P < 0.001), but these variables were no longer significant on regression analysis (Table P < 0.001) and higher respiratory rates . On regression analysis, patients with bed bug infestation had higher heart rates and higher ESI scores (P ≤ 0.03 for both).ED patient characteristics are summarized in Tables is Table . On univ3.23.2.1On univariable analysis, patients with bed bug infestation were not more likely to have a documented past history of asthma, COPD, or bronchitis Table .3.2.2P < 0.001 for both) but not asthma or COPD  were significantly more likely to receive an ED diagnosis of congestive heart failure (CHF) or pneumonia  (Table P = 0.01), CHF (P = 0.003), pneumonia (P = 0.006), and pulmonary edema (P = 0.049). Patients with bed bugs were not more likely to receive a new ED or inpatient diagnosis  for asthma or COPD.On univariable analysis, patients with bed bug infestation (compared with patients without bed bugs) were significantly more likely to receive a diagnosis in the ED, inpatient, or both of asthma, COPD, CHF, pneumonia, dyspnea, pulmonary embolism or deep vein thrombosis, or pulmonary edema (l) Table . On regr3.33.3.1There were no significant differences between those with and without bed bugs and for the ED administration of corticosteroids Table .3.3.2P < 0.001) and regression analysis (P = 0.047), patients with bed bug infestation (compared with patients without) were significantly more likely to receive albuterol (Table P < 0.001).On both univariable analysis (ol Table . In the 3.4n = 198) versus 33.8% (n = 1674) (P < 0.001), respectively, on univariable analysis and OR 1.74 (1.26–2.38) (P = 0.009) on multivariable regression analysis. After additional regression analysis was performed to account for a past or current ED or inpatient diagnosis of dialysis and an ED or inpatient diagnosis of pneumonia, CHF, asthma, and/or COPD, patients with bed bug infestation were still more likely to undergo chest radiography in the ED .Patients with bed bug infestation (compared with patients without) were significantly more likely to undergo radiography of the chest 59.6% (3.5P < 0.001), COPD , pneumonia , or given albuterol in the ED .On regression analysis, patients with bed bug infestation compared with those without were more likely to be admitted to the hospital if they had an ED or inpatient diagnosis of asthma   had a significantly higher number of ED visits during the study period on both univariable analysis and regression analysis (l) Table .4There was an association between ED patients with bed bug infestations and having respiratory complaints in the ED. While patients with bed bug infestation were not more likely to receive an ED diagnosis of asthma or COPD, they were significantly more likely to be treated with albuterol, a β‐agonist used to treat wheezing and bronchospasm in the ED. Even when accounting for potential reasons for ED administration of albuterol, such as hyperkalemia, anaphylaxis, and a diagnosis of COPD or asthma, patients with bed bug infestations were significantly more likely to be given albuterol. Corticosteroids are frequently administered in the ED to patients with asthma or COPD, but not to all patients with bronchospasm, and corticosteroids were not more common among patients with bed bugs. The data suggest that bed bugs could be associated with bronchospastic disease or wheezing in patients without existing asthma and COPD but may not be a major contributing factor for acute asthma and COPD exacerbations. However, patients with bed bugs plus asthma or COPD did have an overall higher number of ED visits during the study period compared with those without bed bugs, but clinical data on these other visits were not included in the data set.Additional investigations are needed to follow up on our findings of bed bugs being associated with pneumonia and CHF. It is possible that variables not accounted for in our regression analyses could eventually better explain these findings.C. lectularius extract caused positive skin reactions in a higher percentage of patients with asthma (37%–50%) compared with patients without asthma (9%–18%).Besides cockroaches, other insects, including moths, mosquitoes, butterflies, and silkworms, are known to cause inhalational sensitization in humans.4.1The patients in our database who had bed bug infestation were probably more likely to have larger chronic infestations, so identification of acute manifestations associated with an early infestation would probably be less likely. It is possible that some patients were misclassified as having or not having an infestation, and an infestation may have begun with insects from emergency medical services or the ED, but those possibilities are less likely based on previous research at UH including patient surveys, analysis of the life stages of captured bed bugs, and bed bug traps in the UH ED.Only 48.0% of the patients (2538 of 5284) had documented past medical histories in the data set; of those, only documented past medical histories from UH were available. Patients in the data set may have sought medical care outside of the UH network, and therefore their past medical diagnoses may not have been included in the analysis. Patients admitted to the hospital may have received more diagnoses than patients discharged from the ED. The study did not include physical examination findings, so the association between bed bugs and wheezing could not be adequately ascertained although a previous survey of UH ED patients with bed bugs found that 18% had wheezing, which is a rate higher than for undifferentiated ED patients.4.2Patients with bed bug infestation in the ED, compared with those without bed bugs, were significantly more likely to be treated with albuterol  but not to receive a diagnosis of COPD or asthma. However, among patients with an ED or inpatient diagnosis of asthma or COPD, and who also had bed bugs (compared with those without bed bugs) were significantly more likely to be admitted to the hospital and to have a higher total number of ED encounters during the study period. Bed bug infested patients were significantly more likely to receive a chest radiograph during their ED encounter and have higher eosinophil counts than uninfested patients, but there were no significant differences in the groups regarding their initial triage peripheral capillary oxygen saturations. Some respiratory diagnoses made in the ED, including CHF and pneumonia, were also more common among patients with bed bug infestation, and additional studies are needed to further assess these associations.This study received institutional review board approval.The sole author designed the study, collected and analyzed the data, and wrote and critically revised the manuscript.The study received no external funding.The author declares that the author has no conflicts of interest.


