Atherosclerosis is associated with various comorbidities; nonetheless, its effect on the postoperative complications of colorectal surgery in older patients with colorectal cancer (CRC) remains unclear. This study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older adults with CRC.Patients aged ≥ 65 years who underwent surgery for CRC between April 2017 and October 2020 were enrolled. To evaluate atherosclerosis, we prospectively calculated the cardio-ankle vascular index (CAVI) measured by the blood pressure/pulse wave test and abdominal aortic calcification (AAC) score from computed tomography. Risk factors for Clavien–Dindo grade ≥ III postoperative complications were evaluated by univariate and logistic regression analyses.p = 0.019), AAC score ; and operative time  were identified as risk factors for postoperative complications. Based on the optimal cut-off values of CAVI and AAC score, the probability of postoperative complications was 27.8% in patients with abnormal values for both parameters, which was 17.4 times higher than the 1.6% probability of postoperative complications in patients with normal values.Overall, 124 patients were included. The mean CAVI value and AAC score were 9.5 ± 1.8 and 7.0 ± 8.0, respectively. Clavien–Dindo grade ≥ III postoperative complications were observed in 14 patients (11.3%). CAVI (odds ratio, 1.522 , Atherosclerosis, particularly that assessed using CAVI and AAC score, could be a significant predictor of postoperative complications of colorectal surgery in older adults with CRC.The online version contains supplementary material available at 10.1186/s12876-022-02600-7. The proportion of older adults in the society is rapidly increasing, and the share of the global population aged 65 years is projected to rise from 10 in 2022 to 16% in 2050 . GeneralAtherosclerosis is one of the crucial pathophysiological processes implicated in cardiovascular diseases, including coronary artery disease, stroke, and heart failure , 9, and The present study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older patients with CRC using the blood pressure/pulse wave test and scoring of arterial calcifications with computed tomography (CT) scans.n = 2), and the remaining 124 patients were included in this study  class; presence of comorbid diseases, such as hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease, and chronic kidney disease; smoking history; steroid use; stroke; previous abdominal surgery; body mass index; blood test results ; prognostic nutritional index ; CAVI; AThis study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The procedures followed were approved by the institutional review board of Tokyo Medical University (T2021-0025). Written informed consent was obtained from all patients prior to their participation in the study.The severity of atherosclerosis was evaluated using the blood pressure/pulse wave test and AAC scoring system.At the time of admission, CAVI was measured using a blood pressure pulse wave analyzer , according to the method described previously . Briefly2 . The total AAC score for each patient was determined by adding the scores from each of the eight regions [As previously described by Agatston et al. , two rad regions , 22 , major complications (class III–IV), and death (class V) . We aimep-values of < 0.05. Variables with p-values of < 0.25 in the univariate analysis were entered into the multivariate logistic regression model to determine the risk factors for postoperative complications with a criterion of p < 0.05. Receiver operating characteristic (ROC) curves were used to determine the cut-off values of CAVI and AAC score. The optimal cut-off value was defined as the point on the ROC curve plotted closest to the point from the upper left corner.All statistical analyses were performed using SPSS software version 27.0 . Categorical variables are expressed as number and percentage (%), whereas continuous variables are presented as mean ± standard deviation. The categorical variables were compared using the chi-squared test or Fisher’s exact test, as appropriate; the continuous variables were compared using the Mann–Whitney U-test. Throughout our analysis, statistical tests were two-tailed, and statistical significance was set at n = 76) than females (n = 48). Patients with ASA class ≥ 2 accounted for 96.8% of patients, as almost all patients had comorbidities. Overall, the mean AAC score was 7.0 ± 8.0 and the mean CAVI value was 9.5 ± 1.8. Table n = 5), intraperitoneal abscess (n = 3), pneumonia (n = 2), anastomotic leakage (n = 2), intestinal ischemia (n = 1), and anastomotic bleeding (n = 1).The study population comprised 124 patients with a mean age of 75.3 ± 6.4 years (Table p = 0.046), AAC score (p = 0.017), CAVI value (p = 0.006), and operative time (p = 0.005) predicted grade ≥ III postoperative complications. The results of logistic regression analysis for postoperative complications are presented in Table p = 0.019), AAC score , and operative time .Univariate analysis showed that male sex  and its radiodensity (HU). It is commonly used in studies of atherosclerosis involving the coronary arteries [Regarding AAC score, calcification occurs in the media of arteries, and the amount of calcification is directly associated with the extent of atherosclerosis . A previarteries . Regardiarteries , 34, 35.arteries , 22 simiarteries , 34, 35.CAVI and AAC score evaluate arterial stiffness and arterial calcification, respectively, although both are markers of atherosclerosis. Additionally, in this study, we evaluated the correlation between these two test results and found no significant relationship  angiography has been reported to provide information on tissue perfusion, identifying a well-perfused location