Cardiovascular disease is the main cause of premature death in patients with type 1 diabetes. Patients with diabetic kidney disease have an increased risk of heart attack or stroke. Accurate knowledge of the complex inter-dependencies between the risk factors is critical for pinpointing the best targets for research and treatment. Therefore, the aim of this study was to describe the association patterns between clinical and biochemical features of diabetic complications.Medical records and serum and urine samples of 4,197 patients with type 1 diabetes were collected from health care centers in Finland. At baseline, the mean diabetes duration was 22 years, 52% were male, 23% had kidney disease  and 8% had a history of macrovascular events. All-cause mortality was evaluated after an average of 6.5 years of follow-up . The dataset comprised 28 clinical and 25 biochemical variables that were regarded as the nodes of a network to assess their mutual relationships.r > 0.6), including cliques for high-density lipoprotein (HDL) markers, for triglycerides and cholesterol, for urinary excretion and for indices of body mass. The links between the cliques showed biologically relevant interactions: an inverse relationship between HDL cholesterol and the triglyceride clique , a connection between triglycerides and body mass via C-reactive protein  and intermediate-density cholesterol as the connector between lipoprotein metabolism and albuminuria . Aging and macrovascular disease were linked to death via working ability and retinopathy. Diabetic kidney disease, serum creatinine and potassium, retinopathy and blood pressure were inter-connected. Blood pressure correlations indicated accelerated vascular aging in individuals with kidney disease (P < 0.001).The networks contained cliques that were densely inter-connected (The complex pattern of links between diverse characteristics and the lack of a single dominant factor suggests a need for multifactorial and multidisciplinary paradigms for the research, treatment and prevention of diabetic complications. A significant number of patients with type 1 diabetes suffer from severe microvascular complications such as diabetic kidney disease and proliferative retinopathy . The patComplex network analysis has gained popularity as new datasets and techniques have become available ,12. ReceThis work illustrates the main modules of clinical and biochemical associations in type 1 diabetes. Our aim is to present the characteristics of diabetic complications as an inter-connected system, instead of focusing on any single variable at a time. We also discuss the biological processes that can be attributed to the observed network structures, and demonstrate the links between multiple chronic conditions, lifestyle, aging, and metabolic traits in their full context.Type 1 diabetic patients were recruited by the Finnish Diabetic Nephropathy Study Group . The design was cross-sectional (serum and urine samples), but with longitudinal records of albuminuria and clinical events before baseline and with all-cause mortality data available after an average of 6.5 years of follow-up from baseline . Type 1 diabetes mellitus was defined as an age of onset below 35 years and transition to insulin treatment within a year of onset. Macrovascular disease (337 cases) was obtained from medical records and defined as a pooled end-point of coronary heart disease (224 cases), myocardial infarction (124 cases), stroke (100 cases), and peripheral vascular disease (91 cases).The classification of renal status was made centrally according to urinary albumin excretion rate (AER) in at least two out of three consecutive overnight or 24 h-urine samples. Absence of diabetic kidney disease (DKD) was defined as AER within the normal range (AER <20 μg/min or <30 mg/24 h) and at least 15 years of type 1 diabetes. This kidney disease negative subset is denoted by 'KDNEG'. Macroalbuminuria or overt kidney disease was defined as AER ≥ 200 μg/min or ≥ 300 mg/24 h. The intermediary range was defined as microalbuminuria (20 ≥ AER <200 μg/min or 30 ≥ AER <300 mg/24 h). Patients on renal replacement therapy  were classified as having end-stage renal disease (ESRD). An additional subset, denoted by 'DMDur<15', was formed from patients with less than 15 years of diabetes duration, and normal  or unknown AER . A total of 296 patients could not be classified.The AER values that were used for the DKD diagnosis were measured in the local health care centers, but not used for statistical analyses. Instead, the continuous 24 h albumin excretion rate was estimated from a single 24 h-urine collection (available for 80% of patients) from which albumin was measured by a central laboratory.et al. submitted). VLDL triglycerides and IDL and LDL cholesterol were estimated by neural network modeling [Education level, smoking and alcohol dose, working status, asthma, rheumatoid arthritis and thyroid disease were determined by patient questionnaires. Education level was defined as the expected number of years in the educational system based on the current occupation, smoking exposure was calculated as the product of daily cigarettes and years of smoking, the daily dose of alcohol was estimated from the type and quantity of drinks consumed. Working status was compressed into a binary trait (disabled vs. employed or unemployed). Serum concentration of the soluble receptor for advanced glycation end-products (SRAGE) was measured by solid phase ELISA  of outliers. Therefore, the continuous variables were sorted and converted to scaled ranks between -1 and 1 to prevent statistical artifacts. Two versions of the dataset were created: one with men and women pooled, the other with separate rank transforms for the sexes.The network of continuous variables was based on pair-wise Spearman's correlation coefficients. Specifically, each variable is considered a node and the nodes are connected by links, the weights of which are quantified by the correlation coefficient. The full networks are too dense and have to be pruned in order to highlight the relevant patterns. There are numerous ways to reduce the network dimensionality , here weP < 0.01) in its spanning tree. This procedure was chosen to avoid selecting too many links for closer inspection, and yet ensuring that as many nodes as possible would be represented.Direct graph-theoretic investigation of the networks provides little useful information since many of the variables are derived or otherwise non-biologically linked with each other. Therefore, structural considerations were made via comparisons between the kidney disease subsets to reduce the distraction from irrelevant connections. Statistical significance was estimated by random permutations of the subset labels [Additional file .Correlation coefficient is not well suited for comparing binary and continuous variables. For this reason, a computationally intensive regression-correlation measure was applied to the full dataset to create the visualization [Additional file Figure There are strong inverse associations between the HDL-clique and IDL cholesterol. Other connections include the links between triglycerides and body mass via C-reactive protein, and the central role of 24 h-urine albumin as the connector of triglycerides, IDL cholesterol, hemoglobin A1c, blood pressure and serum creatinine. Adiponectin links HDL metabolism with 24 h-urine metabolites and SRAGE is located between serum creatinine and body mass. Smoking and alcohol intake are correlated; alcohol consumption is also reflected in apolipoprotein A-I and A-II concentrations, and smoking dose is linked with lower education and - by definition - to higher age. Weight-adjusted insulin dose is inversely associated with aging in this dataset.P = 2.2 × 10-16) and from the patients with short duration (P = 4.0 × 10-32). On the other hand, the DMDur<15 subset is different from the macroalbuminuria subset (P = 1.2 × 10-29).The dataset was divided according to AER and diabetes duration (see Methods) and the subset networks were compared to detect relevant topological features. Table r = 0.02 vs. -0.20, P = 2.5 × 10-5), whereas systolic blood pressure shows stronger dependence in the KDNEG subset . Adiponectin is also age-dependent in the KDNEG subset, but uncorrelated in the macroalbuminuria subset .Table r = 0.05 vs. 0.29, P = 6.3 × 10-8) and SRAGE  in the macroalbuminuria, but not in the KDNEG subset. The associations between albumin excretion and other variables are also negligible in the KDNEG subset. On the other hand, 24 h-urine albumin is significantly correlated with total cholesterol , IDL cholesterol  and triglycerides  in the macroalbuminuria subset.Serum creatinine is connected to adiponectin (P = 5.1 × 10-5), 24 h-urine albumin excretion (P = 0.0010), SRAGE (P = 0.0024) and apolipoprotein B-100 (P = 0.0046) were significantly changed. The ESRD group showed a similar structure: serum creatinine, 24 h-urine albumin and SRAGE were significantly different (P < 0.00050). There were statistically significant differences also in the connectivity of adiponectin (P = 8.1 × 10-6), age (P = 8.3 × 10-5), 24 h-urine urea (P = 0.00032), BMI (P = 0.0021), insulin dose (P = 0.0034) and apolipoprotein A-I (P = 0.0099) when compared with the KDNEG subset.Node strength measures the overall connectivity of a node: it is the sum of the correlation magnitudes that link the node to the rest of the network. A high strength indicates a structurally significant variable, although the value itself is less important and therefore not reported here. The strengths were not different between the microalbuminuria and KDNEG subsets (data not shown). Within the macroalbuminuria subset, the connections surrounding serum creatinine  are connected to the complications via adiponectin, and the clique is located next to the body mass indicators (height and weight). Male gender is connected to body mass, as expected, but there are also weak inverse associations with asthma, thyroid disease and rheumatoid arthritis.The metabolic syndrome is - by definition - a connector between body mass (waist circumference), HDL-metabolism, and triglycerides. The HDL clique is linked to C-peptide an further to age and diabetes duration. On the other hand, age connects to triglycerides via insulin dose and hemoglobin A1c. Finally, the estimated IDL cholesterol is the connector between the triglyceride and cholesterol cliques, and albuminuria.The network analysis showed identifiable cliques of inter-connected variables that were mostly driven by methodological factors and basic biology. That said, there were biologically relevant links between the cliques: body mass and triglycerides were connected by C-reactive protein in the gender-adjusted analysis, IDL cholesterol was the key quantity between albuminuria, triglycerides, cholesterol, HDL-metabolism and hemoglobin A1c, and the close relationship with working ability and microvascular diseases indicated the debilitating effects of diabetic complications. The lack of correlation between age and systolic blood pressure in the kidney disease patients - but inverse correlation with diastolic - reflected the effects of kidney disease on vascular aging.Macrovascular disease was not, as could have been