Type 2 diabetic patients display significantly higher incidence of cardiovascular (CV) events including stroke compared to non-diabetics. Morning blood pressure surge (MBPS) and blunted systolic night-day (SND) ratio have been associated with CV events in hypertensive patients. No studies have evaluated MBPS in newly diagnosed diabetic patients or studied the association with vascular target organ damage at this early time point of the diabetes disease.Ambulatory blood pressure monitoring was performed in 100 patients with newly diagnosed type 2 diabetes and 100 age and sex matched controls. MBPS and SND-ratio were calculated. Markers of early vascular target organ damage included pulse wave velocity (PWV), white matter lesions (WML) on brain MRI, and urine albumin/creatinine ratio (UAE).p = 0.03).No significant differences in MBPS were found between diabetic patients and controls. Neither MBPS or SND-ratio were associated with PWV, UAE or WML in the diabetic group independently of age, gender and 24-h systolic blood pressure. 40.2 % of diabetic patients and 25.8 % of controls were classified as non-dippers (MBPS and SND-ratio are not associated with subclinical markers of vascular target organ damage in our study sample of newly diagnosed type 2 diabetic patients. Type 2 diabetic patients exhibit significantly higher cardiovascular (CV) morbidity and mortality compared with non-diabetics . Recent Only a few studies have examined MBPS as a CV risk factor in type 2 diabetic patients. Both studies included diabetic patients with long duration of diabetes and with hypertension as an isolated risk factor. Eguchi et al.  found noThe reasons for the contrasting findings are unclear and a better understanding of the pathophysiological mechanisms linking MBPS to CV events is needed. It has been suggested, that MBPS may accelerate vascular injury eventually leading to CV events , howeverTherefore, this study was designed to i) assess MBPS and SND-ratio in a sample of recently diagnosed diabetic patients and sex- and age-matched controls and ii) to investigate the association between MBPS and SND-ratio and PWV, urine albumin/creatinine ratio (UAE), and WML in type 2 diabetes.2 (kg/m2). Smoking was defined as current, previous, or never. The study was approved by the Research Ethics Committee of Central Region, Denmark and by the Danish Data Protection Agency. All patients gave their written informed consent to participate.The study sample has been described in detail previously . 100 patBP and heart rate were monitored for 24 h using a non-invasive, portable device  validated according to the British Hypertension Society protocol [The most common definitions of MBPS are the sleep-trough surge and the pre-waking surge, in this study MS1 and MS2, respectively. Alternative definitions have been introduced in the literature  in this The clinical perspectives regarding MBPS were discussed by Li et al. . Using tBrain MRI was performed with an eight-channel SENSE head coil on a 1,5-T MRI scanner  to obtain axial T2-flair-weighted scans with a slice thickness of 5 mm. WMLs were assessed by a blinded, experienced radiologist on T2-weighted scans and graded 0–2 using Breteler’s scale  PWV was performed using an applanation tonometer  and SphygmoCor equipment and software, version 8.0 . The transit time was determined by the intersecting tangent algorithm. The distance between the two arteries was measured directly on the body using a tape measure and the PWV calculated as distance divided by time (m/s). UAE was evaluated by albumin/creatinine ratio in a morning urine sample. MRI data were not available for four participants because of claustrophobia. PWV data were not recordable in four participants because of atrial fibrillation and in three patients due to obesity.t tests. Assumption of normal distributions was tested by histograms and Q-Q plots. Skewed data  were log-transformed prior to analysis to obtain normal distribution. Categorical data were tested by Chi2 test. Baseline data are presented as means ± SD or median  for skewed data. Associations between morning surge data/systolic night day-ratio and UAE and PWV were assessed by Pearson’s correlation coefficient and by multivariate linear regression analysis. Association with Breteler score was assessed with ordinal logistic regression analysis. In all multivariate analyses, we adjusted for age and sex, and in analyses in the pooled sample additionally for the effect of diabetes (yes/no). Blood pressure levels may confound the association between morning surge/systolic night-day ratio and the three outcomes . Accordingly, the effect of including 24-h systolic BP in the analyses with age and sex was also evaluated in supplementary analyses. PWV is also known to be associated with office mean BP and heart rate, and the effect of including these parameters together with age and sex in the analyses with PWV as outcome was also assessed. A two-tailed P value of less than 0.05 was considered statistically significant. All statistical calculations were performed with software from Stata version 11; StataCorp LP, College Station, Texas, USA). Not all morning BP surge parameters could be calculated for all participants due to missing BP data during the night. Accordingly, we did power calculations for different potential sample sizes. With 80 participants in each group, a standard deviation of 10 mmHg and a 5 % α-level, we had 97 % power to detect a difference of 6 mmHg in morning surge between the groups. With 60 participants in each group, a standard deviation of 10 mmHg and a 5 % α-level, we had 90 % power to detect a difference of 6 mmHg.Group differences in continuous variables were assessed using paired Clinical and laboratory characteristics are presented in Table Systolic BP was used for all 5 MBPS calculations in the 200 participants. Missing values were due to removal of the portable recording device < 2 h after waking up  and insufficient night-measurements . Accordingly, 817 out of 1000 calculations were successful. As our inclusion was based on matching data, only matched data was used for comparing diabetic patients and controls and to this end we excluded MS-data without a match. Finally, 79 matched calculations were available for MS3, 68 for MS4 and 63 for MS1, MS2 and MS5.p = 0.13), , , , . The SND-ratio was significantly higher in the diabetic group than in the control group, Fig. p = 0.02). 39 patients with diabetes (40.2 %) and 25 of the controls (25.8 %) were classified as non-dippers, p = 0.03.No significant differences were found for any of the five definitions of MBPS when comparing the diabetic group and the control group, Fig. Univariate and multivariate regression analyses between MBPS and the subclinical markers PWV, UAE and WML are presented in Table β = 0.42 ± 0.17; p = 0.02) even when adjusting for age, sex, diabetes mellitus and 24-h systolic BP . This might be a chance finding rather than an actual validation of the threshold, as none of the other MS-calculations showed the same tendency.Participants with a surge above 20 mmHg in the MBPS parameters used by Li et al. (MS1 and MS2) did not show increased PWV, UAE or WML when compared to participants with a surge below 20 mmHg. However, MS5 above 20 mmHg was significantly associated to UAE . No association was seen when normotensive diabetic patients were evaluated separately. MS1 was significantly associated with lnUAE in normotensive control subjects (n = 47) in both univariate and multivariate analyses including age, gender and 24-h SBP  as were MS4 and MS5 . No association was found to WML or PWV for normotensive participants. MS4 was significantly associated with PWV in a small (n = 24) subgroup of isolated hypertensive controls even with adjustments for age, sex, 24-h SBP and mean arterial pressure and heart rate at time of measuring (p = 0.01) (data not shown).As previous studies on MBPS primarily have focused on hypertensive patients, we divided the two groups into hypertension/normotension based on ABPM data (normotension: <130/80 mmHg on 24-h ABPM) and repeated all univariate and multivariate analyses. In pooled data on all normotensive participants (n = 91) MS1 was significantly associated with lnUAE in univariate and multivariate analyses including age, gender, 24-h SBP and diabetes  could be hypothesized to affect the MBPS we divided the groups according to AHT (yes/no). No statistically significant associations between MBPS measurements and PWV, WML or lnUAE in either treated or untreated patients were found after multivariate adjustments including age, gender, diabetes, and 24-h SBP (data not shown).β = 8.04 ± 2.79, p = 0.01 and β = 6.31 ± 2.48, p = 0.01, respectively). The association remained in a fully adjusted model with further adjustment for mean arterial pressure and heart rate . When evaluated separately, the association was significant in normotensive diabetics (n = 55) in univariate analysis , but lost in a fully adjusted model. In the normotensive controls (n = 54), an association was seen only in the fully adjusted model . All groups in AHT were associated with PWV in univariate analyses, but associations were lost when adjusting for age and gender (data not shown). No relation was found to either lnUAE or WML . As the group consisted of only 24 hypertensive controls, the multivariate analysis is prone to over-fitting and can at best be interpreted as hypothesis generating. MS1 was associated with lnUAE in pooled data on normotensive participants as were MS1, MS4 and MS5 in the subgroup of normotensive control subjects. This might indicate a linkage between the morning urine and the MBPS, but needs further investigation.Previous studies in non-diabetic hypertensive patients have found associations between MBPS and cerebro- and cardiovascular morbidity, especially incidence of stroke –9, 33. WThe significant association between SND-ratio and PWV in normotensive participants extends previous reports of hypertensive patients  and mighOur study has limitation that should be observed when interpreting the results. Due to the cross sectional study design we cannot infer causality regarding the association between MBPS and the three outcomes; PWV, UAE and WML. Furthermore, the diabetic patients had a relatively low PWV and UAE, and the range was quite narrow for both. Thus the chance of finding a signal is reduced and our results may not be applicable in other populations. Lastly, the lack of the statistical difference in the subgroups might be a consequence of low statistical power.None of the five definitions of morning blood pressure surge or the systolic night-day ratio were associated with early markers of vascular target organ damage in our study sample of newly diagnosed type 2 diabetes patients. Even though previous studies have found valuable information regarding cardiovascular risk in MBPS in hypertensive patients and SND-ratio in diabetes patients, this study indicates, that these ambulatory blood pressure measurements are not independently associated with PWV, UAE, or WML at early time point of the diabetic disease.