for colorectal transections . This isSecondly, a previous study has reported that patients with high ligation of the inferior mesenteric artery (IMA above left colic artery) had a 3.8 times higher chance of leaking than those with low ligation (IMA below left colic artery)  in sigmoOur study had some limitations. First, this was a single-center prospective cohort study; therefore, our findings should be confirmed in a larger-scale study. Second, we only investigated calcification around the origin of the superior mesenteric artery and inferior mesenteric artery based on the AAC score. However, to assess systemic atherosclerosis, other regions may have to be investigated as well.Atherosclerosis, evaluated based on CAVI and AAC score, was a risk factor for postoperative complications of elective colorectal surgery in older patients with CRC. We emphasize that the preoperative evaluations of atherosclerosis in colorectal surgery in older patients with CRC may help surgeons perform surgery safely and appropriately tailor postoperative management.Additional file 1: Scatter plots of CAVI and AAC score. Pearson's correlation coefficient was 0.10 between AAC score and CAVI


Higher intracranial pressure variability (ICPV) has been associated with a more favorable cerebral energy metabolism, lower rate of delayed ischemic neurologic deficits, and more favorable outcome in aneurysmal subarachnoid hemorrhage (aSAH). We have hypothesized that higher ICPV partly reflects more compliant and active cerebral vessels. In this study, the aim was to further test this by investigating if higher ICPV was associated with lower cerebrovascular resistance (CVR) and higher cerebral blood flow (CBF) after aSAH. In this observational study, 147 aSAH patients were included, all of whom had been treated in the Neurointensive Care (NIC) Unit, Uppsala, Sweden, 2012–2020. They were required to have had ICP monitoring and at least one xenon-enhanced computed tomography (Xe-CT) scan to study cortical CBF within the first 2 weeks post-ictus. CVR was defined as the cerebral perfusion pressure in association with the Xe-CT scan divided by the concurrent CBF. ICPV was defined over three intervals: subminute (ICPV-1m), 30-min (ICPV-30m), and 4 h (ICPV-4h). The first 14 days were divided into early (days 1–3) and vasospasm phase (days 4–14). In the vasospasm phase, but not in the early phase, higher ICPV-4h  was independently associated with a lower CVR in a multiple linear regression analysis and with a higher global cortical CBF  in a univariate analysis. ICPV-1m and ICPV-30m were not associated with CVR or CBF in any phase. This study corroborates the hypothesis that higher ICPV, at least in the 4-h interval, is favorable and may reflect more compliant and possibly more active cerebral vessels.The online version contains supplementary material available at 10.1007/s10877-022-00894-2. Intracranial pressure variability (ICPV) in acute brain injuries such as aneurysmal subarachnoid hemorrhage, aSAH –3 and trIn this study, we aimed to improve the understanding of the ICPV concept, by investigating the actual relation between ICPV and global cerebrovascular resistance (CVR) and cerebral blood flow (CBF) in aSAH patients with ICP monitoring and CBF imaging during neurointensive care (NIC). Our hypothesis was that higher ICPV would be associated with a lower CVR and higher CBF.Patients with aSAH, admitted to the NIC Unit, at the Uppsala University Hospital, Sweden, between 2012 and 2020, were eligible for this study. All those 147 adult (age ≥ 18 years) patients who were intubated and mechanically ventilated with ICP monitoring and had at least one Xe-CT scan CBF imaging within the first 14 days after aSAH were included in the study.Patients were treated in accordance with our standardized ICP- and cerebral perfusion pressure (CPP)-oriented treatment protocol to avoid secondary insults, as described in detail in previous studies , 13.ICP was monitored with an external ventricular drainage (EVD) system  and in a few cases with an extra intraparenchymal sensor device . Arterial blood pressure (ABP) was monitored in the radial artery at heart level. CPP was defined as the difference between mean arterial blood pressure (MAP) and ICP. Physiological data were collected at 100 Hz using the Odin software .ICPV was analyzed in three ways with different time intervals Fig. : (a) sub131Xe was administered to the breathing circuit for 4.5 min, and CT scans synchronized to the xenon inhalation were obtained. Regional CBF in 20 cortical regions of interest  of the CT image was calculated at four different levels of the brain  12 months after ictus, by trained personnel using structured telephone interviews. GOS-E ranges from death (1) to upper good recovery (8) , 27.The analysis primarily (i) aimed to determine the association of ICPV in relation to CVR and global cortical CBF.The association between ICPV and CVR and cortical CBF was evaluated in the early phase (days 1–3) and the vasospasm phase (days 4–14) using the Spearman test. For patients with multiple Xe-CT measurements in each of the two phases, only the first scan of the phase was included. Multiple linear regression analyses were performed with CVR and global cortical CBF, respectively, as the dependent variable, and ICPV-4h in addition to age, WFNS grade, ICP, and CPP as baseline variables in the vasospasm phase. The regression analyses were limited to only ICPV-4h, not the other ICPV-measures, and only in the vasospasm phase, based on the significant findings in the univariate Spearman analysis. There were only a few missing observations and those were excluded from the analyses. A p-value < 0.05 was considered statistically significant. The statistical analyses were done using SPSS