expected, the closest to the diabetic kidney disease and blood pressure clique, but the node was located near age and diabetes duration. Nevertheless, the connections to microvascular complications and mortality were evident via retinopathy and reduced working ability. The available data and definitions may also have favored the stronger links with aging: the vascular events were determined from (past) medical records, not at the time of the study visit. There may also be a survival effect: those patients that reach the late stages of kidney disease may have more resilience against cardiovascular disease by having higher HDL cholesterol, for instance ,25.Mortality and kidney disease were not connected directly, although part of the same node group. Instead, laser-treated retinopathy and anti-hypertensive treatment had a direct link with death, and there was also a strong inverse connection to working ability Figure . MacroalThe DCCT Study has established the beneficial effects of tight glycemic control on diabetic complications ,27. Herer < 0.3) and cannot be considered clinically significant. This is most likely due to the robust but less sensitive rank transform, the need to avoid linear artifacts in data imputation, and the observational nature of the study. In particular, 24 h urinary albumin excretion was weakly correlated with the other variables, which may be the result of the large biological variation in cross-sectional urine collections. There were only a few cases of asthma, rheumatoid arthritis or thyroid disease, which further reduced the power of the regression-correlation approach. Despite the problems, the negative associations with male gender were consistent with previous results [The patient material was extensive with detailed clinical characteristics and biochemical measurements from serum and urine. On the other hand, the dataset was not complete and special procedures had to be taken to impute the missing values. Many of the correlation coefficients were small  but, although statistically significant, the modest time gap did not interfere with the descriptive nature of the network approach.The subset analyses were not matched for age. However, the association between age and diabetes duration was comparable between the groups (except within DMDur<15) and the age variances were similar [Additional file Lipid abnormalities have been previously linked with diabetic kidney disease -33 and lLow-grade chronic inflammation has emerged as a possible link between obesity and insulin resistance. For instance, when adipose tissue expands to accommodate excess lipids, macrophages therein are exposed to non-esterified fatty acids and respond by increased release of inflammatory cytokines ,38. The Serum adiponectin is another signaling molecule that can be traced to adipose tissue - it is decreased in obesity and insulin resistance . On the Aging and diastolic blood pressure are first positively correlated but then become negatively correlated at higher age. The process is accelerated in type 1 diabetes, most likely due to arterial stiffening ,44. The The various clinical and biochemical risk factors that predispose to cardiovascular disease and diabetic complications share mutual connections that have overlapping origins in methodology, physiology and pathology. It may not be possible to fully isolate the effects of the various components in the traditional reductionist framework. Therefore, we think that the complex pattern of links between diverse characteristics such as working ability, life style, aging and biofluid chemistry is explicit evidence to develop multifactorial and multidisciplinary paradigms for the research, treatment and prevention of diabetic complications.The authors declare that they have no competing interests.VPM designed and conceived the study, wrote the statistical software, analyzed the data and wrote the manuscript. CF collected the clinical data and reviewed the manuscript. LT collected the clinical data and reviewed the manuscript. JW collected the clinical data and reviewed the manuscript. KK participated in conceiving the study and reviewed the manuscript. MAK participated in conceiving the study and in writing the manuscript, PHG participated in conceiving the study, in collecting the clinical data, and in writing the manuscript.Comparison of kidney disease groups. Median values (50% quantile) and 68% intervals  of the five patient subsets. The Kolmogorov-Smirnov test was used for continuous data. The P-values were obtained by comparing a given subset against the KDNEG group.Click here for fileNetwork methodology. A description of the statistical and visualization methods that were used in the study.Click here for fileThe Finnish Diabetic Nephropathy Study Group. A listing of the hospitals and health care centers that have participated in the recruitment of patients.Click here for file


Anaemia has been shown in previous studies to be a risk factor for cardiovascular disease in diabetic patients with chronic kidney disorder. This study was aimed to assess the prevalence of anaemia and kidney dysfunction in Caribbean type 2 diabetic patients that have been previously shown to have a high prevalence of the metabolic syndrome.2. Comparisons for within- and between-gender, between diabetic and non-diabetic subjects were performed using Student's t-test while chi-square test was employed for categorical variables.155 type 2 diabetic patients and 51 non-diabetic subjects of African origin were studied. Anthropometric parameters were measured and fasting blood samples were collected for glucose, creatinine, glycated hemoglobin and complete blood count. Anaemia was defined as haemoglobin < 12 g/dl (F) or < 13 g/dl (M). Kidney function was assessed using glomerular filtration rate (GFR) as estimated by the four-variable Modification of Diet in Renal Disease (MDRD) study equation. Subjects were considered to have chronic kidney disease when the estimated GFR was < 60 ml/min per 1.73 m2, p < 0.001) than non-anaemic patients.The diabetic patients were older than the non-diabetic subjects. While male non-diabetic subjects had significantly higher red blood cell count (RBC), haemoglobin and hematocrit concentrations than non-diabetic female subjects (p < 0.001), the RBC and hematocrit concentrations were similar in male and female diabetic patients. Furthermore, irrespective of gender, diabetic patients had significantly higher prevalence rate of anemia than non-diabetic subjects (p < 0.05). Anaemic diabetes patients had significantly lower GFR (67.1 ± 3.0 vs. 87.9 ± 5.4 ml/min per 1.73 mA high prevalence of anaemia was identified in this group of type 2 diabetic patients previously shown to have a high prevalence of the metabolic syndrome. It is therefore recommended that diagnostic laboratories in developing countries and elsewhere should include complete blood count in routine laboratory investigations in the management of diabetic patients. Trinidad and Tobago has high prevalence of diabetes mellitus that the International Diabetes Federation has projected that by the year 2025, 11.8% of the population will be diagnosed with type 2 diabetes . Poor glOne hundred and fifty-five  type 2 diabetic patients visiting, consecutively, eight lifestyle disease clinics at primary care setting in Tobago (between June and November 2006) participated in the study. Patients were considered as type 2 diabetic if they had been managed on oral hypoglycaemic medication and/or diet/exercise since diagnosis (except on occasions when patients took insulin to control hyperglycaemia). The protocol was as previously published . BrieflyFifty-one  apparently healthy non-diabetic subjects living in the same environment/city (Tobago) with the diabetic patients qualified to participate in the study as non-diabetic control subjects. Each volunteer underwent compulsory oral glucose tolerance tests  to detect undiagnosed diabetes (fasting plasma glucose > 7.0 with 2-hour plasma glucose > 11.1 mmol/L) and impaired glucose tolerance (2-hour plasma glucose > 7.8 mmol/L) . Subjectpriori approval by our institutional Ethics Review Committee. All subjects were studied at the clinics in the morning after an overnight (12–14 hours) fast. Details of self-reported ethnic origin and age were directly ascertained from the patients and recorded. Then, waist (cm), at the level of the umbilicus with the patient standing and breathing normally, and hip circumferences (cm), at the level of the largest projection of the buttocks, were obtained by tape measure while weight (kg), with standard hospital balance, and height (m), with metal rule, were measured . Then, fasting blood sample was collected from each subject and, for the non-diabetic subjects alone, 75 g anhydrous glucose in 250–300 ml water was given to each subject and blood samples collected every 30 minutes for 120 minutes. Blood samples were preserved in appropriate tubes for complete blood count, creatinine, glucose and glycated haemoglobin measurements.Informed consent was obtained from both the diabetic and non-diabetic subjects that participated in the study. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a 1c) was determined using boronate affinity assay  while complete blood count was measured using the routine Coulter counter machine .Plasma glucose and serum creatinine were measured in multi-channel auto-analysers using dry slide kits . Glycated haemoglobin (HbA-1.154) × (age-0.203) × 1.212 (if black) × 0.742 . GFR was expressed in ml/min/1.73 m2 [2 [The results are expressed as mean ± SE. The Statistical Package for the Social Sciences  software was used in all analyses. Anemia was defined as haemoglobin < 12 g/dl in females and < 13 g/dl in males . Kidney /1.73 m2  and pati73 m2 [2 . Compari2, p < 0.001) than diabetic patients without anemia. Similarly, diabetic patients with anaemia had significantly higher levels of glycated hemoglobin (index of blood glucose control), creatinine and higher prevalence of kidney dysfunction than non-diabetic subjects with anaemia (Table Table This study has shown that anaemia was more prevalent in diabetic than non-diabetic subjects irrespective of gender, and diabetic patients with anaemia had the lowest kidney function compared with patients without anaemia or non-diabetic subjects with anaemia. The implications of these findings in relation to diabetes management are further discussed.All the new frontiers in the management of type 2 diabetes are aimed at achieving optimal blood glucose control so as to prevent macro- and micro-vascular complications -22. In tIn this study, anaemia was more prevalent amongst the diabetic patients than non-diabetic subjects and the former group of subjects were previously shown to have a high prevalence of the metabolic syndrome . The limThe authors declare that they have no competing interests.CEE – involved in conception, design, acquisition of data, data analysis, interpretation and drafting of manuscript. AJ–L – involved in conception, interpretation and drafting of manuscript. EN – acquisition of data, interpretation and drafting of manuscript. DS – acquisition of data, data analysis, interpretation and drafting of manuscript. FO – acquisition of data, interpretation and drafting of manuscript.