The inotropic agents used in the ICU are dobutamine and milrinone; unfortunately, they have shown significant side effects when used for myocardial depression during septic shock. Our objective is to describe Mn behavior in septic shock.t test. P < 0.05 was considered significant.We reviewed 72 clinical records of patients with diagnosis of septic and mixed shock who received Mn through January to December 2013. Demographic, hemodynamic, metabolic and gasometric data were recorded before and after Mn infusion. The PiCCO monitoring system was used. Data were expressed as mean and standard deviation. The statistical analysis used Student's 2 increased: 71.1 ± 10.3 to 76.1 ± 7.3 (P < 0.05). PaCO2 arteriovenous difference and lactate were reduced: 7.36 ± 3.3 to 6.04 ± 3.6 and 18.7 ± 14.9 to 13.1 ± 9.1 (P < 0.05). CVP, MAP, RVSI, VSTI, EVLWI and base excess showed no significant difference. Mn initial average dose was 0.35 ± 0.13. NE before and after Mn infusion showed no significant difference: 0.11 ± 0.20 versus 0.12 ± 0.22.Seventy-two patients were studied: 36.5% were women, mean and SD of age, APACHE II, mechanical ventilation days and long ICU stay were: 67 ± 16 years, 18.5 ± 5.9 points, 14.9 ± 12.9 and 24.5 ± 21.9 days, respectively. A total 20.3% of the patients received dobutamine. Thirty-nine percent presented mixed shock. Global mortality was 23%. After Mn infusion: cardiac index (CI) increased: 3.1 ± 1 to 3.3 ± 1.1, cardiac rate increased: 82.4 ± 14.4 to 88.3 ± 18 and ScvO2, PaCO2 arteriovenous difference and lactate are related variables.Mn optimizes cardiovascular performance in septic shock and mixed shock, without affecting hemodynamic variables and global tissue perfusion. In addition, we observed that the IC, ScvO


To evaluate the efficacy of azelnidipine and amlodipine on diabetic nephropathy and atherosclerosis, we designed a prospective and randomized controlled clinical study in type 2 diabetic patients with stable glycemic control with fixed dose of anti-diabetic medication. Although there was no difference in blood pressure between both groups, urinary albumin excretion and maximum carotid intima-media thickness were reduced in azelnidipine group, but not in amlodipine group. In addition, inflammatory cytokine levels were decreased only in azelnidipine group which possibly explains such beneficial effects of azelnidipine on urinary albumin excretion and carotid atherosclerosis. Dear Editor,It is well known that both type 2 diabetes and hypertension lead to the onset of cerebrovascular and cardiovascular events via the augmentation of inflammation and the progression of atherosclerosis. Therefore, physicians have to choose the most appropriate medication for the prevention of such complications. Diabetic nephropathy is also one of the life-threatening major complications and its progression is accelerated in the presence of hypertension , 2. AngiWe enrolled a total of 38 subjects with type 2 diabetes whose blood pressure was not sufficiently controlled by treatment with 20 mg/day of olmesartan for over 2 months. Insufficient control was defined as follows: systolic blood pressure >130 mmHg and/or diastolic blood pressure >80 mmHg according to the guideline by Japanese Society of Hypertension. Patients who signed an informed consent prior to this trial were randomly divided in azelinidipine (16 mg/day) and amlodipine group (5 mg/day). We evaluated the effects of azelnidipine and amlodipine after 32 weeks. Patients who met inclusion criteria were as follows: patients with type 2 diabetes and without well-controlled blood pressure by treatment with olmesartan; 40 < age < 75 years old; hemoglobin A1c (NGSP) is below 9.4 %. The following patients were excluded: with suspiciously secondary hypertension or non-diabetic kidney disease; with congenital dyslipidemia or extremely high LDL-cholesterol (>200 mg/dl); with advanced hepatic disease (AST > 75 IU/ml) or advanced renal failure ; in pregnancy; with current history of any malignant neoplasm; with using steroids, any hormonal medications, any diuretics, immune-suppressing medications and/or potassium drug; with past history of stroke or myocardial infarction occurring within past 6 months from the start of the trial. There was no dropout during the follow-up period.Carotid IMT was measured using Aplio ultrasonography (Toshiba), and images of carotid artery were scanned by computer and analyzed using IntimaScope software (MEDIA CROSS). Plasma MCP-1 (R&D systems), TNF-α (R&D systems), HMW adiponectin (R&D systems), leptin (R&D systems), soluble vascular cell adhesion molecule-1 (VCAM-1) (R&D systems) and soluble intercellular adhesion molecule-1 (ICAM-1) (RayBiotech) were measured using enzyme-linked immunosorbent assay kits. All values were expressed as mean ± s.e.m. We used the Mann–Whitney U test for unpaired data and the Wilcoxon signed-rank test for paired data.p < 0.05), but the efficacy of lowering blood pressure was similar , although we cannot exclude the possibility that the difference of the effects on heart rate was influenced by the difference at baseline and there was not statistically significant difference in heart rate between the two groups at follow-up point.There was no difference between the two groups in any clinical background including age, BMI, duration of diabetes, blood pressure and biochemical laboratory data except for heart rate Table . Heart rlar Fig. a. Heart p < 0.05), but not after amlodipine treatment  , although average IMT was not altered in both groups , and TNF-α levels were also reduced only in azelnidipine group (p = 0.055). There was no difference between the two groups in the effects on HMW adiponectin and leptin levels  and amlodipine (5 mg/day) have similar ability to decrease blood pressure in hypertensive patients complicated with type 2 diabetes. However, azelnidipine delayed the progression of urinary albumin excretion and carotid atherosclerosis, which was not observed with amlodipine. We assume that the reduction of inflammation by azelnidipine explains, at least in part, its beneficial effects on urinary albumin excretion and carotid atherosclerosis.


Schizophrenic patients suffer from more metabolic or sleep problems. Little is known about risk factors. We recruited 17 patients with chronic schizophrenia from the rehabilitation center in a medical center in Taiwan and measured their demographic data, cognitive performance, and physical fitness, metabolic profiles and sleep parameters. They were divided into two groups according to clinical severity, then compared in terms of metabolic and sleep parameters.Those with more severe symptomatology had more metabolic abnormality and shorter slow wave sleep (SWS). Our findings suggest clinical symptoms as linked with heavier body weight, wider neck circumference, elevated blood pressure, and shorter SWS. Further studies are warranted to confirm the preliminary finding and to elucidate the underlying mechanism Prevale patients, 6]. Me. Me1 BioStudy was approved by China Medical University Hospital Institutional Review Board (IRB). All participants gave written informed consent.14 and daily benzodiazepine doses as diazepam equivalents . O. O17]. OPatients’ weight and height, body mass index (BMI), neck circumference (NC), waist circumference, hip circumference, and waist-hip ratio (WHR) were recorded. Body fat was assessed by Omron body fat scale. Physical fitness was gauged according to a profile distributed by Bureau of Health Promotion, Department of Health, Taiwan. First, we checked sit-up frequency in one minute. Second, they underwent three-minute 35-centimeter-ladder climbing. We checked post-exercise heart rate (PEHR) at the end of the first minute (PEHR1), the second minute (PEHR2), and the third minute (PEHR3) while they stopped exercise. PEHR2 and PEHR3 were checked via similar method with total climbing time recorded.Heart rate, systolic and diastolic blood pressure were measured before blood examination. Blood samples were taken at 8:00 a.m. after a 12-hour overnight fast, with subjects’ blood withdrawn from an antecubital vein to measure plasma levels of glucose, insulin, total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, and cortisol. Insulin was quantified by chemiluminescent immunoassay sandwich method, and serum glucose by glucose-oxidase-based assay. We rated insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR), assessed by the formula of fasting insulin (μU/ml) x fasting glucose (mg/dl)/405 .The presence of metabolic syndrome was recorded as defined by National Cholesterol Education Program (NCEP) guidelines: waist circumference ≧102 cm  and ≧ 88 cm , triglyceride (TG) ≧ 150 mg/dl, HDL-cholesterol < 40 mg/dL  and < 50 mg/dL , blood pressure ≧130/85 mmHg, and fasting glucose ≧ 110 mg/dl. MetabolSleep rating scales were self-recorded by all subjects preceding polysomnography examination: Pittsburgh Sleep Quality Index (PSQI) , InsomniSleep architecture was assessed for each 30-second epoch coded as Wake, Stage 1, Stage 2, Stage 3+4 , and Rapid Eye-Movement (REM) sleep according to criteria made by Rechtschaffen and Kales . ArousalWe divided participants into two groups according to severity of clinical manifestation Cut-off value was median number of the PANSS total scores. Student’-T test compared all variables between the two groups.Age and gender between groups were similar, as was duration of education and age at illness onset. Duration of illness of the H-PANSS group was longer. Clinical Global Impression (CGI)  tallied Cognitive performances between groups were similar. Table Body weight and neck circumference (NC) in the H-PANSS group were higher than those in the L-PANSS group. Body height, BMI, waist circumference, hip circumference, WHR and body fat between groups were similar, as was physical fitness measured by sit-up and climbing Table . Both syThe mean scores of respective sleep questionnaires, including ESS, ISI, PAS, and PSQI, were similar between L-PANSS and H-PANSS groups Table . ParametTo our knowledge, this is the first study to suggest that severer clinical symptoms are associated with metabolic and sleep disturbance in patients with schizophrenia. In more detail, this study demonstrates that schizophrenia patients with severe symptomatology may have more metabolic abnormalities including heavier body weight, wider neck circumference, and elevated systolic/diastolic blood pressure. We found no intergroup statistical significance in terms of blood sugar, insulin, cortisol, and lipid profiles. This is the first study to suggest that schizophrenic patients with more severe symptoms might have decreased oxygen saturation. It also demonstrated that patients with more severe symptoms had reduced SWS when their sleep efficiency and total sleep time were similar to the low PANSS group. Results concurred with prior studies: positive symptoms of schizophrenia increased REM sleep eye movement density, short REM latency, reduced sleep efficiency and prolonged sleep latency , 27], , , 29]. C. C29]. CThe strength of this study is control over two groups of patients similar in basic demographic data, cognitive function performance, and physical fitness. Limitations of the study included small sample size and cross-section design. In sum, this study suggests clinical symptoms as linked with heavier body weight, wider neck circumference, elevated blood pressure, and shorter SWS in schizophrenic pateints. Further studies must confirm preliminary findings and elucidate the underlying mechanism.This study is supported in part by Taiwan Department of Health Clinical Trial and Research Center of Excellence (DOH103-TD-B-111-004).