version 28 .The study was approved by the Swedish Ethical Review Authority (Dnr 2020-05462). Written, informed consent was obtained during NIC from the next of kin.In this study, 147 patients were included. Twenty-seven patients had done a Xe-CT only in the early phase, 73 only in the vasospasm phase, and 47 patients in both phases . The demographic, admission variables, treatments, and outcome variables are described in detail in Table The clinical and physiological data during the Xe-CT CBF imaging in the early phase (n = 74) and the vasospasm phase n = 120) are described in Table 0 are desHigher ICPV-4h was associated with lower CVR  and higher CBF  in the vasospasm phase Table ; Fig. 3,In multiple linear regression analysis with CVR as dependent variable Table , higher The interest in physiological variability has recently increased both in general , 29 and In the current study on 147 aSAH patients with ICP monitoring and CBF imaging, we found in the vasospasm phase that higher ICPV-4h was univariately associated with higher global cortical CBF and lower CVR, and this association held true for CVR in a multiple regression analysis. These findings corroborate earlier studies from our group, i.e. that higher ICPV is generally favorable and may reflect better CBF regulation with more compliant and active cerebral vessels. ICPV-1m and ICPV-30m were not associated with CVR and CBF. We have no clear answers for these findings. One potential explanation could be that ICPV in the 4-h interval might better reflect the relatively persistent increase in CVR that is thought to occur following cerebral vasospasm in aSAH, and that ICPV in the sub-minute and 30-min intervals might reflect more brief changes in cerebrovascular reactivity.The implications of our earlier findings and the results of this study are that ICPV is an interesting variable that seems to reflect important aspects of the intracranial physiology. The ICPV measures change within a quite small range of 0–5 mmHg and it may still be difficult to use bedside considering all the factors that contribute to any change in ICPV. For example, higher ICPV in cases chiefly explained by a low intracranial compliance is likely not beneficial and could be associated with lower CPP and disturbed autoregulation. Instead, most likely, these ICPV measures may be of value as a part in multimodality monitoring to determine the probability of development of certain cerebral states such as imminent cerebral vasospasm, ischemia, and the risk of brain infarctions. Considering the complexity of analyzing such data, ICPV might be best suited as one of many variables for an integrated interpretation by an artificial intelligence systems as an aid in clinical decision-making in future NIC units.The strengths of the study was a relatively large patient population with high-resolution physiological data in combination with Xe-CT CBF imaging. The results were also consistent with previous theories and findings. There are also some limitations. The reliability of ICP wave form analysis with an open EVD has been questioned, since it may alter the ICP signal to some extent . HoweverHigher ICPV-4h was associated with a lower CVR and higher global cortical CBF in the vasospasm phase. This was consistent with our hypothesis that higher ICPV may reflect a greater variation in CBV partly due to more compliant and active cerebral vessels.Supplementary file1 (DOCX 273 kb)Supplementary file2 (DOCX 277 kb)Below is the link to the electronic supplementary material.


Bloodstream infection (BSI) is a significant cause of mortality among patients with fever of unknown origin (FUO). Inappropriate empiric antimicrobial therapy increases difficulty in BSI diagnosis and treatment. Knowing the risk of BSI at early stage may help improve clinical outcomes and reduce antibiotic overuse.We constructed a multivariate prediction model based on clinical features and serum inflammatory markers using a cohort of FUO patients over a 5-year period by Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression.Among 712 FUO patients, BSI was confirmed in 55 patients. Five independent predictors available within 24 h after admission for BSI were identified: presence of diabetes mellitus, chills, C-reactive protein level of 50–100 mg/L, procalcitonin > 0.3 ng/mL, neutrophil percentage > 75%. A predictive score incorporating these 5 variables has adequate concordance with an area under the curve of 0.85. The model showed low positive predictive value (22.6%), but excellent negative predictive value (97.4%) for predicting the risk of BSI. The risk of BSI reduced to 2.0% in FUO patients if score < 1.5.A simple tool based on 5 variables is useful for timely ruling out the individuals at low risk of BSI in FUO population.The online version contains supplementary material available at 10.1186/s12967-022-03796-8. Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae is still high .www.chictr.org.cn, ChiCTR1800020037) [Ethical approval was granted by the Institutional Review Board of Huashan Hospital, Fudan University for prospectively collecting the patient data. All the prospectively enrolled patients signed the informed consent form before data collection. This cohort study was registered at Chinese trial register 0020037) . The pri0020037)  (Additio0037 . ThAll of the enrolled patients were adults (at least 18 years of age) satisfying the criteria for classic FUO, i.e., body temperature above 38.3 °C on three or more occasions and at least 3-week duration of illness, in which no diagnosis was made after 1 week of hospital admission , 12. TheCorynebacterium species which were often associated with blood culture contamination. However, multiple positive cultures for common commensals  were considered