Non-pharmacological treatment options for hypertension have the potential to reduce the risk of cardiovascular disease at a population level. Animal studies have suggested that garlic reduces blood pressure, but primary studies in humans and non-systematic reviews have reported mixed results. With interest in complementary medicine for hypertension increasing, it is timely to update a systematic review and meta-analysis from 1994 of studies investigating the effect of garlic preparations on blood pressure.We searched the Medline and Embase databases for studies published between 1955 and October 2007. Randomised controlled trials with true placebo groups, using garlic-only preparations, and reporting mean systolic and/or diastolic blood pressure (SBP/DBP) and standard deviations were included in the meta-analysis. We also conducted subgroup meta-analysis by baseline blood pressure (hypertensive/normotensive), for the first time. Meta-regression analysis was performed to test the associations between blood pressure outcomes and duration of treatment, dosage, and blood pressure at start of treatment.Eleven of 25 studies included in the systematic review were suitable for meta-analysis. Meta-analysis of all studies showed a mean decrease of 4.6 ± 2.8 mm Hg for SBP in the garlic group compared to placebo , while the mean decrease in the hypertensive subgroup was 8.4 ± 2.8 mm Hg for SBP , and 7.3 ± 1.5 mm Hg for DBP . Regression analysis revealed a significant association between blood pressure at the start of the intervention and the level of blood pressure reduction .Our meta-analysis suggests that garlic preparations are superior to placebo in reducing blood pressure in individuals with hypertension. Hypertension (systolic blood pressure (SBP) ≥ 140 mm Hg; diastolic blood pressure (DBP) ≥ 90 mm Hg) is a known risk factor for cardiovascular morbidity and mortality, affecting an estimated 1 billion individuals worldwide [Allium sativum) has played an important dietary as well as medicinal role in human history [Garlic ] to identify intervention studies investigating the effect of garlic on blood pressure. We also checked reference lists of previously published systematic reviews and meta-analyses for additional primary studies ,41.In the systematic review we included published intervention studies , reporting effects of garlic on blood pressure and published in English or German Table . StricteThe number of subjects in intervention and control groups, mean SBP and DBP at start and end of intervention and SD were collated from text, tables or figures. Methodological quality was assessed independently by two investigators (KR and PF) using guidelines by the Cochrane Collaboration  Tables  and 3, a2>50%) we used the random effects model for meta-analysis, otherwise the fixed effects model was considered appropriate .-21.11-21Ten of the eleven studies included in the meta-analysis reported complete SBP and SD data required for meta-analysis, and eleven studies reported DBP and SD data Table  , -7.36, -1.77] mm Hg compared with placebo (p < 0.001) Figure . SubgrouMeta-analysis of eleven studies of the effect of garlic on DBP did not show a significant difference between garlic and placebo groups  Figure . However2 = 57.1%). However, we found no heterogeneity in the subgroup analysis of studies with hypertensive individuals at start of intervention (I2 = 0%). The same trend was observed for meta-analysis of DBP with I2 = 83.2% for pooled analysis of all ten studies and I2 = 0% for subgroup analysis of studies with hypertensive subjects at start of intervention.Heterogeneity was moderate for meta-analysis of SBP of all ten studies , range 600–900 mg/d), duration of intervention , and SBP or DBP at start of intervention . SBP or DBP at start of intervention proved to be a significant predictor for heterogeneity , strengthening the results of subgroup meta-analysis. None of the other variables tested showed a significant association with blood pressure outcomes (data not shown). Furthermore, regression analysis did not provide any evidence to suggest that receipt of industry funding (n = 3) was associated with blood pressure outcomes.Funnel plots and Egger regression tests suggested no publication bias in the meta-analyses Figure .Figure Our meta-analysis suggests that garlic supplementation exerts a hypotensive effect compared to placebo, in particular in individuals with high blood pressure . Meta-analysis of all studies showed a mean decrease of 4.6 ± 2.8 mm Hg for SBP in the garlic group compared to placebo (p = 0.001), while the mean decrease in the hypertensive subgroup was 8.4 ± 2.8 mm Hg for SBP and 7.3 ± 1.5 mm Hg for DBP (p < 0.00001). Low heterogeneity in the subgroup analyses in addition to regression analysis confirmed that starting blood pressure was a significant predictor for treatment effect of garlic on blood pressure.Interestingly, garlic-only intervention arms of reviewed studies which were not suitable for meta-analysis also showed a trend for greater reduction in BP with higher starting BP. These observed trends are in line with the findings from our subgroup meta-analyses, supporting the evidence for a hypotensive effect of garlic in individuals with high or high normal blood pressure.Whilst data from two studies ,27, inclHeterogeneity observed in the meta-analyses including all studies could only partly be explained by starting BP, while dosage and duration of treatment were not associated with BP outcome. The absence of an association between dosage and blood pressure change may suggest that the hypotensive effect of garlic is comparable for dosages between 600 and 900 mg per day of Kwai powder. On the other hand, detection of an association between duration of garlic intake and blood pressure change may have been limited because the majority of studies (7 out of 11) took final BP measurements at 12 weeks.Our findings of the effect of garlic preparations on SBP/DBP are comparable to the hypotensive effects of commonly-prescribed blood pressure drugs, e.g. beta-blockers of 5 mm Hg for SBP, angiotension converting enzyme inhibitors (ACEI) of 8 mm Hg for SBP , and angMost studies included in this review used garlic powder dosages of 600–900 mg per day, providing potentially 3.6–5.4 mg of allicin, the active compound in garlic . In compSupplementation with garlic preparations compared to raw garlic provides the advantage of reducing or avoiding garlic breath and body odour, and prevents possible destruction of active compounds in the cooking process. Since garlic generally has a high tolerability , supplemFuture research investigating a dose-response relationship between standardised garlic preparations and blood pressure would be warranted, as limited data are available . MoreoveThis systematic review and meta-analysis suggests that garlic preparations are superior to placebo in reducing blood pressure in individuals with hypertension. Future large scale long-term trials are needed to investigate whether standardised garlic preparations could provide a safe alternative or complementary treatment option for hypertension in clinical practice.BP: blood pressure; CI: confidence interval; DBP: diastolic blood pressure; mg/d: milligram per day; mm Hg: millimetre mercury; RCT: randomised controlled trial; SBP: systolic blood pressure; SD: standard deviation.The authors declare that they have no competing interests.KR, ORF and NPS conceptualised the study and obtained funding. Data was acquired independently by KR and PF. KR, PF and TS undertook data analysis and interpretation. KR prepared the manuscript with contributions from all co-authors. All authors approved the final version.The pre-publication history for this paper can be accessed here:Characteristics of studies excluded from the meta-analysis examining the effect of garlic on blood pressure.Click here for file


Background/Aim. Ghrelin has effects on nutrient intake and growth. The cause of growth retardation in congenital heart disease is multifactorial. The aim of the present study is to investigate the ghrelin in congenital heart disease and the association of ghrelin with TNF-Materials and methods. We measured serum ghrelin, TNF-Results. In comparison to controls, serum ghrelin, TNF-Conclusion. Serum ghrelin levels is elevated in acyanotic and cyanotic patients with congenital heart disease. Increased ghrelin levels represents malnutrition and growth retardation in these patients. The relation of ghrelin with cytokines may be explained by the possible effect of chronic congestive heart failure and chronic shunt hypoxemia. Ghrelin, a 28-amino-acide peptide, is a potent stimulator of growth hormone release thathas been implicated in the control of food intake and energy homeostasis inhuman begins and rodents –5. GhrelTumor necrosis factor  actions , 11. IL- actions .The relationship between congenital heart disease (CHD), malnutrition, and growthretardation is well documented . InfantsThe study was conducted on 47 children with acyanotic CHD, 21 childrenwith cyanotic CHD, and 25 healthy children. All patients' cardiac diagnoses weremade on the basis of clinical and laboratory examinations. None of the patientshad associated abnormalities or pulmonary hypertension. Body mass index (BMI)was calculated as the ratio of body weight (kg) and squared height (m). Thelocal ethics committee approved the study protocol. Informed consents were obtainedfrom the parents of the subjects.All blood samples were drawn at 08-09 am and stored −20°Cuntil the procedure. Serum ghrelin, TNF-All data were analyzed by SPSS software, version 10.0 for Windows. Data werepresented as mean ± standard deviation. The given data were compared between groups using one-way ANOVA, followed by Post-hoc; Bonferroni test. Correlation between the parameters were explored with Spearman's correlation. In 47 acyanotic patients, mean age was Serum ghrelin levels were significantly higher than in acyanotic and cyanotic groups compared to in the control group (P<.0001) . Serum In both acyanotic and cyanotic groups, serum ghrelin levels were negativelycorrelated with BMI (Figures . IL-6 an Figures . GhrelinThe cause of growth retardation in CHD is multifactorial. Inadequate caloric intake,malabsorption, and increased energy requirements caused by increased metabolismmay all contribute. However, inadequate caloric intake appears to be the mostimportant cause of growth failure in CHD , 15, 16.Ghrelin is accepted as a good marker of the nutritional state, mainly in situations ofmalnutrition, like anorexia nervosa, owing its fast recovery after weight gain . The invAlthough the cyanotic patients had a more pronounced retardation in both height andweight than in the acyanotic patients, we found that serum ghrelin levelssignificantly elevated in the acyanotic patients than in the cyanotic patients(turbance . Alteratturbance . Weintraturbance  reportedWe found that serum TNF-ablished , 24. Carablished , 26. Thiablished . In addiablished .In the present study, ghrelin correlated to positively with TNF-a et al.  have shoIn conclusion, serum ghrelin level is elevated in cyanotic and acyanotic patientswith CHD. Increased ghrelin levels represents malnutrition and growthretardation in these patients. Additionally, the relation of ghrelin with cytokinesmay be explained by the possible effect of chronic congestive heart failure and chronic shunthypoxemia.