BackgroundHigh blood pressure is a major cardiovascular risk factor. It is a leading cause of increasing morbidity and mortality worldwide. One-third of the adult population worldwide suffers from hypertension. Salt intake, obesity, decreased physical activity, and smoking are well known to increase blood pressure. Fluid retention is the main contributing factor to primary hypertension and adversely affects the cardiovascular system. The emerging evidence suggests a relationship between blood pressure and hydration status. Our study aims to assess the correlation between hydration status and blood pressure. We aim to assess the hydration status in subjects with normal and high blood pressure and to investigate the association of hydration status with hemodynamic measurement.MethodologyThis cross-sectional and observational study included adult (>18 years) male and female subjects who agreed to participate. In total, 235 subjects were recruited by convenience sampling from (1) patients and caregivers attending geriatric and internal medicine clinics, and (2) visitors coming to King Fahad University Hospital at Al-Khobar. There were five patients on oral diuretics who were excluded from the study. Data were collected from September 2021 to March 2022. Hydration status was measured by a bioelectrical impedance analyzer . Hemodynamic measurements included heart rate per minute, systolic blood pressure, diastolic blood pressure, pulse pressure (the difference between systolic and diastolic blood pressure), and mean arterial pressure calculated as blood diastolic pressure plus one-third of pulse pressure. Statistical analyses were performed using SPSS statistics for windows, version 28.0 . Descriptive data were reported using means with standard deviations for numerical data and relative frequencies (percentage) for categorical data. P-values of less than 0.05 were considered statistically significant. Comparison between groups was done using a one-way analysis of variance test.ResultsExtracellular water percentage was higher in hypertensive (45.0 ± 2) than prehypertensive (43.5 ± 3) or normotensive (43.0 ± 2) (p = 0.001) subjects. In contrast, intracellular water percentage and total body water percentage were significantly negatively related to hypertension status.ConclusionsOur results have shown a strong association between hypertension status and hydration parameters. In our study, hypertensive subjects tended to have lower total body water percentage and intracellular water percentage  than normotensive subjects. This might promote more research regarding the relationship between hypohydration and cardiovascular disease pathophysiology. This outcome should raise awareness about proper hydration as hypohydration can be a causative factor for hypertension. Hypertension is a major cardiovascular risk factor for morbidity and mortality worldwide . UndiagnWater constitutes 63% of the adult body; it is distributed between the compartments of intracellular water  and extracellular water  . AlthougCardiovascular parameters are highly affected by body fluid. A reduction in ECW causes blood pressure to drop ; this isThis prospective, cross-sectional, and observational study recruited adult (>18 years) male and female subjects. Subjects were recruited by convenience sampling from (1) patients and caregivers attending geriatric and internal medicine clinics, and (2) visitors coming to King Fahd University Hospital at Al-Khobar. We excluded people with severe heart failure, those on diuretics, clinically diagnosed kidney disease, severe dementia, terminal illness, pregnant women, and those who refused to consent. People with contraindications for using bioimpedance  were also excluded from the study. Data were collected from September 2021 to March 2022. Institutional Review Board (IRB) approval was obtained from the Imam Abdulrahman Bin Faisal University IRB office (IRB-UGS-2021-01-344).Procedure and measurementWe utilized an interview-based questionnaire where the participants were informed about the study aims and procedure and then signed the informed consent. During the interview, investigators asked about demographic data including age and gender. History was taken from participants regarding cardiovascular risk factors and smoking status. Height, weight, and body mass index (BMI) were calculated and documented. Measurements of waist and hip circumferences were taken according to the World Health Organization protocol . It indiHemodynamic measurementsProcedures were explained and participants were instructed to lay supine and calm on the bed for five minutes before the examination. Blood pressure and heart rate were assessed from the left arm at the level of the left brachial artery using a digital sphygmomanometer  The mean of three blood pressure and heart rate readings were used for analysis, with a one-minute interval between each measurement. The difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) was used as the pulse pressure. The mean arterial blood pressure was calculated as DBP plus one-third of pulse pressure . The bloBioimpedance measurementHydration status was assessed by bioelectrical impedance using the Bioscan Model 920 . Bioscan model 920 is a non-invasive, painless, simple, inexpensive method that provides information about body composition, for example, fat mass, TBW, ECW, and ICW . It was Statistical analysisData were analyzed by SPSS version 21 . Descriptive analysis was presented as percentage (%), mean, and standard deviation. Comparison between groups was done using the one-way analysis of variance test for variables with normal distribution, and a 95% confidence interval was applied.The demographics and clinical characteristics of the study population are presented in Table Table Our data demonstrated that TBW is lower in hypertensive patients. This may signify the role of chronic hypohydration on blood pressure pathophysiology. However, this decrease can be attributed to several factors, such as advancing age, increase in BMI, or use of diuretics in hypertensive participants (patients on diuretics were excluded from the start).Total body water and blood pressureOur data demonstrated that TBW percentage of body weight was lower in hypertensive patients. However numerous studies testing the acute effect of dehydration on blood pressure have reported contradicting results. Our study aligns with previous animal research that linked episodic dehydration with hypertension in animals with renal damage . AnotherExtracellular water and blood pressureWe found a strong association between ECW and high blood pressure. This finding is in line with previous studies on peritoneal dialysis and CKD patients ,9. SeverIntracellular water and blood pressureOur results have demonstrated an inverse relationship between high blood pressure and ICW, which is consistent with some previous studies ,22. HoweStudy limitationsThere are several limitations to our study. First, the study sample was relatively small. Second, our sample was predominantly males as many females were unwilling to participate due to cultural aspects. Other limitations include the age difference between hypertensive and normal subjects, BMI difference, and no laboratory or clinical assessment to define dehydration status. Further research is needed to confirm our results and assess the interaction between hydration and high blood pressure.Our results have shown a strong association between hypertension status and hydration parameters. Hypertensive subjects tended to have lower TBW and ICW than normotensive subjects in our sample. This might promote more research regarding the relationship between hypohydration and cardiovascular disease pathophysiology. This outcome should raise awareness about proper hydration as hypohydration can be one of the risk factors of hypertension.


Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis. Septic shock is a pathological syndrome of life-threatening multiorgan dysfunction caused by a dysregulated host response to infection . Acute kMicrocirculation refers to the capillary system that connects the arteries and veins. It is essential to the function of every organ and system in the body for the transport of oxygen and nutrients and the removal of toxins. Impaired microcirculation is a hallmark of septic shock and is the pathophysiological basis for the failure of multiple organs, including the heart, intestines, liver, brain, and kidneys ,19. The Hypoxia in the medulla also exacerbates renal injury by involving the tubuloglomerular feedback mechanism (TGF). Hypoxia in the thick ascending branch of the Henle collaterals can lead to decreased production of adenosine triphosphate, which decreases sodium reabsorption, activates TGF, and reduces the glomerular filtration rate by constricting the afferent small arteries, which again triggers a vicious cycle of medullary hypoperfusion and hypoxia . In concIn clinical practice, intractable hypotension due to sepsis is preferentially resuscitated by fluid therapy to achieve the blood pressure target, thereby restoring circulating volume and improving renal perfusion . A retroAdditionally, 0.9% physiological saline was found to be at risk of causing or exacerbating metabolic acidosis and progression to AKI and RRT in critically ill patients with sepsis ,41. HoweIn septic hypotension, if the blood pressure target cannot be achieved by fluid augmentation, clinicians can also implement resuscitation to improve the microcirculatory perfusion of the kidneys and other organs through the use of a vasopressor. Currently, the commonly used drugs include norepinephrine, dopamine, pressor, and angiotensin II .Norepinephrine increases the arterial pressure through α-adrenergic receptor-mediated vasoconstriction and is the medication of choice for septic hypotension ,54,55. IDopamine is a natural precursor of epinephrine and norepinephrine. It excites mainly the α receptors, β receptors, and peripheral dopamine receptors, and it has shown comparable efficacy with epinephrine in the treatment of infectious shock . Due to Vasopressin increases arterial blood pressure primarily by stimulating the arginine vasopressin receptor 1A (AVPR1A) located on vascular smooth muscle cells to induce vasoconstriction. It is currently recommended as a pressor agent that is unresponsive to norepinephrine, and/or it reduces the dose of norepinephrine required to achieve the blood pressure target ,68.In a sheep septic AKI model, vasopressin had better renoprotective effects than norepinephrine ,70. In cAngiotensin II, an endogenous circulating hormone with potent vasoconstrictive effects, effectively increases blood pressure in patients with vasodilatory shock who do not respond to high doses of conventional vasopressors, such as norepinephrine . The decSepsis often leads to intractable hypotension, resulting in hypoperfusion and microcirculatory disorders in multiple organs, including the kidneys. Aggressive clinical correction of blood pressure can largely improve renal blood supply and restore renal function ,82,83. MFor patients with septic shock with a history of hypertension, European experts suggest personalized blood pressure targets, perhaps with a higher MAP leading to better clinical improvement . A studyIn addition to MAP, mean perfusion pressure (MPP) is often used as a clinical indicator of blood pressure. It refers to the difference between the MAP and central venous pressure (CVP) . In a siKidney replacement therapy is an effective method to treat internal environment disorders caused by kidney failure in septic patients. It also removes toxins to replace renal function, improves blood pressure by removing inflammatory mediators, and helps ultrafiltrate the overload fluid in oliguric AKI ,99. At pIntermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are often used to address fluid overload, and CRRT was previously thought to be advantageous in septic hemodynamically unstable AKI patients ,101. MorClinicalTrials.gov identifier: NCT03175328); the study will enroll 460 patients with KDIGO 2 sepsis AKI from multicenter China, whose findings will help clinicians choose the right time to initiate CRRT.Other RRT modalities, such as continuous low-efficiency daily dialysis and prolonged intermittent kidney replacement therapy, have shown both hemodynamic stability and cost-effectiveness and are recommended for use in septicemic patients . HypotenSome advanced RRT filters have been shown to be effective in removing proinflammatory cytokines and endotoxins, such as the oXiris blood filter, which effectively removes endotoxins, tumor necrosis factor-α, interleukin-6, interleukin-8, and interferon gamma in patients with sepsis . Two FreBlood pressure control in sepsis directly affects the function of multiple organs, including the kidney, as well as the survival rate of patients. It is one of the difficult problems faced by clinicians. In septic hypotension, abnormal microcirculatory shunts leading to renal medullary ischemia and hypoxia are important pathological processes in AKI, and improving microcirculatory perfusion is the goal-oriented approach to improve renal function. Due to the inconsistency in perfusion pressure, the MAP target for patients with septic AKI is recommended to be set to individualize the blood pressure target based on patient-specific conditions, and more research is needed to determine whether a higher blood pressure is needed. Fluid resuscitation is the primary means of improving hypotensive shock, but decreased urine output after renal impairment often leads to fluid overload and requires RRT to maintain positive volume balance. Poor fluid resuscitation requires the addition of pressor drugs to constrict blood vessels to improve the blood pressure and improve the perfusion to all organs. However, more research evidence is needed to provide a clinical basis for patient treatment, including fluid and vasopressor choice, alternative treatment options, and so on, to achieve better blood pressure management goals, improve kidney function, and reduce mortality.


A family history of arterial hypertension is an important risk factor for arterial hypertension. This study aimed to verify the mediating role of high central adiposity in the relationship between family history of arterial hypertension and blood pressure in schoolchildren. p < 0.05.Cross-sectional study with 118 schoolchildren of both sexes aged between 11 and 17 years. Weight, height, waist circumference and body mass index z score were verified. Somatic maturation was predicted by age for peak growth velocity. The family history of arterial hypertension was verified and defined as hypertensive schoolchildren with systolic blood pressure or diastolic blood pressure. Mediation analysis was used with linear regression models applied by PROCESS macro for SPSS (version 22.0), with significance p = 0.005), and those with a family history of arterial hypertension and who had a waist circumference greater than those without a family history of arterial hypertension was significant . Likewise, the relationship between family history of arterial hypertension and systolic blood pressure was attenuated when waist circumference was included in the model , indicating waist circumference as a mediator with an influence percentage of 19%. For boys, waist circumference is not a mediator of the relationship