true BSI events if the second culture occurred on the same or subsequent day [BSI was defined by positive blood cultures in a patient with systemic signs of infection, excluding bacteria such as uent day .The following clinical and laboratory data were collected, including patient demographics, clinical features, comorbidities, laboratory test results, patient outcomes, and discharge diagnoses. Invasive procedure included endoscopy, puncture, tissue biopsy, hemodialysis and acupuncture. Catheter use including urinary catheter, peripherally inserted central catheter, drainage tube, nasobiliary duct and gastric tube. Implantations included double J tubes, pacemakers, artificial joints, heart valves, artificial ossicles, coronary stents, inferior vena cava filters and fracture internal fixation devices. Corticosteroid use referred to receiving an equivalent dose of ≥ 15 mg prednisone per day; chemotherapy referred to receiving cytotoxic anti-tumor drugs to cure or alleviate cancer.The results of blood culture within 48 h of admission were also recorded and carefully evaluated. CRP and PCT  were measured for all the prospectively enrolled FUO patients within 24 h after admission per the manufacturer’s instruction. The CRP and PCT data within 24 h after admission were retrieved from the electronic case record for the retrospectively enrolled FUO patients.t-test or Mann–Whitney U-test. The categorical variables were compared between groups by Pearson’s Chi-square test or Fisher’s exact test. The difference was considered statistically significant when the two-sided p value was < 0.05.The continuous random variables were firstly evaluated by Kolmogorov–Smirnov test to verify the normality of their distribution, then compared between groups by Student The missing data for a variable were subjected to imputation when no more than 20%, otherwise, the variable was removed from the analysis. Predictive mean matching (PMM), Logistic regression, and Bayesian polytomous regression methods were used to impute the missing values for continuous, dichotomous, and categorical variables, respectively. The continuous random variables were evaluated by restricted cubic splines with four knots at the 5th, 35th, 65th, and 95th percentiles of the distributions for their possible non-monotonic relationship to the dependent variable (BSI). The variables monotonously related to BSI were converted to binary variables according to the best cutoff value. Those non-monotonously related variables were converted to multi-category variables according to the spline curve graph. Considering the relatively small number of observed events in this study, least absolute shrinkage and selection operator (LASSO) regression augmented with tenfold cross validation was adopted to minimize the potential collinearity of variables measured from the same patient and over-fitting of variables, which used the λ operator to penalize the absolute value of regression coefficients. Specifically, the larger the value of λ operator would shrink the smaller absolute value of regression coefficient to zero, leaving only the strongest predictors. For model concision, a value of λ with five predictors left for variable screening were selected for this study. The variables identified by LASSO regression analysis were subsequently entered into logistic regression. The statistically significant variables were used to construct the final predictive model.The receiver operating characteristic (ROC) curve and the corresponding area under the curve (AUC) were used to evaluate model discrimination. Hosmer–Lemeshow test was used to evaluate the model calibration. After internal validation via 1000 repetitions of Bootstrap resampling, the resulted regression model was further simplified to a scoring system according to the method previously described . CalibraOverall, 527 retrospective FUO patients and 185 prospective FUO patients were enrolled. Fifty-five cases of BSI were identified, including 48 in the retrospective cohort, and 7 in the prospective cohort. The cohort of 712 FUO patients and 55 BSI patients were used to develop the prediction model.Escherichia coli (36.3%), Streptococcus spp. (10.9%), and Klebsiella pneumoniae (10.9%)  showed non-monotonic U shape association with BSI. These variables were converted to 3-category variables for analysis  and calibration . Bootstrap simulation suggested no significant overoptimism .Each of these five independent variables was scored according to the corresponding β-coefficient of the variable. The sum of the score was calculated as the risk score of BSI for an individual patient, which ranged from 0 to 6 points Table . The risWe developed a novel practical diagnostic instrument to predict the risk of BSI in FUO patients following the TRIPOD guidance. To our knowledge, no such prediction tool has been reported specifically for the FUO patients. The scoring system consisted of five variables routinely assessed for FUO patients in clinical practice: diabetes mellitus, chills, CRP, PCT, and neutrophil percentage. These variables are readily tested or available to clinicians for calculating the risk score of BSI. The newly developed scoring tool was internally validated and showed good discrimination and calibration abilities.Previous studies have shown that the commonly used inflammatory markers such as PCT and CRP alone are not accurate enough in identifying BSI –18. PCT Some authors have used the prediction model combining risk factors and clinical manifestations with inflammatory markers to identify BSI at early stage. Su et al. developed a scoring tool to predict BSI for the patients (> 15 years of age) in the emergency department . Their sClostridioides difficile infections, and promotes the spread of