Foot ulceration is the main precursor to lower limb amputation in patients with type 2 diabetes worldwide. Biomechanical factors have been implicated in the development of foot ulceration; however the association of these factors to ulcer healing remains less clear. It may be hypothesised that abnormalities in temporal spatial parameters (stride to stride measurements), kinematics (joint movements), kinetics (forces on the lower limb) and plantar pressures  contribute to foot ulcer healing. The primary aim of this study is to establish the biomechanical characteristics  of patients with plantar neuropathic foot ulcers compared to controls without a history of foot ulcers. The secondary aim is to assess the same biomechanical characteristics in patients with foot ulcers and controls over-time to assess whether these characteristics remain the same or change throughout ulcer healing.The design is a case–control study nested in a six-month longitudinal study. Cases will be participants with active plantar neuropathic foot ulcers (DFU group). Controls will consist of patients with type 2 diabetes (DMC group) and healthy participants (HC group) with no history of foot ulceration. Standardised gait and plantar pressure protocols will be used to collect biomechanical data at baseline, three and six months. Descriptive variables and primary and secondary outcome variables will be compared between the three groups at baseline and follow-up.It is anticipated that the findings from this longitudinal study will provide important information regarding the biomechanical characteristic of type 2 diabetes patients with neuropathic foot ulcers. We hypothesise that people with foot ulcers will demonstrate a significantly compromised gait pattern  at base line and then throughout the follow-up period compared to controls. The study may provide evidence for the design of gait-retraining, neuro-muscular conditioning and other approaches to off-load the limbs of those with foot ulcers in order to reduce the mechanical loading on the foot during gait and promote ulcer healing.The online version of this article (doi:10.1186/s12902-015-0057-7) contains supplementary material, which is available to authorized users. Foot ulceration is the main precursor to lower limb amputation in patients with diabetes worldwide . EstimatAlthough biomechanical studies have helped to identify potential triggers of ulceration, whether such triggers change and by how much when DFUs are healing remains largely unknown , 10. It Detailed information about the biomechanical factors in patients with active DFUs may provide evidence for the design of gait-retraining and neuro-muscular conditioning and more efficient offloading methods to reduce the mechanical loading on the foot during gait –12. FindA case–control study nested in a six month longitudinal study was planned. The study will be performed in Townsville, a regional town in north Queensland, Australia with an approximate population of 175,000 and an estimated type 2 diabetes prevalence of 4.4 % . Type 2 The primary and secondary outcome measures of the case control and longitudinal studies include several biomechanical variables. These variables will be grouped into gait and plantar pressure outcomes and will contribute to four main families of hypotheses. The four families of biomechanical hypotheses are 1) abnormal TSPs, such as speed of walking and stride length; 2) restricted kinematics (movement patterns); 3) altered kinetics,  and 4) elevated plantar pressures on the ulcerated and non-ulcerated foot . The kin2 recorded within the plantar aspect of foot at ten anatomical sites;Mean peak pressure: The mean peak pressure (average peak pressure), in N/cm2 recorded within the plantar aspect of foot at ten anatomical sites;Maximum peak pressure: The maximum peak pressure in N/cm2 at ten anatomical sites;Total contact area of the foot: The area of the plantar aspect of the foot in contact with the pressure platform in cmEstimated vertical ground reaction force: The contact area multiplied by the mean peak plantar pressure in Newtons (N) at ten anatomical sites.Primary outcome measures relating to plantar pressure will include the:TSPs ;Kinematic variables ;Kinetic variables (forces): Reported as the vertical, medial-lateral and anterior-posterior components of ground reaction force during the gait cycle in Newtons (N);Primary outcome measures relating to gait will include:Muscle voltages for six lower limb muscles including the vastus medialis, peroneus longus, tibialis anterior, semitendinosus and medial and lateral gastrocnemius during the gait cycle;2).Joint accelerations and velocities, in the sagittal, transverse and frontal planes during the gait cycle, reported as degrees per second (°/s) and degrees per second squared ;Joint moments generated at the hip, knee and ankle bilaterally in the sagittal, transverse and frontal planes during the gait cycle, reported in Newton meters (Nm).Secondary outcome measures for gait will include:2; 3.9 (1.0) N/cm2; and 4.7 (2.0) N/cm2 for the HC, DMC and DFU groups, respectively. It was estimated that those with DFUs would have at least a 20 % higher plantar pressure than the control groups due to the observed difference in means of those with DPN and healthy controls [The DFU group will demonstrate significantly poorer TSPs compared to controls at baseline.The DFU group will demonstrate significantly restricted kinematics at the ankle, knee, hip and pelvis compared to controls at baseline.The DFU group will demonstrate significantly altered kinetics  compared to controls at baselineThe DFU group will demonstrate significantly different plantar pressure. characteristics  compared to controls at baseline.The TSPs in the DFU group will remain poorer at 3 and 6 months follow-up compared to the DMC group.The kinematics of the DFU group will remain different at 3 and 6 months follow-up compared to the DMC group.The kinetics of the DFU group will remain different at 3 and 6 months follow-up compared to the DMC group.The plantar pressure characteristics of the DFU group will remain different at 3 and 6 months follow-up compared to the DMC group.We plan to examine multiple hypotheses in this study. Sample sizes were calculated to test the hypothesis that forefoot plantar pressures were different in patients with active DFUs compared with controls. This hypothesis was chosen for the sample size calculation since previous studies suggested this measure had large between patient variability and therefore was likely to require the largest sample size . The effcontrols . We alsoDue to the large number of hypotheses, we planned to correct for multiple testing which is described in detail in the statistical analyses section. We inflated the sample sizes to account for a proposed 10 % drop-out rate during the six month follow-up and therefore 31, 123 and 58 participants were required in the DFU, the DMC and the HC groups, respectively. An interim analysis of the study is planned after recruiting 50 % of the estimated number of participants for each group. This is to re-assess the proposed sample sizes since the initial effect size was based on patients that had DPN but no DFUs. A post-hoc power test will be performed to re-assess actual statistical power when recruitment is concluded. This test will be focused on plantar pressure values measured in the forefoot. All sample sizes were performed using the G*Power statistical software  .The DFU and DMC patients will be recruited from inpatient wards, outpatient clinics and community health clinics within the Townsville Hospital and Health Service District, Queensland, Australia. The HC group will be recruited through community advertising and from staff at the university where the study will take place. The study is approved by The Townsville Hospital and Health Service District and the James Cook University human research ethics committees . Written informed consent will be obtained from all participants at the time of screening for participation in the study and for publication of de-identified data.Inclusion criteria for the cases (DFU group) include: males and females above the age of 18 years; a diagnosis of type 2 diabetes  and a single active unilateral plantar DFU of >3 months duration which is not completely epithelialized. The DMC group will comprise males and females above the age of 18 years, with a diagnosis of type 2 diabetes (similarly defined as for the DFU group) and no history of plantar DFUs. The HC group will comprise participants who do not have either a diagnosis of type 2 diabetes or any foot ulcer history as assessed on interview and examination.All participants will be required to be able to ambulate without any assistance or mobility aids. The exclusion criteria were designed to exclude participants with problems impacting on mobility which would likely mask the impact of plantar DFUs on gait. Exclusion criteria for recruitment to all three groups are: (1) chronic or acute orthopaedic, musculoskeletal, vestibular, visual or neurological problems affecting mobility (other than DPN) at the time of screening; (2) any history of orthopaedic surgical intervention of the lower limb ; (3) presence of any form of diabetes other than type 2 diabetes; (4) planned vascular reconstruction; (5) pregnancy; and (6) systemic disease affecting mobility or leading to chronic inflammation of any lower limb joint.All participants will need to demonstrate visual acuity adequate for walking. This will be assessed by asking the participant whether they