between family history of arterial hypertension and blood pressure.It was observed that 34.7% of the students have family history of arterial hypertension, 36% of the girls and 44.2% of the boys have arterial hypertension. In girls, the relationship between waist circumference and systolic blood pressure was direct (β = 0.535 Elevated central adiposity was a mediator of the relationship between family history of arterial hypertension and high blood pressure in girls, indicating the importance of family health strategies in the prevention and management of arterial hypertension in children and adolescents. Among the non-communicable chronic diseases  arterial hypertension (AH) is a multifactorial clinical disease characterized by persistently high levels of pressure, which causes changes in the function and/or structure of target organs. Risk factors include genetics, ethnic group, age, sex, obesity, sedentary lifestyle , high soThe early diagnosis of AH in childhood and adolescence is necessary to recognize this reality and act in the prevention of cardiovascular events, since the change in blood pressure in childhood can predict AH in adulthood , 8, simpFor a better approach to this health problem, it is essential to prioritize the most vulnerable population groups and identify as much as possible the risk factors for the development of AH. In addition to genetic predisposition, an environmental aspect that has reached large proportions and is related to AH is physical inactivity and sedentary lifestyle which, associated with inadequate nutrition, result in obesity –14, loweTherefore, conducting population-based diagnoses of AH associated with family history reinforce the importance of including blood pressure assessment in schoolchildren, together with anthropometric values , 20. In Thus, observing the main causes of AH, in addition to the potentiating factors of its existence, are important aspects in the attention of public and social policies, which collaborate for the control and prevention of the same , 23. ProThis is a cross-sectional study carried out during the period from August to December 2017, consisting of a sample of 118 schoolchildren in the age group from 11 to 17 years (mean age 14.6 ± 1.5 years), 75 girls (mean age 14.9 ± 1.4 years) and 43 boys (mean age 14.1 ± 1.5) from primary and secondary education from two private schools in the city of São José dos Pinhais, Paraná, in southern Brazil. The sample consisted of conglomerates, each associated city school, in which it was considered a conglomerate. The proportional stratified sample procedure was used, so that schools with a larger population contributed more to the sample. Participants were selected by convenience, as the selection was not randomized, but voluntary. In addition, the number of participants was proportional to the number of students from each educational institution. While the sample size calculation was performed to verify the sampling power of the analyzes chosen for this study.After the consent of the educational institutions, visits were made to the classrooms to invite and present the research objectives to the students and the questionnaire on family history of arterial hypertension was sent to the parents. Data collection was always carried out by the responsible researcher, who provided some health professionals oriented to the evaluations.The sampling power was calculated posteriorly in the GPower v3.1 program. for the t-test statistic to compare the presence and absence of a family history of hypertension. Effect size (d) 0.50 was assigned, α 0.05. Furthermore, the sample could f hi calculated according eat final sample of this study (118 school). Based on these parameters, the current sampling power of 0.82 for the present study was observed.Pregnant women, individuals with limitations that prevented them from participating in some procedure, and those who did not have the Free and Informed Consent Terms in accordance with Resolution 466/12 of the National Health Council involving signed human beings were excluded from the study. The present study was approved by the Research Ethics Committee of the Pontifical Catholic University of Paraná, PUC – PR, under registration 2,198,319, and followed the resolution 466/2012 of the National Council of Health in Brazil. The schoolchildren’s parents or legal guardians signed free and informed consent forms.Anthropometric Standardization Reference Manual [Anthropometric measurements were taken at school in a standardized way, following the procedures recommended by the e Manual . Body weGrowth reference data for 5–19 years 17 [software, version 1.0.4. Participants with BMI-z between ≥ -2 and <  + 1 were classified as overweight, between ≥ 1 and < 2 as obese, and those with BMI-z ≥  + 2 according to age group and gender were classified as normal weight.To verify the nutritional status according to the body mass index (BMI), the ratio between body weight (kg) and height squared (m2) was calculated, as well as the body mass index z-score (BMI-z) was calculated according to the years 17  using thA flexible and inelastic tape measure with a precision of 0.1 cm for the measurement of waist circumference (WC), measured at the midpoint between the last costal arch and the iliac crest. The waist circumference classification followed the cut-off points: WC values ≤ p10: low WC, WC values ≥ p10 and < p75: adequate WC, WC values ≥ 75 and < p90: high WC, and WC values ≥ p90: very high WC. Central obesity was defined as WC > p75 for age and sex .Biological maturation was estimated by the somatic maturation method predicted by age for peak growth velocity (APGV) . This meBP classification according to age, sex and height percentile following the new Brazilian Guideline on Arterial Hypertension for children and adolescents . BP measSchoolchildren aged up to 13 years with systolic blood pressure (SBP) or diastolic blood pressure (DBP) above the 95th percentile for sex, age and height were defined as hypertensive. In children aged ≥ 13 years as: Normotensive: BP < 120/ < 80 mmHg; High blood pressure: BP 120/ < 80 mmHg to BP 129/ < 80 mmHg; Stage 1 hypertension: BP 130/80 mmHg or up to 139/89 mmHg and Stage 2 hypertension: BP ≥ between 140/90 mmHg [The FHAH was assessed through a questionnaire sent to the parents and/or guardians of the students to identify whether the father, biological mother or both were hypertensive. The survey analysis was classified into two categories: “Positive Hypertension Family History and “Negative Hypertension Family History”.Descriptive data were presented as mean and standard deviation for continuous variables and relative and absolute frequency for categorical variables. The correlation matrix was used for analysis between dependent, independent, and mediating variables. To verify whether the association between FHAH and BP was mediated by WC linear regression models were applied by PROCESS macro for SPSS (version 22.0). The PROCESS macro used bootstrapping methods to test mediation hypotheses , using aThe objective of this model was to investigate the total (c) and direct  effects, reflected by the non-standardized regression coefficient and the significance between the independent and dependent variables in each model. The model also explored the indirect effect obtained from the product of the coefficients (a × b), which indicates the change in the dependent variable (SBP and DBP) for each unit change in the independent variable (FHAH) that is mediated by the proposed mediator (WC). The indirect effect was