antibiotic-resistant bacteria. Inappropriate antibiotic use is a common problem in FUO population. Mert et al. reviewed the records of 20 FUO patients, who finally were diagnosed as adult onset Still disease, and found that 18 of the patients received unnecessary antibiotics prescription [The unnecessary antimicrobial therapy increases the risk of adverse drug reactions and secondary cription . At prescription , 28. HowThis study has some limitations. More than 700 FUO cases were included over 5 years, but there are still few cases of BSI. The results were from a single center and have not been externally verified. Therefore, it is required to further evaluate the utility of this scoring tool in other medical institutions. Other relevant markers such as IL-6 were also used in the diagnosis of severe infections, but they were not routinely tested for FUO patients in the study center at that time, so they were not included as possible variables in the screening. The diagnostic performance of this model is unclear for the fungal BSI in FUO cases because no fungal pathogen was isolated in this study.In summary, a simple scoring system was constructed with a combination of five variables: diabetes mellitus, chills, CRP (50–100 mg/L), PCT (> 0.3 ng/mL), and neutrophil percentage (> 75%) in the cohort of 712 FUO patients. The tool is helpful for clinicians to identify the FUO patients at low risk of BSI, and so avoid inappropriate antibiotic use. The clinical utility of this scoring tool still needs to be confirmed by external validation with larger sample size.Additional file 1: Table S1. The organismsisolated from blood culture from 55 cases of bloodstream infection in the modeldevelopment cohort. Figure S1. Association betweencontinuous variables and BSI in FUO patients demonstrated by restricted cubicsplines (RCS). BSI bloodstream infection,ESR erythrocyte sedimentation rate, FUO fever of unknown origin, Nper neutrophil percentage, temp body temperature, WBC white blood cell count. FigureS2. Variables selectionusing the least absolute shrinkage and selection operator (LASSO) binarylogistic regression model. Panel A. LASSO coefficient profiles of the candidatevariables. Panel B. Tuning parameter (λ) selection in the LASSO model using tenfoldcross-validation via minimum criteria.Additional file 2. TRIPOD checklist:prediction model development and validation.


Background: Despite increased cerebral blood flow (CBF), cerebral infarcts occur in patients with sickle cell disease (SCD). This suggests increased CBF does not meet metabolic demand possibly due to compromised cerebral vasodilatory response. Hypothesis: In adult SCD patients, cerebrovascular reactivity (CVR) and speed of vasodilatory response (tau) to a standardized vasodilatory stimulus, are reduced compared to normal subjects.Methods: Functional brain imaging performed as part of routine care in adult SCD patients without known large vessel cerebral vasculopathy was reviewed retrospectively. CVR was calculated as the change in CBF measured as the blood-oxygenation-level-dependent (BOLD)-magnetic resonance imaging signal, in response to a standard vasoactive stimulus of carbon dioxide (CO2). The tau corresponding to the best fit between the convolved end-tidal partial pressures of CO2 and BOLD signal was defined as the speed of vascular response. CVR and tau were normalized using a previously generated atlas of 42 healthy controls.Results: Fifteen patients were included. CVR was reduced in grey and white matter . Tau Z-scores were lengthened in grey and white matter . Hematocrit was the only significant independent predictor of CVR on multivariable regression.Conclusion: Both measures of cerebrovascular health (CVR and tau) in SCD patients were attenuated compared to normal controls. These findings show that CVR represents a promising tool to assess disease state, stroke risk, and therapeutic efficacy of treatments in SCD and merits further investigation. Sickle cell disease (SCD) compromises cerebrovascular vascular health. By age 30, over 50% of SCD patients have suffered a cerebral infarct . In respTreatment of SCD focuses on prevention through regular blood transfusions that decrease stroke risk . However2). CVR has been used to examine the cerebrovascular health in patients with steno-occlusive disease , are reduced compared to healthy subjects. Our aim was to explore possible associations of CVR and tau with clinical and biological characteristics.We hypothesized that in adult patients with SCD, CVR and the speed of the vasodilatory response (tau)  to a staThis study conformed to the standards set by the latest revision of the Declaration of Helsinki and were approved by the Research Ethics Board of the University Health Network. Patients were participants in prospective studies in which CVR was measured. All patients provided written and informed consent for the original studies.For the manuscript preparation, we followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.We conducted a single center, retrospective, cross-sectional study.Participants were drawn for the SCD comprehensive care center at the University Health Network .Adult patients (≥18 years), with any SCD genotype were included if they had undergone functional brain imaging performed as part of routine care between 1 January 2017 and 20 November 2018. They were excluded if they had known cerebrovascular disease .Patient characteristics, biological variables and radiological findings were extracted from the electronic patient record.http://bios.ugr.es/dss-calculator/). Systolic blood pressure was recorded immediately prior to functional brain imaging.Sickle cell disease comorbidities and complications were defined as previously reported . The SCDFor laboratory variables, most