had visited an optometrist in the last twelve months and whether they had difficulty walking due to visual impairment. If they have not visited an optometrist, participants would be required to do this before being considered for the study. Visual acuity will then again be checked prior to group allocation. We do not plan on excluding participants with diabetic retinopathy as this is an associated microvascular condition of diabetes, provided that participants do not disclose limitations in their vision that affected their walking ability. All participants unable to fulfil these criteria will be excluded from the study. Peripheral artery disease will be excluded as a major contributing cause of foot ulceration by a number of methods. Firstly the DFU patients will be reviewed by a board accredited vascular specialist (JG) who will take a relevant history and perform clinical examinations to exclude significant peripheral artery disease. DFU patients will need to demonstrate an absence of symptoms of intermittent claudication  and an a2 for 3 months recorded in the medical records. These risk factors are either known to influence foot ulcer development or healing [A previously developed and detailed case report form  will be used to estimate HbA1c as a measure of long-term glycaemic control with the RIANT II TURBO Link System  . Serum lPhysical examination will involve the assessment of height, weight, body mass index (BMI), body fat percentage and waist and hip circumference. All clinical and anthropometric measures (described below) will be carried out three times and averaged. Participant’s height will be measured using a wall mounted telescopic metal stadiometer . Percentage body fat (% body fat) will be estimated using bioelectrical impedance scales  which also measures weight (Kg) . BMI wilBlood pressure (systolic and diastolic) will be measured using an electronic blood pressure machine  mounted on a mobile stand . SystoliThe peripheral arterial examinations will first comprise the palpation of the dorsalis pedis and posterior tibial pulses for their presence or absence as well as strength  . The ABPNeurological examination will consist of a 10 g (size 5.07) monofilament sensation test , a 128 HMonofilament sensation will be assessed at ten sites  on each foot including the plantar surfaces of the heel on the medial and lateral sides, hallux, apex of toes 2–5, metatarsal one, metatarsal five and the dorsum of the foot between the first and second metatarsals . The exaThe lower limb examination will encompass an assessment of the static range of movement of the ankle joints, sub-talar joints and the first metatarsophalangeal joints using previously described methods , 51. A g2) [The University of Texas Wound Classification System (UTWCS) is a validated tool for the measurement of foot ulcers . The UTW2) . Other i2) , 59. If 2) ) then a 2) , 62 to i2) .The type of offloading utilised and the type and frequency of wound dressings will also be collected , 65, 66.The three dimensional movement analysis component of the study will involve attaching reflective markers to the participant’s skin over the surface of key anatomical landmarks . This enA standard VICON Nexus procedure will be used during motion capture  . Ten walThe Footscan® pressure plate  will be used for plantar pressure assessment with the associated Foot Scan® processing software. This platform is two meters in length, 0.4 m in width and contains 16,384 sensors capturing at 100 Hz. The plantar pressure platform is freestanding. The platform has been used for previous biomechanical research in participants that have diabetes . Ten walFollow-up assessments will be performed on all participants in the DFU and DMC groups at three and six months. The HC group will be only examined at baseline as it is anticipated that the gait and plantar pressure of these participants will not change during short term follow-up . The cast-test for continuous variables. Non-parametric analyses with the Kruskal Wallis test and the Man Whitney U test will be used if the data is not normally distributed. Pearson’s chi-square tests or Fisher’s exact tests will be used for categorical variables. Fisher’s exact test will be used where the expected frequencies are less than or equal to five. Similarly, primary and secondary continuous data outcomes will be initially analysed using one way ANOVA or Kruskal Wallis test based on distribution of the data. Outcomes will be corrected for multiple testing where more than the planned number of hypotheses are tested and where more than the planned four families of hypotheses are tested. The Holm correction will be used for correcting p-values of unplanned tests [The Statistical Package for the Social Sciences (SPSS) version 22.0 for Windows  will be used for statistical analyses. Continuous data will be reported as mean ± standard deviation or median and interquartile range based on the distribution of data in the three groups. The Shapiro-Wilk test will be used to test for normality. All primary and secondary outcome variables will first be assessed graphically using scatter and box plots and using correlation analyses to look at between group differences in data. If the data is of normal distribution, parametric analyses will be used. Explanatory variables will be compared between the groups using one way ANOVA and between the DFU and DMC groups using student ed tests . This wied tests . Where pWe report the methodology for a longitudinal study investigating the gait and plantar pressure characteristics of patients with active DFUs. There is a paucity of studies investigating the biomechanical characteristics of patients with active neuropathic DFUs and thus a need to better document these characteristics. Altered biomechanical characteristics are likely to influence the healing of plantar DFUs. It may be possible to address altered biomechanical characteristics to reduce the mechanical loading on the ulcerated foot during gait using gait retraining techniques in addition to off-loading the foot. The design of these interventions is likely to be improved by further understanding of gait during the presence of an ulcer. We believe this study will provide important observations regarding the association between gait and foot ulcer healing.


Background. New-onset diabetes after transplantation (NODAT) is associated with decreased graft survival and an increased risk for cardiovascular disease. The objective of this study was to evaluate the risk factors for development of NODAT and its' relationship with arterial stiffness and left ventricular mass index (LVMI) in kidney transplant recipients. Methods. 159 kidney transplant recipients were selected from our transplantation center who underwent renal transplantation between years 2007 and 2010. Results. Among 159 patients, 57 (32.2%) patients were with NODAT who were significantly older than patients without diabetes (P: 0.0001). Patients with NODAT had significantly higher pulse wave velocity (PWv) (P: 0.033) and left ventricular mass index LVMI (P: 0.001) compared to patients without NODAT. Further analysis was done according to LVMI as follows: LVMI > 130 g/m2 (n: 57) and LVMI ≤ 130 g/m2 (n: 102). We observed higher office systolic and diastolic BP, serum trygliceride, glucose, creatinine, age, and HbA1c (P: 0.0001) levels in patients with LVMI > 130 g/m2. Linear regression analysis revealed that HbA1c was the major determinant of LVMI . Conclusions. HbA1c is the major determinant of LVMI, so strict control of serum glucose levels is essential for preventing cardiovascular disease in patients with NODAT. New-onset diabetes after transplantation (NODAT) is a serious complication associated with decreased graft and patient survival as well as an increased risk for cardiovascular disease , 2. New-The precise incidence of NODAT is difficult to determine, with a widely dispersed reported incidence between 2% and 50% , due to Presence of left ventricular hypertrophy and arterial stiffness are independent determinants of cardiovascular disease in patients with end-stage renal disease . Left veArterial stiffness is an independent predictor of cardiovascular events in patients with hypertension –17, ESRDThe objective of this study was to evaluate the risk factors for the development of NODAT and its relationship with arterial stiffness and left ventricular hypertrophy in kidney transplant recipients.Between years 2007 and 2010, 63 (23.59%) kidney transplant patients out of 267 were diagnosed to have NODAT in our center. Among these, 159 kidney transplant recipients were selected according to the following exclusion criteria: (1) irregular drug usage or patient incompliance, (2) lack of regular follow-up data, (3) pretransplant diabetes mellitus history, (4) bone marrow transplant or other solid organs before or at the time of transplantation (including previous kidney transplantation), (5) malign disease, rheumatologic or chronic inflammatory disease of unknown origin, systemic vasculitis history, (6) acute rejection periods after the first year of transplantation, (7) unstable cardiac disease including heart failure (ejection fraction < 50%) and/or ischemic heart disease history , (8) atrial fibrillation or elevated heart rate (>100 beats/min), (9) coronary bypass before or after transplantation, (10) transiently elevated fasting plasma glucose (FPG) or diabetic blood glucose profile during the first 3 posttransplant months, (11) graft failure (glomerular filtration (GFR) rate < 30 mL/min), and (12) history of peritoneal