estimated using 95% confidence intervals, considered significant when it does not contain zero.p ≤ 0.05 was considered significant for all analyses.Thus, the following criteria were used to establish mediation: (I) the independent variable (family history of hypertension) is significantly related to the mediator (WC); (II) the independent variable (FHAH) is significantly related to the dependent variables (SBP and DBP); (III) the mediator (WC) is significantly related to the dependent variables (SBP and DBP); and (IV) the association between independent and dependent variables is attenuated when the mediator is included in the regression model. The analyses were adjusted for the APGV and the probability value p < 0.05). While the girls had higher levels of DBP (p < 0.05).Table p = 0.009). In the second equation (c), negative FHAH was inversely associated with SBP (p = 0.014). In the third equation (b), the relationship between WC and SBP was positive . While the fourth equation (c’) indicated that when FHAH and WC were simultaneously included in the model, WC was not associated with SBP . Thus, the relationship between FHAH and SBP was attenuated when WC was included in the model, indicating that WC was a mediator of this relationship. In addition, it was estimated that the percentage of influence of WC on the relationship between FHAH and SBP was 19%. Regarding DBP, the results indicated that WC does not act as a mediator.Figure Figure Primary AH is considered a multifactorial disease, but with a strong genetic component, a factor that can influence BP levels and be associated with a higher concentration of inflammatory mediators, which contribute to the development of AH. In this context, the present study sought to identify the mediating role of high central adiposity in the relationship between a family history of arterial hypertension and blood pressure in schoolchildren.The sample profile revealed that one third of the participants had a positive FHAH. In relation to anthropometric variables, boys presented higher WC compared to girls. Despite this, girls had higher levels of DBP, which suggests that a FHAH may be an important predictive factor for AH . DespiteIn the mediation models, WC assumed a more consistent mediating role when verifying the relationship between the family histories of AH and SBP in girls. The percentage of influence of 19% of WC in the relationship between the family history of SBP in females was observed, denoting that central adiposity plays an important role in the high SBP of girls with a FHAH, which implies that they may be in a higher level of risk factor . CorroboHowever, the results indicated that WC was not a mediator of the relationship between the FHAH, with both SBP and DBP among male students. However, most studies have mentioned higher prevalence of AH in this population, which may be related to intra-abdominal fat accumulation, sodium reabsorption, increase in pro-inflammatory cytokines, which causes increased blood pressure , 40. In In fact, central obesity, in addition to other extrinsic factors, such as low level of physical activity, hypercaloric diets  are amonThe present work has some limitations that must be considered for the interpretation of the results. Among them, we can highlight the fact that it is a cross-sectional study that does not allow causal associations. In this way, the measurement of SBP and DBP was performed in a single visit to the school, not allowing the assessment in an outpatient setting. Another aspect concerns the parents’ diagnosis of AH having been self-reported using a questionnaire. In view of this, the clinical assessments of blood pressure, as well as anthropometric assessments to analyze the association of these variables, were not performed. Despite the limitations pointed out, the relevance of this study is highlighted in diagnosing high blood pressure levels in schoolchildren associated with their parents’ history of hypertension, as well as associating central obesity as a risk factor for these changes.The correlates identified in this investigation must take into account all factors to detect schoolchildren and their families at the highest possible risk of AH. The presence of FHAH and anthropometric changes can be used for early prevention and management of this important public health problem, prioritizing periodic assessments and future strategies for more vulnerable population groups with overweight and obesity, low levels of physical activity and with a FHAH.The results found in this study provide data on the association of excess abdominal fat and diagnosis of AH in schoolchildren, contributing to important aspects of public health. In addition, WC was identified as a mediator of the relationship between the FHAH and SBP in girls. While in boys there was no significant relationship between the presences of AH and positive FHAH in relation to this variable. Early detection of the relationship between excessive central adiposity and the presence of AH, as well as analyzing these results with socioeconomic and behavioral factors, which can interfere with cardiovascular disease and mortality. We conclude that verifying the relationships between excessive anthropometric measurements and the presence of FHAH are essential in public health actions. Simple and low-cost analyzes that can favor the adoption of policies and control actions to ensure a growth in expectation and a healthier lifestyle in children and adolescents and in adulthood.


Acute kidney injury (AKI), closely related to increased mortality, involved 15–20% of hospitalized patients with higher incidence, with about 50% in the intensive care unit (ICU) ,4. HowevThe precocious diagnosis is crucial in clinical practice, such as the distinction between transient and persistent AKI, with obvious consequences for the patient during hospitalization . The firIts pathophysiology varies according to the myriad of conditions associated with its development, and further studies are needed to analyze the mechanisms of AKI and to develop personalized and targeted therapies. Cardiac surgery with cardiac bypass is the classic example of AKI, with pathophysiology based on various interrelated mechanisms, starting from inflammatory and ischemic processes leading to tubular cell injury . ConversNevertheless, if the mechanism of renal damage depends on the primary cause, early recognition of AKI is the starting point to optimize the management and prevent deterioration of kidney function, and the assessment of individual clinical risk needs wider dissemination among clinicians to allow for the identification of patients at high risk.AKI is a clinical diagnosis, and it is unlikely that any single kidney injury marker will fully predict the changes in kidney function in this complex condition. Although various biomarkers have been associated with AKI and adverse outcomes, the clinical application of any single biomarker has failed to demonstrate troponin-like diagnostic performance in myocardial infarction. Recently, a clinical immunoassay for the detection of insulin-like growth factor binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), the NephroCheck test , received US Food and Drug Administration approval for AKI risk assessment in critically ill patients, showing sensitive, specific, and highly predictive properties in AKI adults and children after cardiac surgery . These bWhile cardiologists have electrocardiogram alterations and troponin levels to define acute heart damage accurately and precociously, nephrologists base all