recent values, within 1 year of the functional brain imaging, of hemoglobin, hematocrit, mean corpuscular volume, lactate dehydrogenase, reticulocytes, white blood cells (WBC), neutrophiles, monocytes, lymphocytes, platelets, bilirubin, fetal hemoglobin fraction (HbF), globular filtration rate (GFR) and urine protein were recorded. GFR was approximated using the Modification of Diet in Renal Disease Study equation.SCI were defined as lacunae at least 3 mm in one dimension, visualized on at least 2 planes on Fluid-attenuated inversion recovery (FLAIR) . White m2 where end-tidal partial pressures of CO2 (PETCO2) is equivalent to arterial partial pressures of CO2 PaCO2  running a prospective gas targeting algorithm , that coO2 PaCO2 . The sti3 isotropic, matrix size = 64 × 64, number of volumes = 335, field of view = 24 × 24 cm, acquisition time = 13.4 min). The acquired MRI and PETCO2 data were analyzed using Analysis of Functional NeuroImaging software   MRI. MR imaging was performed with a 3T scanner  with an 8-channel phase-array head coil and consisted of a BOLD acquisition using a gradient echo pulse sequence with echoplanar readout  . BOLD imlsewhere . CVR valc et al. .http://www.fil.ion.ucl.ac.uk/spm/software/spm12]. These masks were used to calculate mean GM and WM values for CVR and tau in each subject. For illustration purposes, only in the maps found in . Here the color scheme bundles z scores broadly into no color for values −1< x < 1 , values from 1 to 2; 2 to 3; >3 and −1 to −2; −2 to −3; −3 + to highlight gross changes.CVR and tau were normalized by calculating voxel-wise Z-scores relative to the mean and standard deviation of the same metric in the corresponding voxels of previously generated atlases of 42 age matched healthy controls that underwent the same CVR protocol (including the respiratory paradigm) as the SCD patients . The Z-vTo avoid confounding by acute medical events, such as vaso-occlusive crises, we excluded blood work that was drawn less than 3 weeks from an emergency department visit or inpatient admission.Patients were scanned within 7 days prior to the scheduled transfusion so that the results were obtained at the participants’ baseline to minimize confounding.For this proof of principle analysis, no sample size was calculated.p ≤ 0.2 were included in the multiple linear regression model. Multi-collinearity was assessed. No adjustment for multiplicity was made. Missing data was not imputed. Statistical analyses were conducted in SPSS .For binary and categorical variables, t- and F-statistic were used to test for associations with CVR metrics. For continuous variables, Pearson r coefficients were calculated. For binary and categorical variables, effect sizes are reported with the Cohen d and η2 statistics, respectively. Univariate analysis was performed to identify possible associations between CVR metrics and 19 predetermined variables chosen for their ability to predict mortality in SCD patients based on a Bayesian network analysis . These v0 and 5 (33.3%) were SC. All patients were on disease modifying therapy: 11 (73.3%) were on hydroxyurea therapy and 4 (26.7%) were on transfusion. Only 1 (6.7%) had a prior history of stroke  were male. SCD genotypes were distributed as follows: 9 (60%) were SS or Sβf stroke . The conf stroke   respectively, p = 0.01). We therefore elected to use the patient’s own resting PETCO2 rather than applying 40 mmHg uniformly across all patients.There is considerable heterogeneity in the resting P 47 mmHg . The PETMRI/MRA uncovered Moya moya in 1 patient. Ischemic lesions were distributed as follows: ischemic territory sequelae in 1 (6.7%) patient with a prior history of stroke, SCI in 3 (21.4%) and white matter hyperintensities in 7 (50.0%). Aneurysms were uncovered in 2 (13.3%) patients. Atrophy was described in 1 (6.7%) patient. Only 5 (33.3%) had none of these findings .In CVR metrics were mapped to the 6 vascular territories supplied by the left and right anterior, middle, and posterior cerebral arteries . CompareWe also computed individual patients’ regional Z-scores for CVR and tau. An example of a representative Z-map for patient 7 is shown . There wp-values ≤0.2 on univariate analysis were selected to build multivariate analysis models.We explored associations between CVR and tau Z-scores and 19 predetermined variables, both for GM and WM -6. Only p = 0.70 and t = 0.91, p = 0.38, respectively) and WM   .p = 0.03). This corresponds to a 0.68 decrease in CVR Z-score for each 0.1L/L decrease in hematocrit (p = 0.30) . In the WM, none of the biologic and clinical variables examined was significantly associated with the CVR Z-score.In the GM, CVR Z-score decreased linearly with decreasing hematocrit  . Similar9/L increase in grey matter, p = 0.05, -0.21 per 1 × 109/L increase in WM, p = 0.02). Unlike CVR however, there was no association between tau and hematocrit or hemoglobin.Increasing WBC count was consistently associated with a reduction in tau Z-score in both GM and WM (−0.19 per 1 × 10p = 0.1). Hemoglobin was not used for the model, because it was highly collinear with hematocrit. This model accounted for a majority of CVR variability in our sample . In the WM, neither age, white blood cells or hydroxyurea were independently associated with CVR in the multivariable model . This model accounted only for part of the tau variability in our sample . In the WM, tau Z-scores were also independently associated only with white blood cells, after adjustment for systolic blood pressure . This model accounted for a majority of the tau variability in our sample .With respect to tau, Z scores in the grey matter were independently associated only with white blood cells, after adjustment for systolic blood pressure  did not