The autocycling group was found to have significantly higher CVP values than the non-autocycling group (P = 0.012). Our data suggest that mechanical ventilator autocycling may be resolved or prevented by the use of a pressure trigger rather than a flow trigger setting in patients with TAHs who require mechanical ventilation.Many patients with end-stage cardiomyopathy are now being implanted with Total Artificial Hearts (TAHs). We have observed individual cases of post-operative mechanical ventilator autocycling with a flow trigger, and subsequent loss of autocycling after switching to a pressure trigger. These observations prompted us to do a retrospective review of all TAH devices placed at our institution between August 2007 and May 2009. We found that in the immediate post-operative period following TAH placement, autocycling was present in 50% (5/10) of cases. There was immediate cessation of autocycling in all patients after being changed from a flow trigger of 2 L/minute to a pressure trigger of 2 cm H Transpls in 2006 patientss in 2006. We mustAfter they have had a TAH implanted, patients typically remain tracheally intubated and mechanically ventilated for several days to weeks. While caring for such patients in our institution, we noticed that many developed postoperative autocycling of the mechanical ventilator when a flow trigger was used to initiate breaths Figure , which st test was done to compare the BMI and CVP values of the autocycling group and the non-autocycling group.Following institutional review board approval, we reviewed the computerized medical records of all patients with a TAH placed at our institution between August 2007 and May 2009. We created a database using Excel  and recorded the central venous pressure (CVP) while the patients were mechanically ventilated, the positive end expiratory pressure (PEEP), mode of ventilation, body mass index (BMI), TAH rate, and both the set and actual respiratory rate while the patients' ventilators were set for both flow and pressure triggering. A 1-tailed equal variance student The medical records of 10 patients were identified for review . Once this occurs, the ventilator delivers an assisted breath.Flow- and pressure-triggered mechanical ventilator modes are designed to allow and assist with spontaneous ventilation. In a pressure-trigger mode, the patient's inspiratory effort is recognized when the airway pressure decreases below the baseline level of PEEP by the set trigger sensitivity , resulting in a continuous expiratory flow of 3.5 L/min. The patients' inspiratory effort is recognized as a drop in expiratory flow by the set trigger sensitivity, consequently resulting in a ventilator-assisted breath. In our case, this would occur when expiratory flow is less than 1.5 L/min.Use of a flow trigger has been shown to decrease the inspiratory work of breathing in patients with chronic obstructive pulmonary disease and intrinsic PEEP (iPEEP). In the Any device that alters resistance from the alveolus to the sensor at the y-piece, such as gas leaks from ventilator circuits, leaks in the cuff of the tracheal tube,10. a heThe autocycling group in our case series did have significantly higher CVP values than the non-autocycling group (P = 0.012), though we can not draw any causative conclusions with this post hoc data. An elevated CVP may reflect decreased intra-thoracic compliance, thereby increasing transmitted pressure changes to the airway with resultant autocycling. The elevated CVP may also simply be a consequence of mechanical ventilator autocycling rather than a cause.2 of 61 after one hour of total apnea. The Jarvik-7 TAH is the most recent structural cousin to our current CardioWest TAH device.TAH oscillations induce significant pulmonary volume displacement as there are large pneumatic pressure changes for each beat,15. A paWhy is it that autocycling occurred in 50% of our patients with a flow trigger but not with a pressure trigger? Modern mechanical ventilators maintain PEEP and compensate for changes in circuit pressure by adjusting the exhalation valve with an active microprocessor control throughout the expiratory period. The micIn summary, autocycling of the mechanical ventilator occurred in 50% of patients who had received TAHs with the use of a flow trigger ventilator setting. Autocycling was resolved in all these patients by changing from a flow trigger to a pressure trigger ventilator setting. Mechanical ventilator PEEP maintenance maintains pressure at the expense of altered flow, ultimately leading to autocycling in the case of a flow trigger. Given the frequency of autocycling in the ICU, this information may be applicable to other patients who are mechanically ventilated. Because advanced ventilator software has significantly diminished differences in inspiratory work of breathing, physicians may consider using a pressure trigger as an initial ventilator mode, or switching to this mode in patients suspected of, or at high risk for autocycling.The authors declare that they have no competing interests.AS reviewed the literature, drafted and completed the manuscript. BP and MM assisted in drafting and reviewing the manuscript. FA performed surgical interventions and reviewed the manuscript. Both FA and BP participated in post-operative management of patients studied. All authors read and approved the final manuscript.


Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.To compare the efficacy and safety of two treatment regimens – intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients.n = 49) or Group B (n = 45). Patients in Group A were administered HC 200 mg IV 6-hourly until discharge from the ED, followed by oral prednisolone 0.75 mg/kg daily for 2 weeks. Patients in Group B were administered MP 125 mg IV bolus, followed by 40 mg MP IV 6-hourly until discharge, and then oral MP 0.6 mg/kg daily for 2 weeks. All clinical variables, peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) were assessed at baseline, at 1, 3 and 6 h and at every 6 h thereafter until discharge from the ED. The patients were followed-up after 2 weeks of discharge. The response to treatment was assessed by clinical and spirometric evaluation. Independent t-tests and chi-square tests were used to compare the two treatment regimens.This was a randomized, prospective study performed in the emergency department (ED) of a tertiary care hospital in North India. A total of 94 patients with acute asthma were randomly allocated to either of the two treatment groups: Group A , FEV1 (P < 0.0001) and asthma score (P = 0.034). There was a significant increase in the blood sugar value at 2 weeks in both the groups. However, the increase was greater in Group A as compared to Group B (P < 0.0001).The baseline characteristics were comparable in the two groups. There was a significant improvement in PEF and FEVThis study suggests that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone. Acute bronchial asthma is a common presentation to the emergency department (ED) worldwide. In the United States, approximately 1.8 million patients present with acute asthma in the ED every year, of which nearly 500,000 patients are hospitalized. Evidence3Most studies conducted on patients with acute exacerbation of bronchial asthma used intravenous (IV) methylprednisolone (MP) initially, followed by oral glucocorticoids  for the next 1–8 weeks. The practice patterns in India strongly favor the use of hydrocortisone (HC) followed by oral prednisolone, as this regimen costs lower than the IV MP/oral MP regimen. However, as MP is known to have beneficial pharmacological properties, such as lesser mineralocorticoid potency, greater The study was conducted over a period of 6 months (from Jun. 2008 to Nov. 2008) in the ED of a tertiary care hospital in North India. The annual patient attendance in the ED is more than 120,000. Ethical approval was obtained from the Institutional Ethics Committee. The patients’ written informed consent was taken before enrolling them in the study. The consent form was made available in both Hindi and English.The study was a randomized pilot study comparing two regimens of glucocorticoids. The patients were blinded to the initial treatment received in the ED, i.e. IV MP or IV HC. However, they were not blinded to the treatment given at the time of discharge, i.e. oral MP or oral prednisolone. One hundred patients were recruited in this pilot study.Patients between 13 and 60 years of age who, during the study period, presented to the ED with moderate [peak expiratory flow (PEF) 50–70% of the predicted value or an asthma score of 8–11] or severe  exacerbation of bronchial asthma were included in the study. Patients below the age of 13 years were managed in the pediatric emergency unit while in patients who were above the age of 60 years, distinguishing between chronic obstructive pulmonary diseases and bronchial asthma might have been difficult at times.Patients were considered to be asthmatic if they had been previously diagnosed to have bronchial asthma or if the medical history and examination findings were suggestive of bronchial asthma, as defined by the British Thoracic Society (BTS) guidelines and the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines.9 Patient1) were obtained. PEF and FEV1 were recorded using an electronic PEF/FEV1 meter . Two recordings were taken at each time point , of which the higher value at each time point was recorded. The ABG analysis was performed using a blood gas analyzer NOVA CCX 1+ .Patients were assessed within the first 5 min of their arrival to the ED to confirm whether they fulfilled the criteria for inclusion and exclusion. Informed consent was obtained from either the patient or the patient’s relatives. Baseline parameters such as pulse rate (PR), blood pressure (BP), respiratory rate (RR), presence or absence of cyanosis, oxygen saturation, arterial blood gas (ABG) analysis, PEF and forced expiratory volume in one second  using the random number table was generated for treatment allocation. Individual random numbers were kept in separate envelopes to maintain allocation concealment.®; Laborate Pharmaceuticals Ltd., Panipat, India) till discharge, followed by oral prednisolone 0.75 mg/kg daily  for 2 weeks. Group B patients received MP 125 mg IV bolus , followed by 40 mg IV 6-hourly till discharge, and then oral MP 0.6 mg/kg daily  for 2 weeks.Group A patients received HC 200 mg IV 6-hourly  and any side-effects. A revisit to any hospital due to recurrence of acute exacerbation during the 2 weeks of follow-up was also recorded.Primary and secondary endpoints were ascertained to compare the efficacy of the two treatment regimens. The primary endpoint was “treatment failure,” which was considered if any of the following criteria was met: need for mechanical ventilation, need for hospitalization, mortality within 2 weeks of initial presentation, readmission for acute exacerbation within 2 weeks of discharge or physician-directed intensification of pharmacologic therapy between discharge from the hospital and follow-up at 2 weeks.1 and PEF during the patient’s stay in the ED and at 2 weeks of follow-up, change in asthma score at 2 weeks of follow-up, length of stay in the ED (if discharged from the ED) and length of stay in the hospital (if admitted to the inpatient care). In addition, the nature and severity of the adverse effects occurring within 2 weeks were observed and compared in the two treatment groups.Secondary endpoints were change in FEVBecause a literature search identified just one study comparing the efficacy between MP and HC, the currt-test was utilized for comparing the means between the groups. An appropriate non-parametric test such as the Mann-Whitney U-test was utilized whenever normality assumption was not satisfied. Between-group comparisons of categorical variables were performed using chi-square (χ2) tests. Within-group comparisons were performed using paired t-test to test the difference between baseline and 2 weeks. Repeated measures analysis of variance (ANOVA) was used to test the difference between the means at different time points within the group. Tukey’s