clinical activities and decisions on the changes in serum creatinine (sCr) or urinary output, which are neither sensitive nor specific for AKI. Several sCr-based classification systems define AKI, but changes in sCr lack sensitivity because nearly 50% of GFR must be lost before sCr increases.How could we diagnose AKI precociously if we have no biomarkers detecting this subclinical stage of AKI? The latter represents the renal functional reserve (RFR), in which the adaptive nephron hypertrophy replies to an acute reduction in the number of functioning nephrons. The capacity of this RFR mechanism diminishes as renal functional mass declines, leading to a gradual rise in SCr, but at least after 48–72 h since the damage started . If creaConsidering the complex and multifactorial causes, a panel of multiple biomarkers of renal stress, injury, and kidney reserve function could provide better discrimination for AKI. Furthermore, more kidney tissue-specific markers may help localize and quantify the severity of AKI, providing a deeper understanding of the pathophysiology of AKI, offering opportunities for personalized management of AKI, and supporting a re-analysis of the existing AKI criteria .In the last decade, the computer decision support improved the diagnostic approach to AKI and its treatment, acting on the awareness problem among clinicians. This system might improve outcomes, reduce nephrotoxic medication and intravascular radiocontrast exposure, increase consultations for nephrology and critical care medicine .If the diagnostic approach to AKI is complex and debated, notwithstanding advances in biotechnologies, the pharmacotherapy for AKI needs to be improved, avoiding schematic protocols, and targeting a personalized strategy. Aki leads to electrolyte and acid-base disorders, fluid accumulation, and metabolic dysfunction, impairing the immune system and reducing the patient’s ability to clear infection ,22. MetaBiomarker-driven application of specific bundles derived from KDIGO recommendations or structured organization of nephrologist teams has permitted reductions in the occurrence of severe AKI cases, the requirement of renal replacement therapy (RRT), and the length of ICU stay, acting on fluid management, titrating vasoactive medication and maintenance of perfusion pressure ,27. In sThe approach in these patients should be based on qualitative strategies rather than a “quantitative belief” underlying that “the more, the better”, referring to the high dose of RRT and the highly intensive dialytic treatments, did not improve clinical outcomes ,30.Defining the intent and goals of kidney support therapy is the principal consideration when deciding to start the RRT with classical parameters, such as metabolic acidosis, hyperkalemia, or severe fluid overload, which could only marginally depict a complex patient with AKI. A ”modern” indication of RRT is to remove pro-inflammatory cytokines, pathogen and damage-associated molecular patterns, pathogen agents, and endotoxin molecules behind traditional parameters, taking advantage of new hemofilters with enhanced biotechnologies in membrane and adsorbent structures. Only personalized therapy could avoid negative results from this approach, identifying specific patient subgroups.In conclusion, if the clinical management starts from the identify patients at risk of AKI, analyzing concomitant and triggering diseases, the attention of the nephrology must not finish after the resolution of this complex condition, neglecting patients at high risk of CKD. A protracted enhancement of function in remnant nephrons during AKI represents a maladjustment in a long period, with a progressive and chronic injury leading to glomerular sclerosis, hyalinosis, and fibrosis with progressing CKD . Unfortu


NTG patients had a mean ICP of 8.5 (2.4) mmHg. Higher TPD was related with lower mean deviation (MD) (p = 0.01) and higher pattern standard deviation (PSD) (p = 0.01). ICP was significantly associated with the lowest averaged PD scores in the nasal VF zone (p < 0.001). There were no significant correlations between ICP and other VF zones with the most negative mean PD value. (p > 0.05). Further studies are needed to analyze the involvement of ICP in NTG management.Growing evidence suggests that intracranial pressure (ICP) plays an important role in the pathophysiology of glaucoma, especially in normal-tension glaucoma (NTG) patients. Controversial results exist about ICP’s relationship to visual field (VF) changes. With the aim to assess the relationship between ICP and VF zones in NTG patients, 80 NTG patients (age 59.5 (11.6) years) with early-stage glaucoma were included in this prospective study. Intraocular pressure (IOP) (Goldmann), visual perimetry (Humphrey) and non-invasive ICP  were evaluated. Translaminar pressure difference (TPD) was calculated according to the formula TPD = IOP − ICP. The VFs of each patient were divided into five zones: nasal, temporal, peripheral, central, and paracentral. The average pattern deviation (PD) scores were calculated in each zone. The level of significance  Population-based studies demonstrated that approximately 50% of patients with primary open-angle glaucoma (POAG) have an IOP level constantly within normal ranges, and are diagnosed with normal-tension glaucoma (NTG) . DespiteRecently, researchers have focused on intracranial pressure (ICP) and translaminar pressure difference (TPD = IOP − ICP) as a component having a potential role in glaucomatous optic neuropathy ,5,6,7. TEighty patients (Caucasians) with early stage NTG were included in a prospective study.The study was approved by Kaunas Regional Biomedical Research Ethics Committee and performed according to the tenets of the Declaration of Helsinki, with patients signing informed consent. Three hundred NTG patients referred to the Eye Clinic, Lithuanian University of Health Sciences were examined between January and October 2018. All subjects underwent a complete ophthalmological and neurological examination and 80 patients met the inclusion criteria.The inclusion criteria were: clinical diagnosis of NTG confirmed by glaucoma specialist , glaucomatous VF changes, an IOP of less than 21 mmHg before treatment). Only patients with early stage glaucomatous VF defects according Hoddap–Parrish–Anderson criteria  were incAll patients were examined by a neurologist to exclude neurological disorders that could affect ICP , usage of oral medications, including carbonic anhydrase inhibitors due to their known effects on ICP.Additionally, patients with uncontrolled systemic diseases, pregnant or nursing women, and patients with a history of allergy to local anesthetics, orbital/ocular trauma or other diseases that could bias the study results were excluded from the study. Current medical treatment, including topical IOP-lowering drugs, was continued.The following measurements were recorded during the study: body mass index , best-corrected visual acuity , Goldmann applanation tonometry, perimetry , confocal laser scanning tomography for optic nerve structural parameters , non-invasive ICP , and TPD , BP was measured with a digital automatic blood pressure monitor . Patients were seated and BP measurements were taken after 5 min of rest. Measurements were taken twice within intervals of 5 min. A third measurement was taken only if there was a difference in systolic blood pressure (SBP) more than 10 mm Hg or diastolic blood pressure (DBP) more than 5 mmHg . The BP Non-invasive ICP was measured using a two-depth Transcranial Doppler (TCD) with