dialysis before transplantation.New-onset diabetes after transplantation was defined as a fasting plasma glucose (FPG) level ≥ 126 mg/dL (7 mmol/L) or symptoms of diabetes plus casual plasma glucose concentrations ≥200 mg/dL (11.1 mmol/L), confirmed by repeat testing on a different day . AccordiAll patients' data were recorded from clinical charts. Visits in outpatient clinic were organized as follows: three visits per week during the first 2 weeks; two visits per week until Day 60; weekly visits until Day 120; monthly visits during the first year; one visit every other month during the second year; and four visits per year thereafter until death or end-stage renal disease . The following parameters were collected: (1) age, (2) gender, (3) posttransplantation duration, (4) pretransplant hemodialysis duration, (5) acute rejection episodes, (6) use of statins, ace inhibitor (ACE) or angiotensin receptor blocker (ARB), (7) immunosuppressive treatment , (8) pretransplant lipid profile , (9) posttransplant lipid profile , (10) FPG and HbA1c levels , (11) office blood pressure measurements, (12) hemoglobin, calcium, phosphorus, albumin and parathyroid hormone levels, (13) creatinine and eGFR (MDRD equation), and (14) cytomegalovirus infection history.Mean values were arithmetic means of each parameter that were collected from patient charts at monthly basis after the first posttransplant of 6 months while other parameters were collected as single values at study inclusion.Maintenance immunosuppressive treatment included prednisone with a gradual tapering and mycophenolate mofetil or sodium associated with cyclosporine, tacrolimus, or sirolimus in most patients. Target through levels at 3 months were 150–250 ng/mL for cyclosporine and 8–12 ng/mL for tacrolimus and sirolimus. Steroids were tapered: 500 mg methylprednisolone intravenous (iv) on Day 0, 250 mg iv on Day 1, and 100 mg iv on Day 2 and 50 mg prednisolone perorally (po) from Day 3 to Day 6, 0.5 mg/kg BW po from Day 7 with a reduction by 5 mg every 2 weeks until 15 mg/day, and then 2.5 mg every 2 weeks until a maintenance dose 5 mg was achieved. All patients were under 5 mg prednisolone treatment within the maintenance immunosuppressive regimen 6 months after transplantation. Antidiabetic treatment modalities  were also recorded for patients with NODAT.Body compositions of all patients were analyzed by using the body composition analyzer (Tanita BC-420MA). Fat mass, fat free mass, muscle mass, visceral fat mass, and body mass index were calculated for each patient.2). Left ventricular mass index values greater than 130 g/m2 (n: 57) were defined as high left ventricular mass.All patients underwent echocardiographic examinations  by the same operator and left ventricular mass was calculated according to the Devereux formula and indexed to body surface area to give left ventricular mass index (LVMI) (g/mPulse wave velocity (PWv) is defined as the velocity of the arterial pulse for moving along the vessel wall. Pulse wave velocity along the aorta was measured by using two ultrasound or pressure sensitive transducers fixed transcutaneously over the course of a pair of arteries separated by a known distance: the femoral and right common carotid arteries. PWv was calculated from measurements of pulse transit time and the distance, according to the following formula: PWv (m/s) = distance (m)/transit time (s). Measurement of PWv values was con-ducted after abstinence from caffeine or smoking and after an overnight fast without intake of antihypertensive drugs. PWv was determined by using the SphygmoCor CvMs V9 system and values > 7 m/s were defined as increased.n: 57) and nondiabetic (n: 102) patient groups and according to presence of left ventricular hypertrophy as increased LVMI (n: 57) and normal LVMI (n: 102) patient groups. Differences between these groups were analyzed separately. Patients with NODAT were also divided into three groups according to their treatment as patients with diet and life-style changes (n = 29), oral antidiabetics (n = 5), and insulin (n = 23) for further analysis.Statistical analyses were performed by using a SPSS software . Subjects were grouped according to the presence of NODAT as diabetic (t or one-way ANOVA (post hoc Tukey) tests according to distribution normality. Skew distributed numeric variables were compared using the Mann-Whitney U and Kruskal-Wallis tests according to distribution normality. Spearman and Pearson Correlation tests were used for correlation analyses. Linear regression analysis was performed to assess the major determinant of high LVMI between correlated variables. A P value < 0.05 was considered as statistically significant.Normality of data was analyzed by using a Kolmogorov-Smirnov test. All numerical variables with normal distribution were expressed as the means ± standard deviations (SD), while variables with skew distribution were expressed as medians and interquartile range (IR). Categorical variables were expressed as percentages and compared by chi-square test. Normally distributed numeric variables were analyzed by independent samples P: 0.0001, Among 159 patients, 57 (32.2%) patients were with NODAT who were significantly older than patients without diabetes . In body composition analysis, fat mass  and fat free mass  were significantly higher in patients with NODAT  (P: 0.861)  . There w: 0.861) .P: 0.023) in patients with NODAT. The percentage of patients with high LVMI (>130 g/m2) was significantly higher in patients with NODAT  and LVMI  compared to patients without NODAT  and LVMI ≤ 130 g/m2  and diastolic  BP, serum triglyceride , glucose , age (P: 0.007), and HbA1c  levels in patients with LVMI >130 g/m2 . Serum calcium, phosphorus, parathyroid hormone (PTH), albumin, hemoglobin, and pretransplantation lipid parameters were similar in both groups .Further analysis was done after dividing study population into two groups according to LVMI as follows: LVMI > 130 g/m n: 102, . We obse130 g/m2 . Serum ch groups . Body coh groups . The perP > 0.05, P: 0.05). When we analyzed relationship between glucose regulation and LVMI when the patients were grouped according to HbA1c levels we observed that LVMI was still significantly higher in NODAT patients with low HbA1c levels  than patients without NODAT .There was no significant difference in LVMI, PWv, or HbA1c levels between NODAT treatment groups   .New-onset diabetes after transplantation is a serious metabolic complication that has been reported to develop in 2–53% of all solid organ transplants and 4 to 25% of renal transplant recipients –26. ThesPosttransplant hyperglycemia usually develops in patients with a high cardiovascular risk profile; older recipients with higher BMI; or those with insulin resistance before transplantation . Older aThe association between the use of tacrolimus and the development of NODAT has been clearly established previously , 31. HowAlthough steroids are known to have a strong diabetogenic effect , 33, we 2. Patients with a high LVMI showed worse renal function, associated with greater proportion of subjects with diabetes mellitus after transplantation. Left ventricular hypertrophy has been strongly linked to renal functional impairment [2. In the context of both left ventricular hypertrophy and NODAT, markers of increased oxidative stress are known to be elevated, leading to graft failure [Left ventricular hypertrophy, one of the structural alterations involved in diabetic cardiomyopathy –39, has pairment , 49, 50. failure .In diabetes, nonenzymatic glycation of proteins and formation of advanced glycation endproducts have the potential to quench nitric oxide and then diminish the vasodilatory capacity of the peripheral muscular arteries , 53. RedHigh pulse wave velocity is a universal marker of aortic stiffness and the link between pulse pressure and NODAT is unknown . Aortic Our study has several limitations. It is a cross sectional study, and our findings need to be confirmed in large long-term prospective studies. Pretransplantation echocardiographic and arterial pulse wave evaluations of patients were absent, so we were not able to discuss the initiation or the progression of LVMI or arterial stiffness. Pretransplant OGTT was not routinely assessed at our center. There are other less consistent risk factors linked to development of NODAT, like HLA phenotype, genetic polymorphisms of interleukins, and donor characteristics, through levels of CNIs. These issues were not addressed in our study. Patients' antihypertensive medication was recorded according to the type of the class and we could not assess the influence of the type and dose because of the small number of patients.The current study confirmed the association of traditional risk factors including age, presence of obesity, and long dialysis duration with the development of NODAT. Patients with NODAT should be accepted as a high risk population with higher prevalence of left ventricular hypertrophy and vascular stiffness. Prevention of NODAT related cardiovascular morbidity may be accomplished with early detection of this metabolic disorder with corresponding therapeutic interventions such as change in lifestyle, weight loss, selection of an appropriate immunosuppressive regimen, and use of antidiabetic drugs. Thus, regular screening of NODAT and initiation of proper treatment and better metabolic control at earliest possible should be the integral part of overall renal transplant management. Relevance and therapeutic consequences must be determined in large-scale prospective studies.