studentized range (q) test was used for multiple comparisons of FEV1 and PEF between different time points. The results were considered significant at the 5% level (P < 0.05).Descriptive statistics  were calculated for each quantitative variable. Independent The data were entered into a database program  and were imported into a statistical software package  for analysis.n = 49) and Group B (n = 45)]  . Six patAt baseline, the patients in the two groups did not differ significantly with regard to age, history of smoking, duration of asthma, medications used for chronic phase, duration of present episode of acute asthma and medications received before presentation to the ED . Also, t1 and asthma score at baseline were not significantly different between the groups.Pulse rate, BP (diastolic and systolic), RR, PEF, FEV1 and asthma score showed significant improvement in both the groups at the time of discharge as well as at 2 weeks of follow-up  as compared to Group B [122.2 (± 12.55) mg/dl] (P < 0.0001). Within the groups, there was a significant difference in blood sugar values at 2 weeks from baseline . Diastolic BP increased significantly from 78.7 (± 7.14) mmHg to 83.5 (± 6.22) mmHg (P < 0.0001) in Group A while systolic BP decreased from 128.3 (± 18.98) mmHg to 123.6 (± 9.2) mmHg (P = 0.032) in Group B. The ABG analysis was performed only at baseline, as based on the patient’s clinical condition; a repeat ABG was not required in most patients.At baseline, the mean blood sugar values were 98.2 (± 12.06) mg/dl and 113.6 (± 20.51) mg/dl in Group A and Group B, respectively  in Group A required ventilator support due to respiratory muscle fatigue; he died 48 h after arrival to the ED.In Group A, two patients (4.17%) had relapsed within 2 weeks. One patient relapsed on the 14At 2 weeks of follow-up, the following adverse events were observed in patients in the two groups: (a) abdominal distension and constipation each in two patients (8.33%) in Group A, (b) burning pain in the epigastrium in two patients in Group A (8.33%) and in one patient in Group B (2.22%) and (c) facial puffiness in seven patients (14.58%) in Group A and in three patients (6.67%) in Group B.It is important to achieve rapid improvement in lung function during the first few hours of severe acute asthma as it is most affected during this time. A prompt corticosteroid therapy is therefore desirable at this stage,13 althou3There are inconsistencies in the various reported studies regarding the role of different corticosteroids in bronchial asthma as the efficacies of corticosteroids may vary due to their dissimilar antiinflammatory potencies. While MPet al. (1984) evaluated the effects of two doses of MP of 125 mg or 60 mg against HC of 100 mg on serum immunoglobulin E levels (IgE). IgE levels decreased significantly in patients treated with the higher dose of MP (125 mg), while there was not much of a decrease in the IgE levels in patients treated with either HC or with a lower dose of MP (60 mg).[et al. (1996), HC was found to be more effective than MP in reducing stay in the asthma unit in patients with acute severe asthma.[Gordon  (60 mg). In anoth (60 mg). In a stue asthma. However,The present study aimed to compare the safety and efficacy of two treatment regimens – IV HC followed by oral prednisolone and IV MP followed by oral MP in acute asthma patients. The study showed that there was a significant improvement in the lung functions within few hours of administration of IV corticosteroids in the ED. However, there was no significant difference in the improvement observed during the first 6 h between the two groups. At 2 weeks of follow-up, the improvement in lung function with oral MP was significantly greater than with oral prednisolone. This difference at the end of 2 weeks could be explained by multiple properties of MP. Methylprednisolone is known to have a greater antiinflammatory potency, with lesser mineralocorticoid action as compared to prednisolone. SpecificP < 0.0001 vs. P = 0.031). This increase could be attributed to administration of oral prednisolone for 2 weeks in Group A. This finding supports the findings from various other studies that have shown the hyperglycemic effects of prednisolone.[In the present study, blood glucose values increased in both the groups at 2 weeks of follow-up; however, this increase was more significant in Group A as compared to Group B  showed, in their study, that a lower dose of IV HC (50 mg) four times a day for 2 days followed by a low-dose oral prednisone is as effective in resolving acute severe asthma as are 200 mg or 500 mg doses of HC, followed by higher doses of prednisone.[There are some limitations to the present study. The sample size of the study was small; however, as mentioned, it was a pilot study. The second limitation is that this study was not double-blinded and there could have been some bias by the physicians involved in conducting the study. The study was performed in the emergency unit with an average staff of 10 physicians per emergency shift with rotation of shifts on a daily basis. Except for the steroid use, other treatments were decided by the emergency physicians who were not part of the study. They were also responsible for deciding about admission or discharge of patients and, therefore, individual physician’s bias is unlikely to have affected the study results. The third limitation is the doses of MP and HC/prednisolone used in the study. Bowler ednisone. also recednisone. MethylprTo conclude, the present study has shown a higher efficacy and safety of IV MP followed by oral MP as compared to IV HC followed by oral prednisolone in acute asthma patients. Based on the results of this pilot study, IV MP followed by oral MP, despite its higher cost, may form the treatment of choice among the two regimens for acute bronchial asthma. Nevertheless, the plasma and biological half-life of MP is two–three times more than HC, so less-


To compare the efficacy and side effects of 3% hypertonic saline and mannitol in the management of raised intracranial pressure in children.Prospective randomized study.Pediatric intensive care unit (PICU) in a tertiary care hospital.200 patients with raised intracranial pressure.Patients were randomized into two statistically comparable groups; Group A (n = 98) was treated with mannitol while Group B (n = 100) was treated with 3% hypertonic saline. Group C (n = 2) included those members of Group A in whom serum osmolality ≥320 mosmol/kg and were then treated with 3% hypertonic saline. Both Drugs were given at a loading dose of 5 ml/kg stat followed by 2 ml/kg in every 6 h(both have same osmolarity) for two days in their respective groups. Besides monitoring, blood pressure (NIBP), mean arterial pressure (pre and post 30 min of drug), serum sodium, chloride and osmolality were measured. Intracranial pressure was assessed indirectly by measuring mean arterial ressure “MAP”. Student paired ‘t’ test was applied.P<0.001) at 0 h in males 0,6 h in females, and moderately significant at 12,36 h in females and significant(P<0.05) at 6,24,42 h in males of Group B. Decrease in coma hours was a highly significant finding (P<0.001) in Group B. In Group B, serum sodium and chloride increased significantly but remained within acceptable limits. There was no difference in osmolality and mortality (fisher Z).Decrease in MAP was highly significant (Mannitol has several side effects, 3% hypertonic saline is a safe and effective alternative in managing cerebral edema. Hyperosmolar treatment is one of the important methods for treating cerebral edema, and has been employed since early 1960. Urea, glycerol and mannitol were used for the treatment of this condition in the early years, but urea and glycerol were soon abandoned because of low efficacy. Mannitol is still used extensively. Side effects such as rebound effect, serum electrolyte imbalance and hypovolemia have led to the continued search for other osmotically active agents. One of them is hypertonic saline.To study the efficacy of hypertonic saline in the treatment of raised intracranial pressure in children in comparison to mannitol.To study the side effects (if any) of hypertonic saline treatment in the management of raised intracranial pressure.Study design: Prospective randomized comparative studySetting: Pediatric intensive care unit (PICU)Data analysis: Continuous data was analyzed by using Student unpaired ‘t’ testInclusion criteria: 200 Children aged 2 to 18 years, admitted to the emergency Department of Pediatrics between Jan 15th, 2007 and May 31st, 2008 with clinical symptoms and signs of raised intracranial pressure.Exclusion criteriaPatients with:compromised renal function (increased Serum creatinine)hepatic encephalopathyserum Na+ (>150 meq/l)diabetic ketoacidosiscerebral malarian = 98): treated with mannitolGroup A : treated with 3% hypertonic saline.Group B  was later made and Included those members of Group A in whom S. osmolality increased to more than 320 mOsm / kg and were then treated with 3% hypertonic saline.Group C (Loading dose(5ml/kg) was followed by maintenance dose (2 ml/kg) in every 6 h in both groups for two days .Blood pressure: By NIBP, at admission and then in every 6 h, both pre and post drug .S. creatinine: Before starting treatment and after 48 h.Blood urea nitrogen: Before starting treatment and after 48 h.Serum electrolytes: Before starting treatment and then in every 12 h.ABG: Before starting treatment, and after 12, 24, 36 and 48 h.Comparison of average reduction of mean arterial pressure (pre and post drug) at definite time (6h) intervals was done to indirectly assess reduction in intracranial pressure.Mean arterial pressure indirectly represents intracranial pressure = mean arterial pressure – intra cranial pressure (ICP) i.e. MAP = CPP + ICP (where CPP remains constants)Formula applied: MAP α ICP3% hypertonic saline was more efficacious than mannitol in the initial 12 h and equally or more efficacious than mannitol therapy later.Decrease in coma hours was a significant additional finding in the group treated with 3% hypertonic saline (Group B).Change in blood biochemistry was within acceptable limits in Group B. Tables –5et al.[For the first time, in 1919, Weed and McKibben reported4et al. demonstret al.9et al.[et al.[et al.[During the period in which mannitol was used intensively, maintenance of serum osmolarity below 320 mOsm/l was recommended because of complications of acute tubular necrosis (ATN) and renal failure. However, it was later understoodthat this complication developed as a result of dehydration and hypovolemia. Children11et al. showed tl.[et al. using 7.Hypertonic saline has been used more frequently in trauma, intracerebral hemorrhage, burn and stroke patients. Our patient group was different in their etiology of brain edema. Rationale of use of mannitol and HS is similar in both traumatic and non traumatic cerebral edema because all cerebral edemas with varied etiologies usually have vasogenic mechanism. In addition, HS is more effective and safer than mannitol. Greater efficacy of HS compared to mannitol can be speculated by different reflection coefficients of these agents. Because et al.,[In terms of the efficacy and side effect profile of the saline treatment in brain edema, the optimum serum-Na concentration and osmolarity are not known. In a retrospective study Peterson et al., though met al.,–11 Thereet al.,–18 So afPotential side effects of hypertonic saline have been reported: MyelinolRenal failure, congestive heart failure, pulmonary edema, hypokalemia and phlebitis were not observed in any of our patients. There was no significant tendency for hemolysis or hemorrhage associated with acute fall in the hematocrit level.In conclusion, in the treatment of cerebral edema of infectious, anoxic, hemorrhagic and traumatic origin, administration of HS is probably more effective and safer than mannitol. However, to determine just when to initiate treatment, how long to continue treatment, and target serum-Na concentration requires monitoring of the intracranial pressure. Further studies are required to resolve these concerns.