patients lying in a supine position and a head frame with a fixed ultrasound transducer for placement over the closed eyelid and a duration of the measurement of approximately 10 minutes. The details of this technique are described in our previous article .The VFs of each patient were divided into five zones: nasal, temporal, peripheral, central and paracentral . The aveStatistical analysis was performed using the computer program SPSS 23.0 for Windows. Methods of descriptive statistics defined all variables. The analysis of the quantitative variables included the calculation of the mean and standard deviation (x(SD)). Association between categorical variables or continuous variables was assessed by Spearman’s or Pearson’s correlation. Associations between VF zones with the most negative averaged PD scores and ICP, IOP, BP, age, and BMI were tested in multivariate analysis. Multifactorial linear regression models were applied to evaluate ICP and TPD associations with IOP and BP by adjusting for age and BMI.p < 0.05 was considered significant.The level of significance Eighty NTG patients  with a mean age of 59.5 (11.6) years were included in this prospective study. The patient’s characteristics are provided in p < 0.001) and lower systolic BP (p = 0.02). Higher TPD was related with lower mean deviation (MD) (p = 0.01) and higher PSD (p = 0.01). ICP and TPD were significantly associated with the most negative averaged PD scores in the nasal VF zone (p = 0.001). There were no significant correlations between ICP or TPD and other VF zones with the lowest averaged PD value within them (p > 0.05).Associations between ICP, TPD and systemic and functional VF parameters are shown in p = 0.02). The lowest averaged PD value in the central VF zone was associated with diastolic BP (p = 0.02), systolic BP (p = 0.01) and OPP (p = 0.02). The lowest averaged PD scores within the paracentral VF zone were correlated with lower BMI (p = 0.006).The lowest averaged PD value within the nasal VF zone was also correlated with diastolic BP (p < 0.001) and IOP ; and no statistical significance (p > 0.05) was found with age, BMI, or BP. The most negative averaged PD scores in paracentral VF zone significantly correlated with BMI  and was not statistically significantly (p > 0.05) correlated with age, IOP, ICP and BP. There were no associations between the most negative averaged PD scores within the temporal VF zone and other parameters (p > 0.05), the most negative averaged PD scores within the peripheral VF zone and other parameters (p>0.05), the most negative averaged PD scores within central VF zone and other parameters (p>0.05) in multivariate analysis.Associations between VF zones with the most negative mean PD values and systemic parameters remained statistically significant in multivariate analysis. The lowest averaged PD value within the nasal VF zone correlated with ICP  associated with IOP and BP, and was not statistically significantly associated with age and BMI (p > 0.05). Results are presented in In age-adjusted and BMI–adjusted multivariate linear regression analysis, both ICP and TPD remained significantly  mmHg in NTG patients. We also found several statistically significant correlations between ICP, TPD and VF parameters. Specifically, higher TPD significantly correlated with lower MD and higher PSD. In addition, ICP and TPD were significantly correlated with the most negative averaged PD scores within the nasal VF zone only as compared to other VF zones.The two-depth Transcranial Doppler mean ICP value in our study was similar to the reported mean ICP as measured by both lumbar puncture ,18 and tIn the study by Loiselle et al., ICP was evaluated non-invasively as the response of the inner ear to two tones at specified levels and frequencies, named as distortion product otoacoustic emission (DPOAE). They assessed the relationship between DPOAE phase and body position and also compared it between POAG, NTG and control groups, and reported no reduced ICP in glaucoma patients . Even thSome previous studies reported that ICP had a tendency to decrease by age ,28. We dPrevious clinical and experimental studies have also reported existing associations between CSF pressure, BP, IOP and BMI . Ren et In this study, we found several statistically significant correlations between ICP, TPD and VF parameters. Higher TPD was correlated with lower MD and higher PSD. Therefore, higher TPD could be estimated as a risk factor playing a role in NTG pathogenesis and in VF changes. Similarly, Ren et al. found that the extent of glaucomatous VF loss was negatively correlated with the height of the CSF pressure and positively correlated with TPD . HoweverTherefore, we found that ICP and TPD were significantly correlated with the most negative averaged PD scores within the nasal VF zone only as compared to other VF zones. The lowest mean PD value within the nasal VF zone remained significantly associated with ICP in a multivariate analysis model. Elevated IOP was proposed as a possible risk factor for the initial nasal step in VF by Park et al. . Our resAs elevated IOP was reported as a possible risk factor for the initial nasal step in VF, the initial parafoveal VF defect had a stronger association with IOP-independent risk factors, such as hypotension or sleep apnea . AhrlichWe also found that the paracentral VF zone with the most negative PD value significantly correlated with lower BMI and the result remained statistically significant after multivariate analysis. The relationship between BMI, as an IOP-independent risk factor, and glaucoma remains controversial . Lower BOur study has several limitations to acknowledge. In our approach we utilized a non-invasive ICP two-depth TCD device measurement methodology, which may not reflect the same values as the invasive gold standard lumber puncture may produce. In addition, in our study ICP was measured in the supine position due to ICP measurement technique restrictions, while IOP was assessed in the sitting position. The difference in posture during measurement may influence biomarkers, as IOP and ICP are pulsatile parameters that are influenced by body position and the cardiac cycle. In addition, visual acuity testing was performed using Snellen charts for statistical analysis while other approaches including use of logMAR may result in different results, especially within a small sample.Some issues evaluating VF changes should be mentioned as well. The nasal VF zone contains the two most eccentric points. A nasal step, a sign in glaucoma, also can be noticed in normal VF, other pathological conditions, as a late sign of the distal edge of the arcuate scotoma, or as an artifact . We inclVF points in contiguous zones, for example nasal and paracentral, are not fully independent, whereas the statistical tests we used assume independence. We presume this should not affect the results as we analyzed VF with early glaucomatous loss. However, the adjacent zones could be important in evaluating patients with moderate or advanced glaucoma with more diffused VF defects. Further clinical studies are needed to confirm the validity of our findings.Higher translaminar pressure difference was correlated with lower mean deviation and higher pattern standard deviation. Intracranial pressure was significantly associated with the lowest averaged pattern deviation values within the nasal visual field zone. These data support additional studies to reveal the mechanistic involvement of ICP in glaucoma pathophysiology, especially as a potential biomarker for NTG.