Although the clinical benefit of imatinib adjuvant therapy for high-risk patients with gastrointestinal stromal tumor (GIST) has been proven, the recurrence rate still remains high. This study aimed to sub-divide high-risk GIST patients with some “very high-risk” factors for more precise prognostic indicator, and possible association with efficiency of imatinib adjuvant therapy.Clinicopathological data were confirmed by pathological diagnosis and clinical records. Recurrence-free survivals (RFS) were evaluated in 370 GIST patients  and 48 high-risk GISTs with imatinib adjuvant therapy after R0 resection.Mitosis count > 10/50 high-power fields (HPF) and serosal invasion are independent prognostic factors for RFS of GIST patients. Mitosis count > 10/50HPF and serosal invasion can sub-divide high-risk GIST patients effectively and significantly improve the area under the curve (AUC) of receiver operating characteristics (ROC) curve for prognostic indicator both in test and validation cohort. Patients with serosal invasion after R0 resection showed a poorer prognosis with imatinib adjuvant therapy.Sub-division of high-risk GIST patients helps to more precisely predicting the prognosis. Serosal invasion may be an adverse predictive factor in high-risk patients and imatinib treatment outcome. Gastrointestinal stromal tumor (GIST) accounts for more than 80% of all gastrointestinal mesenchymal tumors . As it rModified NIH criteria based on NIH consensus criteria is wildly accepted as risk-stratification scheme for GIST and four categories from very low to high risk are used to predict prognosis of GIST patients. The mitosis count, tumor size, tumor site and tumor rupture are important prognostic predictors in this scheme ,7. HowevBecause unclear biological behaviors and high recurrence rates in high-risk GIST patients, some of them suffer worse prognosis than others even they are classified into the same category with the same treatment. To more precisely predict prognosis and possible association with efficiency of imatinib adjuvant therapy for high-risk GIST patients, we tried to sub-divide high-risk GIST patients with some “very high-risk” factors, such as primary sites not from stomach, tumor size > 10 cm, mitosis count > 10/50HPF and serosal invasion, a common pathological diagnosis in malignant tumors. Related recurrence-free survivals (RFS) were analyzed in test and validation cohort.This project was approved by ethics committee of Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine for the use of samples, approval No. 2012031. Informed consents were obtained from all patients before study inclusion.The patient inclusion criteria were as follows: 1) a distinct pathologic diagnosis of GIST; 2) underwent R0 resection, R0 resection in our study defined as margin-free resection and no metastasis detected before and during the surgery; 3) no radiotherapy, chemotherapy, nor other anti-cancer therapies prior to the surgery; and 4) availability of complete clinicopathologic and follow-up data. The patient exclusion criteria were as follows: 1) underwent R1/2 (margin-positive) resection; and 2) locally advanced GIST. The parameters, including patient age, gender, tumor site, tumor size, number of mitoses/50 high-power fields (HPF) and serosal invasion, were recorded in the official pathology database. Cases with tumor rupture were not enrolled in our study because insufficient data in our clinical records. The risk of aggressive tumor behavior was calculated according to the modified NIH criteria, which classified GIST into very low, low, intermediate, and high-risk categories.In patients without imatinib adjuvant therapy and met the criteria in our study, were divided into two cohorts by different surgical time periods for getting more reliable results as a single center research. As the test cohort, 212 cases of GISTs  were collected retrospectively from patients who underwent surgeries at Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine from January 2010 to May 2013. In parallel, we retrospectively assessed another validation cohort collected 158 cases  from the same hospital between January 2004 and December 2009. More details of clinic-pathological characteristics of test and validation cohort could refer to Table Complete follow-up data until December, 2013, for patients in test and validation cohort were available. RFS was calculated from the date of tumor resection until the detection of tumor recurrence or last observation. The median follow-up of the test cohort was 30 months . In the validation cohort, the median follow-up was 69 months . Computed tomography (CT) and/or magnetic resonance imaging (MRI) were used to verify tumor recurrence in suspected cases.Patients with serosal invasion in our study were confirmed by the pathological diagnosis as GIST invading the layer of serosa, including the serosa from the surface of adjacent organs or tissues. An extended local excision around serosal invasion area was conducted for R0 resection. The locally advanced GIST explicitly indicated by CT or MRI before the surgery was excluded in our study because this kind of GISTs not only penetrate serosa layer but also invade parenchyma of adjacent organ always leading to R1/2 resection with very poor prognosis. Neoadjuvent imatinib therapy has already been recommended in this kind of patients by current ESMO and NCCN guidelines. Our study aimed to figure out the prognostic value of GIST which just only invading serosal layer, so local advanced GIST were excluded in our study.KIT and PDGFR gene analysis showed 45 cases with KIT exon 11 and 3 cases with exon 9 mutation, and without any PDGFR gene mutation detected.The criterion of imatinib adjuvant therapy after R0 resection in our study required at least 12 months uninterrupted drugs taking with 400 mg/day. 48 high-risk cases met the criteria of imatinib adjuvant therapy since 2008 in our study. The follow-up median of the patients with imatinib therapy was 38 months ; P-value differences <0.05 were considered statistically significant.Statistical analyses were conducted using SPSS for Windows (version 17.0) and MedCalc (version 11.4.2.0). For comparisons, one-way analyses of variance and chi-squared tests were performed when appropriate. RFS was calculated according to the Kaplan-Meier method. The log-rank test was used to compare the survival distributions. Univariate and multivariate analyses were based on the Cox proportional hazards regression model. Only variables that were significantly different in univariate analysis were entered into the next multivariate analysis. Receiver operating characteristics (ROC) curves were constructed to assess sensitivity, specificity, and respective areas under the curves (AUCs) with 95% CI. All statistical tests were 2-sided. Characteristics of GIST patients in test and validation cohort were shown in Table vs no serosal invasion subgroup). RFS of GIST patients in test and validation cohort classified by modified NIH criteria were shown in Figure P > 0.05)  , mitosis count (≤10 HPF vs > 10/50 HPF subgroup) and serosal invasion  Figure C and D. P < 0.01). The AUC of serosal invasion  were also significantly higher in both the test and the validation cohort (P < 0.01)  were higher than that of modified NIH criteria  with significantly difference both in the test and the validation cohort (P = 0.115). But the RFS of patients with serosal invasion showed sharp decline of the curve as opposed to those without serosal invasion, indicating serosal invasion as unfavorable effect on imatinib adjuvant therapy (P = 0.014) , and the results remained similar in the validation. Criteria of prognostic indicator is always required the accuracy as high as possible but the schemes as simple as possible to meet various clinical cases. Our study demonstrated two common factors, mitosis count > 10/50HPF and serosal invasion. One of them already has been included in high risk schemes of NIH criteria.The prognostic accuracy of modified NIH criteria and sub-groups based on modified NIH criteria were compared using ROC analyses, mitosis count or serosal invasion sub-group, produced better estimats for the risk of GIST recurrence. The AUC was larger for the mitosis count  or serosal invasion sub-groups  than that for modified NIH criteria in test cohort (0.860, 95% CI 0.807-0.902; We further focused on whether mitosis count > 10/50HPF or serosal invasion could affect efficiency of imatinib adjuvant therapy. The results showed that GIST patients with serosal invasion might suffer a poorer prognosis with imatinib therapy, but there was no difference between patients with mitosis count > 10 and mitosis count ≤ 10/50HPF in the RFS. Because of the limitation of the sample numbers and follow-up time in our study, it still needs more works to verify this result, but the high-risk GIST patients with serosal invasion should be noticed in clinical follow-up because of higher possibility in recurrence even with imatinib adjuvant therapy.KIT and PDGFR, but conducting biopsies in such highly malignant GIST may increase the risks of tumor rupture or implantation metastasis.How to improve outcomes of GIST patients with serosal invasion even after R0 resection is still a serious problem. Should this kind of patients need more than 3-year imatinib therapy? The real benefits and optimal time to stop treatment still need further study and it still remains the possibility of recurrence after stopping taking the drugs. Neoadjuvant imatinib therapy, which has been recommended by current ESMO and NCCN guidelines for locally advanced GIST ,18, may In this study, we analyzed several “very high-risk” factors in high-risk group of GIST patients after R0 resection. Serosal invasion appears to improve the modified NIH criteria and predicts an unfavorable outcome in high-risk GIST patients, with or without imatinib treatment. Our study demonstrated the possibility of personalized medical strategy for different GISTs by sub-dividing high-risk patients.GIST: Gastrointestinal stromal tumor; IM: Imatinib mesylate; HPF: High-power fields; RFS: Recurrence-free survival; CT: Computed tomography; MRI: Magnetic resonance imaging; ROC: Receiver operating characteristics; AUCs: Respective areas under the curves.The authors declare that they have no competing interests.W-YZ, HC, Z-GZ made the conception, design and drafted the manuscript; W-YZ, JX, MW, Z-ZZ, LT and C-JW carried out collection and assembly of data; All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/14/105/prepub