Hypertension and proteinuria are medical complications associated with the multisystemic effects of long-term hypercortisolism in dogs with hyperadrenocorticism (HAC).This study investigated the relationships among adrenocorticotropic hormone (ACTH)-stimulation test results, systemic blood pressure, and microalbuminuria in clinically-healthy dogs (n = 100), in dogs affected with naturally occurring pituitary-dependent , or adrenal-dependent hyperadrenocorticism .p = 0.803). However the incidence of hypertension was highest in dogs with ADH (p = 0.017), followed by dogs with PDH, with the lowest levels in clinically healthy dogs (p = 0.019). Presence of microalbuminuria and albuminuria in clinically healthy dogs and dogs affected with HAC was significantly different (p < 0.001); incidences of albuminuria followed the same pattern of hypertension; highest incidence in dogs with ADH, and lowest level in clinically healthy dogs; but microalbuminuria showed a different pattern: clinically healthy dogs had highest incidences and dogs with ADH had lowest incidence. The presence of albuminuria was not associated with blood pressure values, regardless of whether dogs were clinically healthy or affected with ADH or PDH (p = 0.306).Mean systemic blood pressure was similar between clinically healthy dogs and dogs with HAC (Higher incidence of hypertension and albuminuria, not microalbuminuria was seen in dogs affected with HAC compared to clinically healthy dogs; incidence of hypertension and albuminuria was significantly higher in dogs affected with ADH compared to PDH. However, presence of albuminuria was not correlated with systemic blood pressure. Hyperadrenocorticism  is a common endocrine disorder in dogs and is characterized by chronically elevated circulating concentrations of the steroid hormones produced by the adrenal cortex (e.g. cortisol) . The mulApart from hypertension, many complications associated with Cushing's syndrome in humans are also linked with increased urinary albumin excretion rate. These include dyslepidaemia, reduced insulin sensitivity, and hyper-coagulative status. These complications are also associated with canine HAC ,16,18,19Microalbuminuria is defined as the presence of a small amount of albumin (1 to 30 mg/dL) in the urine . MicroalThe purposes of this study were to report the relationship between ACTH-stimulation tests, systemic blood pressure, microalbuminuria and albuminuria in dogs affected with naturally occurring pituitary-dependent (PDH) and adrenal-dependent hyperadrenocorticism (ADH).Informed consent was obtained from all dog owners prior to the study, and number of animals of each breed in each group are shown in Table One hundred clinically healthy client-owned dogs visiting the National Taiwan University Veterinary Hospital from 2005 to 2009 for routine health checkups and/or annual vaccination were included in this study. Of the clinically healthy dogs, 29 were intact females, 19 were spayed females, 45 were intact males, and 7 were castrated males. The average age was 5.1 ± 3.5 years (range 0.9 to 15 years), and average body weight was 11.6 ± 9.1 kg (range 1.8 to 35.0 kg). Thorough physical examination, blood pressure measurements and routine blood work  were performed to exclude heart and renal disorders that might affect blood pressure or cause microalbuminuria or albuminuria.Medical records of 278 dogs in the National Taiwan University Veterinary Hospital during 2005-2009 with clinical signs of HAC and results of ACTH stimulation tests consistent with hyperadrenocorticism were screened. Only 70 of these records included conclusive results from an ACTH stimulation test, ultrasonographic evidence of adrenal glands, blood pressure measurements and microalbuminuria analysis. Therefore, only 70 dogs were included in the study.Inclusion criteria of HAC were clinical signs consistent with a diagnosis of HAC , results of routine serum biochemical analyses that were consistent with a diagnosis of HAC , and affirmative results of adrenocorticotropic hormone (ACTH) stimulation tests (post-ACTH cortisol concentration >20 μg/dL) . Dogs wiAll included dogs were required to have had an ACTH stimulation test with intramuscular injection of 0.25 mg synthetic ACTH . Informed consent was obtained from all owners prior to diagnostic testing. Blood samples for serum cortisol measurements were collected via cephalic venipuncture immediately before, and 1 hour after synthetic ACTH was injected. Serum cortisol concentrations were measured by a validated radioimmunoassay  .In this study, 70 dogs were affected with HAC, with the mean age of 11.7 ± 2.7 years and ranged from 4.5 to 18 years. Dogs had a mean body weight of 9.0 ± 7.6 kg ranging from 2.1 to 43.4 kg. Twenty-seven were spayed females, 21 were intact males, and 11 each of castrated males and intact females. Among these 70 cases, 40 dogs affected with PDH and 30 dogs affected with ADH . The mean age of the 40 dogs affected with PDH was 10.7 ± 2.7 years, ranging from 4.5 to 16 years with a mean body weight of 9.9 ± 8.6 kg, ranging from 2.1 to 43.4 kg. Sixteen were spayed females, 6 were intact females, 12 were intact males and 6 were castrated males. The mean age of the dogs affected with ADH was 12.9 ± 2.2 years, ranging from 8 to 18 years. This group had a mean body weight of 7.9 ± 5.6 kg, ranging from 3.0 to 24.5 kg. Eleven were spayed females, 5 were intact females, 9 were intact males, and 5 were castrated males. Breeds of 70 dogs affected with HAC are shown in Table Systemic blood pressure values of 100 clinically healthy dogs and 70 dogs affected with (pre-treated) HAC were evaluated by the same protocol--Doppler sphygmomanometry. A Doppler Ultrasonic Flow Detector  with an inflatable cuff width of 1.9, 2.5, 3, 4, or 5 cm (depending on the circumference of the antebrachium) was used. The cuff was wrapped around the middle part of the antebrachium, and a Doppler probe coated with ultrasonic transmission gel was positioned over the palmar area to detect blood flow from the arteria digitalis palmaris communis. The cuff was then inflated and deflated to obtain a systemic blood pressure reading via an aneroid pressure gauge. During systemic blood pressure measurement, the antebrachium was maintained at the level of the heart. A series of 5 readings (with 10 to 20 seconds between consecutive measurements) was obtained for each dog, and all measurements were completed within 6 minutes. To minimize procedural stress, all dogs were allowed to assume a comfortable position with only gentle restraint by their owners. The dogs remained in the same position throughout systemic blood pressure measurement. The final systemic blood pressure value was calculated as the mean of 5 readings . The heaFreshly voided urine samples from 100 clinically healthy dogs and 70 dogs affected with (pre-treated) HAC were collected. Urine albumin analysis was carried out within four hours after the freshly voided urine samples were collected. Urine samples with hematuria (≥10 RBC/high power of field), pyuria (≥5 WBC/hpf), or bacteriuria was excluded after a light-microscopic examination of urine sediment. The urine albumin and creatinine concentrations were semi-quantitated  and urinary albumin:creatinine ratio (UACR) was calculated accordingly. In this study, no microalbuminuria, microalbuminuria and albuminuria were defined as UACR < 30 mg/g (0.03), 30-300 mg/g (0.03-0.3), and >300 mg/g (0.3), respectively.p value < 0.05.Comparison of systemic blood pressure between clinically healthy dogs and dogs affected with either PDH or ADH were evaluated by means of ANOVA. Relationship between post-ACTH cortisol concentrations and systemic blood pressure was analyzed by use of linear regression. Association between systemic blood pressure, microalbuminuria status  and health status  were evaluated by Pearson's chi-square test. All statistical analyses were performed using commercially available software . Continuous data are presented as mean ± SD. Statistical significance was determined by a The mean systemic pressure of 100 clinically healthy dogs was 152.8 ± 27.3 mmHg. One  was hypotensive, 87% (87/100) were normotensive, and 12% (12/100) were hypertensive. Among the 100 clinically healthy dogs, 53% (53/100) did not have microalbuminuria, 45% (45/100) had microalbuminuria, and 2% (2/100) had albuminuria  were normotensive, and 31.4% (22/70) were hypertensive. In 70 dogs with HAC, 12.9% (9/70) did not have microalbuminuria, 38.6% (27/70) had microalbuminuria, and 48.6% (34/70) had albuminuria  were normotensive, and 20% (8/40) were hypertensive. Among the 40 dogs affected with PDH, 15% (6/40) did not have albuminuria, 52.5% (21/40) had microalbuminuria, and 32.5% (13/40) had albuminuria. Pre- and post-ACTH cortisol concentrations in the dogs affected with PDH were 4.6 ± 2.9 (ranging from 1.9 to 14.1) and 25.5 ± 11.6 (ranging from 21.6-63.1) μg/dL, respectively  were normotensive, and 46.7% (14/30) were hypertensive. Among the 30 dogs with ADH, 10% (3/30) did not have microalbuminuria, 20% (6/30) had microalbuminuria, and 70% had albuminuria. Pre- and post-ACTH cortisol concentrations in dogs affected with ADH were 8.5 ± 6.0 (ranging from 2.9 to 28.7) and 33.2 ± 23.7 (ranging from 23.6-110.2) μg/dL, respectively (Table p = 0.803). However, incidence of hypertension between clinically healthy dogs and dogs affected with HAC was significantly different (p = 0.019). Presence of microalbuminuria and albuminuria in clinically healthy dogs and dogs affected with HAC was significantly different (p < 0.001); significantly higher incidence of microalbuminuria, but significantly lower incidence of albuminuria in clinically healthy dogs compared to dogs affected with HAC. Overall, presence of microalbuminuria or albuminuria was not associated with the status of blood pressure in either clinically healthy dogs or dogs with HAC (p = 0.141).The mean systemic blood pressure was not different between clinically healthy dogs and dogs with HAC (p = 0.004). Incidence of hypertension in dogs affected with PDH and ADH was significantly different (p = 0.017). Presence of microalbuminuria and albuminuria in dogs affected with PDH and ADH was significantly different (p = 0.007). However, albuminuria was not associated with the status of blood pressure (p = 0.306).The mean systemic blood pressure was significantly different between dogs