APOL1 high-risk genotypes. These findings suggest a role for recipient and donor immunogenetic makeup in recurrent primary FSGS post-transplantation. Further larger studies in well-defined cohorts of primary FSGS that include high-resolution HLA typing and genome-wide association are necessary to refine these hereditary signals.Primary focal segmental glomerulosclerosis (FSGS), typically characterized by diffuse podocyte foot process effacement and nephrotic syndrome (diffuse podocytopathy), is generally attributed to a circulating permeability factor. Primary FSGS can recur after transplantation where it manifests as diffuse foot process effacement in the early stages, with subsequent evolution of segmental sclerotic lesions. Previous published literature has been limited by the lack of stringent selection criteria to define primary FSGS. Although immunogenetic factors play an important role in many glomerular diseases, their role in recurrent primary FSGS post-transplantation has not been systematically investigated. To address this, we retrospectively studied a multicenter cohort of 74 kidney allograft recipients with end stage kidney disease due to primary FSGS, confirmed by clinical and histologic parameters. After adjusting for race/ethnicity, there was a numeric higher frequency of HLA-A30 antigen in primary FSGS (19%) compared to each of 22,490 healthy controls  and 296 deceased kidney donors . Within the group of transplant patients with end stage kidney disease due to primary FSGS, donor HLA-A30 was associated with recurrent disease . Multivariable time-to-event analyses revealed that recipients who self-identified as Black people had lower risk of recurrent disease, probably reflecting enrichment of these recipients with  Focal segmental glomerulosclerosis (FSGS) is a histologic pattern of glomerular scarring associated with diverse forms of kidney damage . PrimaryPrimary FSGS can recur following kidney transplantation and has a negative impact on graft survival. Recurrent primary FSGS manifests initially as nephrotic syndrome and diffuse foot process effacement, identical to minimal change disease (MCD), while segmental sclerotic lesions develop later , 4, probIn addition to primary FSGS, the 2021 Kidney Disease Improving Global Outcomes (KDIGO) classification of FSGS includes three other categories  UndetermAPOL1) kidney risk variants is particularly problematic   , 11. Thalerosis) .Despite the negative impact of recurrent DP on allograft survival , our knoPrevious studies by us and others showed an association between donor inherited factors and recurrence of both membranous nephropathy , 17 and This study was a retrospective multicenter study that included the pathology archives of three North American medical centers: Columbia University Irving Medical Center , Brigham and Women’s Hospital , and Oregon Health & Science University . Each center collected data under approval by their Institutional Review Boards.In this report, strict inclusion criteria were used to select our cohort:(1) Recurrent DP (n=47) was defined as recurrence of nephrotic syndrome  in kidney allograft recipients with ESKD attributed to DP/FSGS, accompanied by allograft biopsies  showing foot process effacement involving ≥ 80% of glomerular capillary surface area. The remaining patient had a biopsy-proven MCD in the native kidney followed by FSGS, and presented 8 days after transplantation with nephrotic syndrome  and serum creatinine of 1.1 mg/dL. Native kidney biopsies and/or pathology reports were available for 29 of these subjects and showed FSGS (n=21) and MCD . The remaining 18 cases had a clinical diagnosis of FSGS but pathologic materials were not available for re-review.(2) Non-recurrent DP (n=27) was defined as absence of nephrotic syndrome post-transplantation in kidney transplant recipients who developed nephrotic syndrome in their native kidney  with a concurrent native kidney biopsy showing near complete foot process effacement (involving ≥ 80% of the glomerular capillary surface area). Of these, 24 subjects had native kidney biopsy showing FSGS and 3 demonstrated MCD (including 2 patients with subsequent native biopsies showing development of FSGS).Serologic and/or molecular typing for HLA-A, -B, -DR, and -DQ was performed for both donors and recipients. The outcome was recurrence of DP in the kidney allograft and the subjects were censored at loss of follow-up or allograft failure. Studied variables including recipient demographics , donor demographics, allograft source, HLA-mismatch , prior kidney transplant, and induction immunotherapy, were extracted from the medical record.To test which HLA antigens that are potentially associated with DP, the most frequent HLA antigens in our transplant cohort were compared to two group of controls:(1) External controls of healthy US residents  from National Bone Marrow Donor Program , providi(2) Internal controls of deceased kidney donors whose kidneys were transplanted at CUIMC in 2010 onwards that were matched with our cohort of DP patients with regard to self-reported ancestry .Statistical analyses were performed using Prism 9  and SPSS Statistics, 26.0 . Categorical data were compared using Fisher Exact test while continuous data were compared using the Mann-Whitney test. With the except of discovery study, P less than 0.05 with two-sided hypothesis testing were considered statistically significant.We identified 74 kidney allograft recipients who had ESKD due to DP/primary FSGS . Subjects were followed-up for a median of 68  months after transplantation. During follow-up, 47 (64%) patients developed recurrent disease [median 34  days post-transplantation] and 40 (54%) developed allograft failure [median 26  months after transplantation].The median age at transplantation was 35 years  . Since 1To test whether HLA-A30 is associated with recurrent DP, we compared the frequencies of this antigen in both recipients and donors with recurrent and non-recurrent disease. While the proportion of recipient HLA-A30 was not significantly different , the frequency of donor HLA-A30 was higher in recurrent disease  (APOL1 had high-risk genotypes (3 G1/G1 and 1 G1/G2).To identify independent predictors for recurrent DP, all transplant patients with ESKD due to DP (n=74) were studied in a time-to event model, where DP recurrence was considered as the outcome of interest Table 1.APOL1 genotypes have also been linked to FSGS  and ≥ 80% of foot process effacement to assemble a relatively pure cohort of DP/primary FSGS . DespiteAlthough not reaching statistical significance by Bonferroni criteria in this relatively small sample, our data suggested an association between primary FSGS in the native kidney and HLA-A30 antigen. Prior studies have shown an association between HLA-A30 and several autoimmune diseases, including type 1 diabetes mellitus, vitiligo, and systemic sclerosis –41, whicDespite the high positive predictive value (92%) of HLA-A30 in predicting recurrent disease, it was not surprising that this relatively low frequency HLA antigen, which has a prevalence of 7% in the general population and 19% in patients with ESKD secondary to primary FSGS, did not reach statistical significance as an independent predictor for recurrent disease in this small cohort.APOL1 genotypes (80%) in Black recipients with non-recurrent DP. It is now well accepted that donor APOL1 kidney risk variants may be a risk factor for podocyte damage in the kidney allograft .Our findings should be interpreted in light of several limitations, including small sample size, low resolution of HLA typing, lack of HLA-DQ typing in several recipients and donors, lack of In conclusion, a strict definition of recurrent DP/primary FSGS is an initial step to advance our understanding of recurrent disease after transplantation. Our pilot study represents the first attempt to systematically assess immunogenetic predictors of recurrent disease in a well-defined cohort of transplant patients with ESKD attributed to DP/primary FSGS. Our results suggest that donor HLA-A30 is a potential risk factors for recurrent DP/primary FSGS while Black recipient race may be a potential protective factor. However, it is still possible that the observed association between HLA-A30 and primary FSGS is affected by the differential distribution of HLA-A30 across worldwide populations. Therefore, future larger GWAS studies that properly control for genetic ancestry are crucial to examine the effects of HLA-A30 in a more comprehensive manner, to refine the donor and recipient genomic signals contributing to recurrent primary FSGS, and to obtain better insights into the pathobiology of recurrent DP . The ultThe original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Columbia University Institutional Review Board. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.IB participated in research design, performance of research, data analyses, and in the writing of the manuscript. PK participated in performance of research and writing of the manuscript. AW participated in research design, performance of research, and writing the manuscript. NA participated in research design, performance of research, and writing the manuscript. MBS participated in research design and writing of manuscript. PK is currently at the Baylor College of Medicine Houston, TX. All authors contributed to the article and approved the submitted version.