have overt cerebral vasculopathy . ConversRisk factors for CVR abnormality in grey and white matters appear to be distinct. The strong association of reduced GM CVR with reduction in hematrocrit, even after adjustment for potential confounders, confirms prior findings . This coThe inability to show a statistical association of hematocrit with CVR in WM and tau could be the result of the small range in hematocrit values and the relationship with CVR not being linear over the small range. We must still consider that hematocrit is not the only driver of the adaptation. WM is comprised mostly of small vessels with a small range in flows. Therefore, tau could be a more meaningful metric for WM than CVR. The longer latency in response of CVR may reflect small vessel disease. SCD has multiple risk factors for small vessel disease such as chronic inflammation, genetic fragility, sleep apnea, that were not assessed. Small vascular injury due to repeated vaso-occlusive episodes, episodes of hemodynamic instability  also has also likely accumulated over many years in the patients. The variation in clinical course may also account for variation in imaging findings between patients.The strong statistical association between white blood cell counts and WM and GM tau was an unexpected finding. This association remained statistically significant even after correcting for potential confounders such as hydroxyurea. Assuming this is not the result of a type 1 error, it would suggest that higher WBC counts, in particular neutrophils, within the normal range, are associated with reduced latency of CVR response. Perhaps the connection is through vascular adhesion, the inflammatory pathway or shared genetic determinants . This fivia production of nitric oxide by hydroxyurea . With 76 statistical tests, just by chance, assuming a type I error of 5%, we could generate up 3-4 false positive results. However, the aim of this exploratory analysis was to generate new hypotheses and we did not want to discard possible real associations on the argument of a possible false positive. Fourth, the control atlas did not include anemic individuals of other etiologies. As such, the data is not controlled for hematocrit so causation cannot be inferred. However, Tau and CVR as measures are comparable between groups. This allowed us to study the correlation with hematocrit. Fifth, we selected normal controls that were within the age range the SCD patients (34.3 ± 13.6 years). Regardless of any age differences that may exist, CVR metrics in normal subjects using our protocol are found to be stable across age groups . Lastly,ETCO2 starting from each subjects baseline PETCO2 and increased by 10 mmHg. Studies have shown that for most individuals the CBF response to PaCO2 over the PaCO2 range of resting ± 10 mmHg remains fairly in the linear range of the resulting BOLD signal  and the cerebral metabolic rate of oxygen (CMRO2). It is assumed that the fractional change in baseline CBV that contributes to the BOLD signal is small compared to that of CBF. It is also assumed that a 10 mmHg increase in CO2 does not affect CMRO2  values and targeting changes in PETCO2 relative to their resting.BOLD MRI was used as a surrogate measure for CBF which requires a number of considerations. First, the BOLD signal increases with CBF as a result of the dilution of the concentration of deoxyhemoglobin with oxyhemoglobin as the oxygen extraction fraction decreases. This in turn produces a non-linear response at very high and low flows , which iD signal . Trancref PETCO2 . Second,ct CMRO2 . Specifict CMRO2 . A finalCMRO2  and rate of responsiveness (too slow) in both grey and white matter in this cohort of adult SCD patients without known large vessel vasculopathy. The relative contributions between the chronic anemic state versus vaso-occlusion- and hemolysis-driven vasculopathy will be determined in future prospective studies with suitable anemic controls. These findings show that measuring CVR using this approach represents a promising tool to assess disease state. Whether this novel tool can predict stroke risk and therapeutic efficacy disease modifying therapeutics in SCD patients merits further investigation.


Biomarkers associated with chronic kidney disease (CKD) may play a crucial role in the early diagnosis of diabetic kidney disease. However, there have been few reports published on serum vascular endothelial cell growth factor (VEGF)-D in patients with diabetic CKD. We divided patients with diabetic CKD into two groups: CKD 3–4 and CKD 5. In total, 42 patients with diabetic kidney disease and seven healthy controls without diabetes mellitus were enrolled in this study. An observational study was conducted to evaluate the serum VEGF-D levels and other clinical parameters in each group and to assess the relationship among these factors. The serum levels of VEGF-D were higher in the CKD 3–4 group and CKD 5 group than in the control group. However, there was no significant difference in serum levels of VEGF-D between CKD stage 3–4 group and CKD stage 5 group. Correlation analysis showed that serum VEGF-D was negatively correlated with estimated glomerular filtration rate but positively correlated with serum creatinine, urine albumin-to-creatinine ratio, and urine protein-to-creatinine ratio. Serum VEGF-D was a good biomarker in receiver operating characteristic analysis and independently associated with CKD stages in multiple linear regression analysis. Circulating VEGF-D was positively correlated with blood growth/differentiation factor-15, endostatin, and chemokine (C-X-C motif) ligand 16 levels. Serum VEGF-D levels were correlated with renal dysfunction, albuminuria, and proteinuria in patients with diabetic kidney disease. Elucidation of the