Standing from a bed or chair may cause a significant lowering of blood pressure (ΔBP), which may have severe consequences such as, for example, falls in older subjects. The goal of this study was to develop a mathematical model to predict the ΔBP due to standing in healthy subjects, based on their Heart Rate Variability, recorded in the 5 minutes before standing.Heart Rate Variability was extracted from an electrocardiogram, recorded from 10 healthy subjects during the 5 minutes before standing. The blood pressure value was measured before and after rising. A mathematical model aiming to predict ΔBP based on Heart Rate Variability measurements was developed using a robust multi-linear regression and was validated with the leave-one-subject-out cross-validation technique.The model predicted correctly the ΔBP in 80% of experiments, with an error below the measurement error of sphygmomanometer digital devices (±4.5 mmHg), a false negative rate of 7.5% and a false positive rate of 10%. The magnitude of the ΔBP was associated with a depressed and less chaotic Heart Rate Variability pattern.The present study showes that blood pressure lowering due to standing can be predicted by monitoring the Heart Rate Variability in the 5 minutes before standing. An orthostatic change, namely a change in body posture from sitting to standing, causes specific changes in heart rate and blood pressure as a compensatory reaction of the body. In fact, in the few minutes after standing, there is a redistribution of the blood volume and a pooling of blood in the lower extremities due to gravitational forces. As a consequence, the venous return to the heart falls and the cardiac filling pressure is reduced diminishing the stroke volume and cardiac output. Therefore, there is a drop in blood pressure (ΔBP) due to the change of position, a condition referred to as Standing Hypotension (SH).To avoid dizziness or fainting due to the limited blood supply to the brain, the blood pressure in the large arteries decreases to compensate and regulate. The objective of this regulatory mechanism is to achieve normal blood pressure as quickly as possible while providing an adequate supply of blood to the vital organs.Healthy subjects respond with an autonomic adjustment, which increases vascular tone, heart rate and cardiac contractility, and stabilizes arterial pressure . In partTherefore, the dynamic of the blood pressure and particularly the capability to restore homeostasis after standing is strongly dependent on the status of the Autonomous Nervous System (ANS). Starting from the hypothesis that the magnitude of the ΔBP a few minutes after standing is dependent on the status of the ANS before standing, which can be estimated using short term Heart Rate Variability (HRV), the research question of the study was: is it possible to predict ΔBP using the HRV measurements recorded in the 5 minutes before standing?The prediction of this ΔBP is particularly relevant as at least 30% of the indoor falls of older subjects happen when they are rising from a bed or chair, such falls in the majority of the cases being due to the ΔBP caused by the activity of standing. Therefore, a model that could predict this ΔBP could help to predict a significant percentage of these falls.The current paper proposes a mathematical model to predict the ΔBP due to standing in healthy subjects, based on the HRV features extracted from an ECG recorded, through the use of wearable sensors, in the 5 minutes before standing.This study was conducted on a group of 10 healthy subjects, enrolled in accordance with the following selection criteria, namely that they were:• no suffering from any pathological cardiovascular conditions, neurological or psychiatric disorders ,3 or oth• not taking any medication at the time of the study;• not professional athletes or high-level sport participants;• had not taken any caffeine or alcohol in the 12 hours prior to the measurements.The Biomedical and Scientific Research Ethics Committee (BSREC) of the University of Warwick approved the experimental protocol and each subject was given detailed information about the study and gave his/her informed consent before starting the measurements.The protocol was defined to maximize the repeatability and reproducibility of the experiments and aimed to simulate as far as possible the real life action of standing from a bed.During the tests, an ECG signal was monitored using a one-lead wearable electrocardiogram sensor, the BH3-M1 (Zhephyr Ltd), attached to lightweight patches (33 grams) using standard ECG electrodes. In addition, a 3 leads ECG was recorded using a wearable biomedical amplifier, the Nexus 10 (MindMedia Ltd) in order to benchmark the signals acquired with the BH3-M1.The BP was measured with a digital sphygmomanometer, the M2 basic (OMRON Ltd), with the left arm comfortably positioned on a horizontal surface and the cuff positioned at the level of the heart at about 2 cm from the inner side of the elbow. The experiments were carried out in a quiet room, with dimmed lighting and a comfortable temperature of about 23°C. All the experiments were carried out at the same time of the morning to minimize the circadian effects on the HRV .The protocol was composed of three phases  as described below : the volunteers were invited to sit in a comfortable position for a baseline recording of BP and an ECG (>2 minutes).• Phase 2 (Lying): the volunteers were invited to lie down in a supine position at about 45 cm from the ground for 10 consecutive minutes (5 minutes of resting + 5 minutes for the recordings): systolic and diastolic BP was recorded four times  in the final 5 minutes before standing; an ECG was recorded during these final 5 minutes.• Phase 3 (Standing): the volunteers were invited to stand up actively (without any help) and to stay in an upright position for 5 minutes. The subjects were all trained to stand up in a uniform manner: tilting the trunk and simultaneous twisting the body to the left; putting on the floor first the left and then the right foot; resting for five seconds; and finally standing up without using their hands to help. Once standing, systolic and diastolic BP was recorded four times  and an ECG was recorded continuously for 5 minutes.After standing the subjects were asked to report any symptoms of vertigo or dizziness and, if this was present, its magnitude (moderate or severe). Phases 2 and 3 were repeated four times after 5 minutes of resting. The whole protocol lasted approximately 100 minutes for each subject.During phases 2 and 3, HRV excerpts of 5 minutes length were extracted from the ECG recordings Figure .The ECG measurements were pre-processed by using Kubios ,6, a MatEach ECG record is cleaned from power line interference, and muscle and movement artefacts, by using a cubic spline interpolation method ,8. The dThe filtered signals were then analysed. A standard linear HRV analysis was performed according to the guidelines of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology . AdditioThe HRV measurements were associated with the BP measurements as described in Figure • 1 HRV excerpt of 2 minutes, 1 systolic and 1 diastolic BP measurement during phase 1 (sitting).• 1 HRV excerpt of 5 minutes, 4 systolic and 4 diastolic BP measurements during phase 2 (lying), which were repeated four times.• 1 HRV excerpt of 5 minutes, 4 systolic and 4 diastolic BP measurements during phase 3 (standing), which were repeated four times.i in the database was constituted by the following 30 pieces of information:Therefore, the database contained nine instances for each subject. Each instance • sub_id: a number value from 1 to 10 to univocally identify each subject;• HRV_id: a number value indicating one of the three HRV excerpts related respectively to the three phases ;• test_id: a number value from 1 to 4 indicating the experiment repetition;• symptom_id: a number value form 0 to 2 to indicate if the subject feels any manifestation of vertigo/dizziness: 0 = no vertigo; 1 = moderate vertigo; 2 = major vertigo;i: the 9 values of the Systolic Blood pressure measured;• SYS_BPi: the 9 values of the Diastolic Blood pressure measured;• DIA_BPf: a vector containing the 22 HRV measurements reported in Table i" was defined as follows:• predictive dataset, contained for each subject 4 instances defined as follows:In order to develop and test a model to predict the magnitude of the BP drop, a second dataset was generated. The new dataset, hereinafter referred to as the where:andnd minute after the standing action (BP7) and the mean of the BP measurements taken in phase 2. Since phase 2 and 3 were repeated four times, 4 instances were generated for each subject and the final complete dataset was composed of 40 instances (4 instances * 10 subjects).In other words, the predictive database contained the HRV measurements extracted from the 5 minute ECGs recorded in phase 2 (while lying) associated with the drop of systolic and diastolic BP detected in phase 3 (after standing). The BP drop (ΔBP) was calculated as the difference between the BP value measured during the 2The BP7 measurement was used because it has been demonstrated that the BP drop is more frequent (observed in about 46% of patients) within 3 minutes after the standing action, in accordance with ,16. Sincn is the number of repeated measurements. Therefore, an error of ±4.5 mmHg was estimated on the measured ΔBP.Where f' of HRV features.A robust multi-linear regression  was usedn HRV features (equation 6):As stated in the introduction, the hypothesis was that the drop of BP after standing could be predicted by using the HRV measurements extracted from the ECGs registered in the 5 minutes before standing. Therefore, we modelled the ΔBP as a combination of where:0 was the intercept and c1...n determined the contribution of the independent variable f1...n.• cε was a random variable normally distributed.• robustfit function of the MATLAB version R2013a [The model was developed by using the n R2013a ,19.f' of HRV features was selected using the so-called exhaustive search method [The best subset h method , investiσest, defined as follows:The best subset was selected as the one that minimizes the Regression Standard Error est σreported on how wrong the regression model was on average using the same units of the predicted value. Smaller est σvalues were considered better because they indicated that the prediction was closer to the fitted line. The est σwas estimated using the leave-one-subject-out approach. Therefore, the robust regression was performed ten times, each time using 9 subjects to develop the model and one to test it. Consequently, 10 values of est σwere computed and the average of these 10 values was used to choose the best feature combination. For this combination of features, the final model was then fitted on the whole dataset .where: Y was the actual value (the observed BP drop), Y' was the predicted value (the predicted BP drop), and N was the number of instances utilised to develop the model. The numerator was the sum of the squared differences between the actual scores and the predicted scores. Therefore, this error represented the average distance between the real BP drop values and the regression line. Consequently, Moreover, the percentage of correctly predicted values (%CP), i.e. those with an error lower than the measurement error of the BP drop (4.5 mmHg), was computed as follows:where Θ represents the Heaviside function .Finally the rate of false positives and negatives was calculated according to the following conventions:• "false negative"-the cases where the ΔBP was underestimated with an error above 5 mmHg • "false positive"-the cases where the ΔBP was overestimated with an error above 5 mmHg A group of 10 volunteers, 7 women and 3 men, with a median age of 30.4 years (range 23-43 years), was enrolled in the School of Engineering of the University of Warwick. All the subjects signed informed consents and met the inclusion criteria. Each subject underwent 33 BP measurements The regression standard error calculated on the testing (leaving one out estimate), the training and the whole dataset was respectively 5.22 mmHg, 4.30 mmHg and 4.29 mmHg.The histogram of the residuals is reported in Figure Figure As shown in Figure This paper presents a model to predict systolic BP drop due to standing relying on HRV measurements extracted from 5 minute ECGs recorded before standing. The proposed model is based on the hypothesis that the magnitude of BP drop in the few minutes after standing is correlated with HRV features extracted from ECG recordings taken in the 5 minutes before standing. According to the mathematical model here proposed, an increased ΔBP appears to be related to:• a reduced overall short-term HRV, as assessed by TINN and RMSSD .• an increased value of HF and/or NN50, which is strongly correlated to HF .