affected with PDH and ADH (p < 0.001). No correlation between systemic blood pressure in either pre-ACTH  or post-ACTH cortisol concentrations  was found.Both pre- and post-ACTH cortisol concentrations between dogs affected with PDH and ADH were significantly different (p = 0.019); incidences of albuminuria followed the same pattern: highest incidence in dogs with ADH, and lowest level in clinically healthy dogs (p < 0.001); but microalbuminuria showed a different pattern: clinically healthy dogs had highest incidence and dogs with ADH had lowest incidence.Overall, the incidence of hypertension was highest in dogs with ADH, followed by dogs with PDH, with the lowest levels in clinically healthy dogs (The incidence of hypertension in dogs affected with HAC has been reported to range from 52.6 (n = 10/16) to 86.1% n = 31/36) [1/36 3,44. In thiIn this study, higher systemic blood pressure and higher incidence of hypertension was associated with ADH compared to PDH. This finding has not been reported in dogs affected with hyperadrenocorticism. However, no correlation between the cortisol concentrations and systemic blood pressure was found. Similar results were also reported in human patients with Cushing's syndrome ,18. The Incidence of microalbuminuria in clinically healthy dogs in this study (45%) was similar to previous studies, ranging from 19 to 52% ,32. SurpIn this study, incidence of hypertension and albuminuria was significantly higher in dogs affected with ADH compared to PDH. This finding has not been reported in dogs affected with HAC. The correlation between systemic blood pressure and albuminuria would be anticipated in dogs with HAC, however, this was not supported in this study. Hypertension is not the only factor associated with presence of albuminuria. Increased urinary albumin excretion rate is also linked to dyslepidaemia, reduced insulin sensitivity, impaired endothelial function and hyper-coagulative status . These cThe cause of albuminuria in dogs affected with HAC can not be answered in this study. Nevertheless, long-term monitoring of albuminuria in terms of treatment and survival time is needed to clarify the importance of albuminuria and HAC in dogs.Incidences of hypertension and albuminuria, but not microalbuminuria, were highest in dogs affected with ADH, followed by dogs with PDH, with the lowest levels observed in clinically healthy dogs. However, the presence of albuminuria was not correlated with systemic blood pressure.The authors declare that they have no competing interests.YHL participated in the designs of the study and carried out the recruitment of cases of hyperadrenocorticism. She also drafted the manuscript. TYH performed measurement of systemic blood pressure, carried out the analysis of urinary albumin and creatinine, and the recruitment of clinically healthy dogs as control in this study. HPH participated in the designs of the study, carried out the recruitment of cases of hyperadrenocorticism and performed the statistical analysis and the manuscript writing. All authors read and approved the final manuscript.


Different components of the autonomic nervous system may be affected by different disorders to varying degrees. The aim of this study is to report first experiences with a new device  which measures heart rate variability (HRV), sympathetic skin responses (SSR) and the pulse wave transit time (PTT). We examined 190 healthy volunteers  and in 89 subjects  PTT during VM was investigated. In a subset of 24 subjects PTT was compared to conventional blood pressure recording. Thereafter, normal data were compared to patients with polyneuropathy (PNP) and Parkinson syndromes. All parameters of HRV decreased with age. 6 parameters for HRV at rest, during deep respiration and the valsalva ratio were reclassified into three age categories: under 40 (n=96), 40 – 60 (n=71) and 60 or older (n=23). Applying the lower limits of normal (5%-tile) subjects did not have more than 2 of these 6 parameters in the pathological range PTT reduction during phase IV of the valsalva manoeuvre was greater than 7.7 ms (5%-tile) but not age dependent. Patients with PNP had reduced HRV and SSR, Parkinson patients had more frequently impaired blood pressure regulation according to PTT assessment. Our investigation shows that the FAN® might be useful for clinicians to detect autonomic disorders.  The autonomic nervous system has three major components: Parasympathetic , sympathetic noradrenergic (vasoconstrictive) and sympathetic cholinergic (sudomotor). All three components may be affected by different disorders to varying degrees. In orthostatic hypotension, which occurs in Parkinson syndromes, sympathetic adrenergic failure may be predominant -3. In dihardware. The FAN®  records HRV and SSR based on the standard recording techniques and algorithms used already in autonomic function studies , 18. BloNormal subjects were 190 volunteers free of any illnesses affecting the heart and the nervous system. 102 of these subjects were men, 88 women. The mean age was 42.9 years, ranging from 16 to 88. Care was taken that none of the subjects were under any medication directly affecting heart rate . In this respect, ß-blockers, antidepressants and antihypertonics were the most important to consider. Furthermore, the volunteers were instructed to abstain from smoking and drinking coffee on the day of investigation. In all subjects, HRV was assessed according to the protocol given below. In ten of the subjects , HRV tests were repeated on another day in order to estimate test-retest reliability. In 89 normal subjects , the PTT change during Valsava manoeuvre was assessed. This measurement was performed twice in all 89 subjects. In 24 of these PTT was compared to standard beat-to-beat blood pressure measurement using a blood pressure monitor . The sequence of PTT and blood pressure measurement was balanced. In order to assess the discriminating value of our normal data, two groups of patients, in whom autonomic dysfunction was common, were investigated. The first group were 34 patients with sensory-motor polyneuropathy (PNP). PNP was diagnosed clinically and confirmed by nerve conduction studies. The aetiology of PNP was diverse. Main causes were diabetes, alcoholism, paraneoplasia and vitamin B 12 deficiency. The mean age of PNP patients was 55.9 years, ranging from 25 to 80. The second group of patients consisted of 22 patients with Parkinson syndromes. According with clinical criteria, patients were classified as typical and atypical (including suspicious multiple system atrophy). For the purpose of our study, all Parkinson syndrome patients were pooled. The mean age in this patient group (11 men and 11 women) was 67 (range 46-83). For obvious reasons, all patients were treated with anti-Parkinson medication  which may have interfered with autonomic function tests. In the same way as with the normal subjects, patients were instructed not to take ß-blockers, antidepressants or antihypertonics before measurement.As a prerequisite, patients and normal subjects were investigated during morning hours and laid supine for at least 20 minutes in our temperature controlled lab before starting the investigations. At first, heart rate variation during deep respiration was assessed; thereafter, the valsalva manoeuvre was performed and, finally, the heart rate variability at rest for 2 minutes and the heart rate response to active standing up were assessed.After finishing the HRV assessment, the blood pressure response to the valsalva manoeuvre was assessed. PTT measurement was performed two times; beat-to-beat blood pressure was assessed on the same occasion.The sympathetic skin response was assessed in patients at the end of the session. Description of the FAN®:The FAN® has several major components. The most important one is an interface box for recording of ECG, SSR, breathing frequency and expiratory pressure e.g. during valsalva manoeuvre. ECG, SSR and breathing frequency were digitized with a sampling rate of 500 Hz; the expiratory pressure can be recorded with the limits of 0-100 mm mercury. The interface also offers the opportunity to record one analogue external signal such as the pulse-wave or the blood pressure from an external monitor (digitizing rate 500 Hz). The interface also supplies acoustical  and electrical outputs  for triggering the SSR. The second component is a so-called “feedback box”, which displays a bar moving up and down indicating the selected rhythm of breathing for the subjects. Close to the moving bar the actual breathing is displayed by LEDs moving up and down according to the breast excursions. This allows a feed-back control of breathing. The third component is a Laptop PC to process the signals. Internal software automatically extracts relevant parameters (as described below) but also allows the definition of new parameters and test designs. The last component is a printer to make a hard copy of the results.Heart rate variability (HRV): Subjects were instructed to perform 6 rhythmic breathing cycles per minute by observing the bar moving up and down on the feed-back box. In order to control breathing, a sensor was attached to the subjects’ chests. If necessary, subjects’ breathing was displayed on the feedback monitor close to the moving bar. Heart rate was recorded by standard ECG electrodes fixed at the extremities. During three minutes of deep respiration, the median value of the maximum differences between the longest and shortest R-R intervals (max-min) and the median ratio of the longest and shortest R-R intervals (max/min) within the 18 (=3 x 6/min) breathing cycles were calculated. In addition, the coefficient of variation (VC) and the root mean square of successive differences (RMSSD) of all R-R intervals were obtained.The Valsalva manoeuvre (VM) was performed after one minute of sitting. After this time, the subjects were instructed by an acoustic beep to maintain an expiratory pressure of 40 mm mercury for 15 seconds. The 40 mm mercury value was displayed as a bar on the feedback control box and the patient´s expiratory pressure was displayed close beneath. The Valsalva ratio (VR) was calculated on the basis of the longest R-R interval within 30 seconds after the manoeuvre and the shortest R-R interval during or within the first five seconds after the manoeuvre.HRV at rest was recorded when the subjects lay supine for 5 