• an increased determinism , and, therefore, a decline of non-linear heartbeat dynamics .As HF is an indicator of parasympathetic function, while the overall variability is considered a marker of both sympathetic and parasympathetic tones , the comA few previous studies have compared HRV features between subjects with and without significant standing hypotension, which is defined as a sustained reduction of systolic blood pressure of at least 20 mmHg or of diastolic blood pressure of 10 mmHg within 3 minutes of standing. In particular, Barbic et al.  found a The current study has some limitations, in particular, the small sample size and the selection of healthy volunteers, which could limit the generalizability of the results to other population subgroups, such as middle-aged and elderly individuals with comorbidities. In addition, our results should be considered as preliminary, because we have tested a novel hypothesis, which has not been explored before. Hence, these results should be corroborated by further investigations, using larger samples across a wider age range. Nevertheless, our findings are intriguing because they suggest that a reduced overall short-term HRV might represent a predictive parameter for SH, which is one of the main causes of indoor falls. Previous studies aiming to prevent falls used wearable accelerometers -30, presThis study suggests that the lowering of blood pressure in the few minutes after standing can be predicted by monitoring HRV features recorded in the 5 minutes before standing. Particularly, more significant blood pressure decreases were observed in subjects presenting a depressed and less chaotic HRV pattern. This could reflect a transient depressed autonomic response causing a slower recovery of homeostasis and adjustment of blood pressure.As a future work we will perform a large-scale experimental phase in which we will recruit more subjects across a wider age range to investigate the generalizability of the results obtained in this preliminary study. Moreover, further studies will investigate the influence of other factors, e.g., time of day, previous medications, and cardiovascular disease.In this way we can refine the developed mathematical model, if necessary, in order to predict falls by detecting the cardiovascular and autonomous nervous system states (CVS/ANS). Additionally, the model will be implemented and embedded in a real-time mobile monitoring system in order to inform the patient and, in the case of a hospitalised patient, the medical staff about the high possibility of having a significant drop in blood pressure two minutes before this might happen. In any case where the model predicts a fall, the system can recommend to the patient not to perform any fast standing action alone.ΔBP: blood pressure lowering due to standingECG: ElectroCardioGramHRV: Heart Rate VariabilityBP, Blood Pressure;SH, Standing Hypotension;SYS, Systolic Blood Pressure;DIA, Diastolic Blood Pressure;HDFP, Hypertension Detection and Following-up Program;NHS, National Health Service;ANS, Autonomous Nervous System;OR, Odds Ratio;CI, Confidence Interval;BSREC, Biomedical and Scientific Research Ethics Committee;%CP, Percent correct prediction;mmHg, millimeter of mercury;LF, low frequency;HF, High frequency.The authors declare that they have no competing interests.GS refined the study protocol, collected the data, processed the signals, and drafted the first version of manuscript. PM contributed to the predictive model development, and to the writing of the manuscript. SS contributed to the study design, to the preparation of the ethical approval submission, the clinical interpretation of the findings and to writing of the paper. PDP contributed to the writing of the paper. LP conceived the study, prepared the ethical approval, coordinated the study execution, developed the predictive model and contributed to the writing of the paper. All the authors read and approved the final version of this paper


Obesity is strongly associated with hypertension. Despite numerous mechanistic links the association is not fully understood. Western diet increases uptake of Toll-Like receptor 4 (TLR4) ligands such as free fatty acids or endotoxin. We recently demonstrated that TLR4 ligands are involved in the development of hypertension. We hypothesized that TLR4 ligands are involved in obesity-associated hypertension and investigated the TLR4 single nucleotide polymorphism (SNP rs 498790). This SNP is frequent, associated with cardiovascular disease and characterized by blunted response upon exposure to TLR4 ligands.2) was investigated by multivariate regression analysis.We investigated 3657 patients undergoing coronary angiography. Blood pressure was determined in standardized manner prior angiography. The diagnosis of hypertension was based on record data. Patients were characterized for TLR4 single nucleotide polymorphism (SNP) rs4986790. Patients were stratified according to quartiles of Body mass index (BMI) and according to the polymorphism. The association between the TLR4 polymorphism and blood pressure in obese patients  and less diagnosis of hypertension as controls. In obesity the TLR4 SNP rs4986790 was an independent predictor of SBP.Systolic blood pressure increase with obesity was blunted in cases with TLR4 SNP rs4986790. The increasing prevalence of obesity worldwide is a serious health hazard. Obese individuals are at increased risk for diabetes, hypertension, renal failure, and other cardiovascular diseases. Clinical studies have confirmed a strong relationship between obesity and hypertension , 2. In lChronic low-grade inflammation is linked to hypertension, being one important feature shared by obesity and hypertension , 9. ThisParticipants were examined at I. Medizinische Klinik rechts der Isar der Technischen Universität München or Deutsches Herzzentrum München. Between 1993 and 2002, 3657 patients were enrolled in a dedicated registry including patients with and without myocardial infarction . The locSBP and DBP were determined under standardized conditions in the laying position . Clinical and laboratory data were prospectively collected in an online database. Source data check was done with 20 % of the data. We selected from the TLR4 genes 12 reported SNPs and focused on the rs4986790 (Asp299Gly) as this SNP is frequently present and this SNP is known to demonstrate reduced activity on TLR4 ligands.TLR4 gene, TLR4A allele) deposited under accession number AF177765 in GenBank (http://www.ncbi.nlm.nih/entrez/). The primers used for amplification of the SNP rs4986790 (Asp299Gly) were 5′ TTGAAGAATTCCGATTAGCATACTTAGAC 3′ and 5′ TCACCAGGGAAAATGAAGAAACAT 3′. Allele-specific signalling was accomplished with the use of the fluorogenic dyes 6-carboxy-fluorescein (FAM) and VIC (proprietary dye of Applied Biosystems) which were attached to the 5′ end of the probe oligonucleotides. Minor groove binder (MGB) groups were conjugated with the 3′ end of the oligonucleotides to facilitate formation of stable duplexes between the probes and their single-stranded DNA targets. The structures of the probes were as follows : FAM-5′ CCTCGATGATATTATTGACT 3′-MGB (for 896A), VIC-5′ CTCGATGGTATTATTG 3′-MGB (for 896G).[BccI  (TLR4 SNP rs4986790). The results obtained with the different methods were fully consistent, which demonstrated the reliability of the TaqMan systems that were used for genotyping of the SNP rs4986790 in the entire study population. Genotype determination was done by workers who had no knowledge of clinical, laboratory, or angiographic data of the individuals enrolled in the study.In summary, a blood sample was drawn from each participant during the regular routine examination for coronary artery angiogram. Genomic DNA was extracted from peripheral blood leukocytes with the QIAamp DNA Blood Kit  or the High Pure PCR Template Preparation Kit . Genotype analysis was performed with allele-specific fluorogenic oligonucleotide probes in an assay combining the polymerase chain reaction (PCR) and the 5′ nuclease reaction . Primers and probes were established with the Primer Express software  after import of a DNA sequence (Homo sapiens 2. The primary model was to assess the relation between blood pressure across BMI quartiles in cases and controls. In the next step we focused on the upper BMI quartile and compared blood pressure between cases and controls. Discrete variables are expressed as counts (percentage) and compared with the use of the χ2 test or Fisher’s exact test, as appropriate. Continuous variables are compared by means of the unpaired, two-sided t test. Genotype frequencies in the case group were compared with values predicted by Hardy–Weinberg equilibrium with the use of the χ2 test. Multivariate analysis used age, gender and hypercholesterolemia. Statistical significance was accepted for P-values <0.05. The probability of a false negative association result because of population stratification is low, because the study participants were consecutively recruited from a defined geographic area of southern Germany with limited recent immigration. The sample size allowed an analysis with 80 % power to detect a six mmHg decrease of SBP among the cases with the TLR4 SNP rs4986790 at a two-sided α-error of 0.05.Data are presented as mean ± SD. The analysis compaired genotype distributions between the BMI quartiles. The BMI quartile ranges for the whole cohort were for quartile 1 (Q1) a BMI < 24,64, for quartile 2 (Q2) BMI ≥24.65-26,89, for quartile 3 (Q3) BMI ≥ 26.90-29.50 and for quartile 4(Q4) BMI ≥ 29,51 kg/mWe investigated a cohort of 3017 patients who underwent coronary angiography. Distribution of the patients according to quartiles of body mass index (BMI) revealed no differences for age, gender or smoking. However the metabolic profile of the patients in the upper BMI quartile was markedly altered. Lipid profile showed higher triglycerides and lower HDL-cholesterol in the upper BMI quartile. In the upper quartile the diagnosis of diabetes and hypercholesterolemia was higher as compared to other BMI quartiles.Similarly systolic blood pressure, pulse pressure and diagnosis of hypertension increased across BMI quartiles whereas diastolic blood pressure remained stable. In line with the presence of hypertension in the upper BMI quartile the number of antihypertensive drugs was higher in the upper quartile Table . The samIn this cohort, 319 cases with the TLR4 SNP rs4986790 were identified. The TLR4 SNP rs4986790 cases were distributed according to the Hardy-Weinberg equilibrium HWE = 0.32). In comparison to controls, TLR4 SNP rs4986790 cases were comparable for age, gender and smoking habits  was investigated . This TL9Gly was Our major finding was that TLR4 SNP rs4986790 cases were protected against the blood pressure increase across BMI quartiles. General characteristics were comparable between cases and controls and the Hardy–Weinberg equilibrium was comparable between BMI quartiles. Therefore the data were comparable between cases and controls. The blood pressure effect was in particular present in the obese cases as compared to the obese controls. This was not explained by intensified antihypertensive treatment or history of myocardial infarction. The regression analysis showed for obese patients that the TLR4 SNP rs4986790 remained a significant predictor of blood pressure even after multiple adjustments. The limitation of this study was that we restricted our analysis to one polymorphism. We did not perform a genome wide association study (GWAS). Additionally we did not measure the amount of TLR4 ligands in our patients.In summary our results suggest that in obesity associated hypertension TLR4 SNP rs4986790 cases present a lower SBP, pulse pressure and less hypertension. This finding needs to be confirmed in GWAS and functional studies need to be performed to address the role of TLR4 signaling in obesity associated hypertension.