minutes. Breathing cycles were not feedback controlled during this test. The important variables were VC and RMSSD within these 5 minutes.Directly following HRV at rest, subjects were instructed by an acoustic beep to stand up and stay upright for one minute. The posture index (PI) was calculated on the basis of the longest R-R interval (20 – 40 heartbeats) and the shortest R-R interval (5- 25 heartbeats) after standing up .As a surrogate of beat to beat blood pressure, the pulse wave latency (PTT) was employed. The PTT was calculated by measuring the interval between the R wave of the ECG and the onset of the pulse wave, which was recorded on the right earlobe by a photoplethysmograph. The VM causes a 4-tailed blood pressure response. It has been shown that late phase II and phase IV depend on the function of the autonomic and, in particular, sympathetic nervous system. Since late phase II is poorly defined on a time basis, this study focuses on phase IV, the blood pressure overshoot (= PTT reduction in relation to baseline) after the VM. Thus, two parameters were calculated, the mean PTT at rest during 30 seconds of sitting before VM and the mean of the 5 shortest PTTs within 15 seconds after the end of the VM. PTT assessment during VM was performed two times consecutively. In a subset of subjects (n=24) the VM was repeated a third time. Now instead of PTT, beat-to-beat blood pressure was directly recorded by a Finapres® monitor and the signal was imported into the FAN®. Due to the fact that the FAN® allows to connect only one external signal, PTT and blood pressure must be recorded subsequently.The SSR was described more than 100 years ago. Briefly, SSR mainly depends on the differential activation of sweat glands under emotional control at glabrous skin on palms and soles, and thermoregulatory controlled sweat glands on hairy skin. This differential activation can be recorded as a skin potential. Any arousal activates predominantly “emotional” sweat glands, which causes a change of the skin potential. SSR amplitude in healthy subjects varies substantially on different occasions and the latency of this very slow potential is hard to define. However, it has been shown that SSR can be elicited in any healthy subject . TherefoStatistical analysis was performed using the software package “SPSS 10.0 for windows” . In order to analyze the dependence of the different parameters (HRV and PWL) on age, height and weight, a logarithmic regression was chosen. Influences of sex or smoking habits were determined employing an univariate ANOVA for each variable. The lower limit of normal values was determined as the 5% percentile. Test-retest reliability was estimated using the Pearson correlation coefficient. Healthy control subjects and patients were compared with an ANCOVA model adjusted for age. Parameters were presented as mean +/- SD, where applicable. Significance was considered if p < 0,05 was reached.Normal values and test-retest reliability of standard parameters of heart rate variation (HRV).All 8 parameters of heart rate variation decreased with age in perfect alignment with a logarithmic curve. This is applicable to the four parameters during two minutes of deep respiration , the Valsalva Ratio (VR), the two parameters during 5 minutes at rest  and the posture index.1 and 2). Therefore, these two values were dropped from further analysis.For obvious reasons, max/min during deep respiration,VR and posture index cannot be less than one. Plotting individual values against age revealed that the calculated 5%-tile line did not cross this border in the VR. The lower limit of max/min during deep respiration, however, crossed 1 on the Y-axis below the age of 50, and the lower limit of the posture index was never greater than 1 .Subsequently, normal subjects were reclassified into three age groups: below 40 (n=96), 40– 60 (n=71) and 60 or older (n=23). The respective lower limits of normal values of all parameters are shown in Table In general, neither body weight nor height played significant roles, with one exception: the valsalva ratio increased with increasing height . Sex or smoking habits had no effect on HRV parameters .2.Test – retest variability (n=10) was moderate and was maximised for HRV during deep respiration, which was controlled by feedback breathing, and at rest. It was fairly low if more active participation of subjects was required (VR and posture index). For details, see Table 4). However, test - retest reliability was poor if the test was repeated several weeks later (n=10) and did not reach significance for mean PWL before VM (r=-0.57) and PWL reduction during phase IV (r=0.17).PTT during Valsalva manoeuvre (n=89): The blood pressure overshoot during phase IV of the VM, namely the reduction of PTT in relation to the baseline, was neither significantly affected by age , nor height  nor weight . There was also no significant effect generated by sex (F=0.003) and smoking habits (F=0.95). The 5% -tile of PTT reduction in phase IV was 7.7. This means that a PWL reduction of 7.7, or more, as compared to mean PWL assessed during 30 seconds before the VM should be considered as normal. Test- retest reliability within one experimental session was good. The results of the mean PTT before the VM were significantly correlated in both tests . The results for PTT reduction in phase IV of the VM in both sessions showed less but significant autocorrelation  PTT at rest was 154 +/- 19.2 ms and during phase IV of the VM 144 +/- 17.3 ms (p<0.001). As expected blood pressure increased during phase IV  while heart rate slightly but significantly increased .Correlation analysis revealed that before VM systolic blood pressure at rest  and mean blood pressure  were both negatively correlated to PTT. After VM (phase IV) only the heart rate was positively correlated to PTT . All other parameters (including the differences between phase IV and baseline) were not correlated to absolute PTT at rest, during phase IV or PTT difference between both time points.3).In a group analysis, patients with polyneuropathy showed reduced heart rate variability. Using an ANCOVA model adjusted for age, parameters obtained for these PNP patients during deep respiration and the coefficient of variation at rest were significantly lower than those from the control subjects. The Valsalva ratio and RMSSD at rest failed to distinguish between PNP patients and control subjects. Highest F-scores were found with the coefficient of variation both during deep respiration and at rest . Individual analysis, however, revealed that only 3 of 34 patients were below the lower limit of normal values (PWL baseline – PWL phase IV < 7.7).Heart rate variability was far less reduced in patients suffering from extrapyramidal disorders than in PNP patients. Just two parameters, the coefficient of variation during deep respiration  and the coefficient of variation at rest , were reduced. The remaining parameters were not different from control values. On an individual basis only 1 of 22 patients had to be classified as having “pathological HRV”.Blood pressure regulation during phase IV of VM, however, was significantly impaired . Accordingly 5/22 patients had parameters below the lower limits of the normal range.Direct comparison of both patient groups revealed that blood pressure regulation was significantly more impaired in patients with Parkinson syndromes .The SSR on the feet was not obtained from the control group but only from patients. In 6 / 34 neuropathy patients, SSR could not be obtained, five of them had “pathological HRV”. SSR could not be elicited in 5 / 22 Parkinson patients, but none of them had “pathological HRV”.Our results suggest that the FAN ® system  might be well suited to comprehensively assess autonomic function. We were able to define and apply to different patients groups normal values for heart rate variability (HRV) and for pulse wave transit time (PTT) changes during Valsalva manoeuvre. In particular the latter result could simplify the assessment of blood pressure regulation in the clinical routine.In a first step we defined lower limits of normal HRV investigating 190 normal subjects. All single parameters followed a logarithmic decrease with age. This is in accordance with previous studies . Other bin the time domain with age and the lack of sex effects were in good accordance with previous reports about normative date on HRV in normal subjects. [ In these studies spectral analysis has been also used to study autonomic nervous system function, in particular for differentiation between parasyspathetic and sympathetic function. Since specificity of spectral HRV components has been questioned several times [The decrease of HRV ubjects. , 38. In al times  we intenFor quantitative evaluation of blood pressure, continuous measurement is a prerequisite. However, continuous blood pressure measurement normally requires expensive, sophisticated hardware . PTT, thHowever, we never intended to introduce PTT as a substitute of absolute blood pressure recording. The PTT in our study must be regarded as a relative parameter. It allows only the estimation of blood pressure changes. Our results show that if this prerequisite is considered, PTT might indicate cardiovascular changes during VM as it has been shown before in hemodialysis  and spinIn order to get an impression whether our normal data might be sensitive enough to detect autonomic disturbances we investigated patients with polyneuropathy and Parkinson syndromes. Polyneuropathy is associated with “cholinergic” autonomic failure - reduced HRV and absent SSR . In our We appreciate that our patients’ groups are inhomogeneous (neuropathy) and under medication (Parkinson’s disease). However, the aim of investigating patients in addition to normal subjects has been to provid an estimate about the value of our normal data to prove “normality”. This has been accomplished. For such a goal the cause of autonomic failure seems of minor importance.It was astonishing that we were able to detect exactly the pattern of autonomic failure which could be expected from previous studies.In conclusion our study provides data showing that the FAN® might be a useful tool to assess different function parameters of the autonomic nervous system. In particular the assessment of PTT offers the opportunity to investigate large numbers of patients with sympathetic failure.