role of VEGF-D as a biomarker requires further study. The cardiovascular complications of diabetic kidney disease are primarily due to endothelial damage or dysfunction, including atherosclerotic changes and inflammation.Diabetes mellitus (DM) is a well-known risk factor associated with cardiovascular diseases, including cerebral infarction, myocardial disease, and congestive heart disease.,3 Diabet disease.,5 The ca Thus, serum biomarkers associated with endothelial injury may play a crucial role in the early detection of CKD progression in patients with diabetes.Serum creatinine and albuminuria are very useful markers or indicators for identifying patients at risk of CKD development, including diabetic kidney disease, and they are clinical predictors of CKD progression.,9 Thus,  It has been demonstrated that high serum levels of VEGF-D are associated with atrial fibrillation, ischemic stroke and heart failure. Recently, increased VEGF-D values have been linked to all-cause mortality in patients with coronary artery disease.Vascular endothelial growth factors (VEGFs) play important roles in the maintenance of vascular and lymphatic vascular endothelial cells under normal and pathological conditions. Vascular endothelial growth factor D (VEGF-D), a secreted glycoprotein belonging to the VEGF family, binds to vascular endothelial growth factor receptor (VEGFR)-2 and VEGFR-3. As VEGF-D binds both to VEGFR-2 and VEGFR-3, it increases angiogenesis and lymphangiogenesis through VEGFR-2 and VEGFR-3, respectively.,11 It ha failure.,13 RecenTo identify the relationship between serum VEGF-D levels and renal function, we measured the levels of serum VEGF-D in patients with diabetic CKD. We also evaluated the relationships between serum VEGF-D levels and clinical parameters including albuminuria, proteinuria, and other biomarkers related to kidney function in patients with diabetic kidney disease.22.1This was a single-center, observational study carried out at the Jeonbuk National University Hospital for patients with diabetic CKD. The study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Ethical Committee of Jeonbuk National University Hospital . Informed consent was obtained from all the subjects involved in the study.We defined type 2 diabetes as fulfilling at least one of the following criteria that was used in a previous study:1.self-reported type 2 DM;2.physician-diagnosed type 2 DM according to laboratory data;3.fasting blood glucose ≥126 mg/dL (two tests); or4.HbA1c >6.5%.2 and 15 to 29 mL/min/1.73 m2, respectively, and 14 patients with diabetic CKD stage 5 were defined as CKD-EPI eGFR < 15 mL/min/1.73 m2. In addition, diabetic kidney disease in this study was defined as a condition when patients with DM type 2 simultaneously had the following: CKD-EPI eGFR < 60 mL/min/1.73 m2 and urine albumin-to-creatinine ratio (UACR) > 30 mg/g or urine protein-to-creatinine ratio (UPCR) > 150 mg/g.To analyze the serum levels of VEGF-D in healthy people and patients with diabetic CKD stage 3 or 4 and CKD stage 5, we divided the CKD patients into two groups: CKD 3–4 stage (CKD 3-4) and CKD stage 5 (CKD 5). We enrolled a total of 49 patients, including seven controls, 28 CKD 3–4 patients, and 14 CKD 5 patients. All enrolled patients were above 20 years of age and the 7 controls had DM. Twenty-eight patients with diabetic CKD stage 3 or 4 were defined by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) based on an eGFR of 30 to 59 mL/min/1.73 m2 resulting from acute renal dysfunction due to various clinical conditions, and DM patients with eGFR > 60 mL/min/1.73 m2, showing results of UACR or UPCR, which fulfilled the diagnostic criteria for diabetic kidney disease. All enrolled patients with diabetic kidney disease were predialytic CKD patients.In this study, we excluded patients with CKD undergoing hemodialysis or peritoneal dialysis, patients with previous histories of dialysis and transplantation, diabetic CKD patients with eGFR < 60 mL/min/1.73 m2.2Blood samples (∼7 mL) were drawn from patients in the supine position to investigate serum levels of VEGF-D in patients with diabetic CKD and healthy patients. Immediately following collection and centrifugation, serum and urine samples were transported to the Biobank of Jeonbuk National University Hospital and stored at −80°C until analysis. The serum for this study was provided by the Biobank of Jeonbuk National University Hospital. The serum levels of VEGF-D, growth/differentiation factor-15 (GDF15), endostatin, and chemokine (C-X-C motif) ligand 16 (CXCL16) were measured using the Luminex 200 System  and the Human Magnetic Luminex Assay Kit .2.3Serum and urine creatinine levels were measured using the kinetic rate Jaffe method. We used the CKD-EPI creatinine equation to calculate the eGFR, considering race as “non-black.”2.4t test or Welch's t test. One-way ANOVA was performed for comparison of more than two groups. For non-normally distributed variables, the Mann–Whitney U test or Kruskal–Wallis H test was used accordingly. Post hoc analysis was performed using Bonferroni's algorithm. For categorical variables, data were expressed as sample number and percentage, N (%), and the chi-square test or Fisher's exact test was used for comparison of sample proportions as appropriate. Pearson correlation and Spearman correlation coefficients were computed to analyze the correlation between continuous variables. Predictors and outcome variables were identified and analyzed using multiple linear regression. Non-normally distributed variables were logarithmically transformed. Receiver operating characteristic (ROC) curve analysis was performed to estimate the prediction accuracy of the continuous values. The cutoff value was selected, where the summation of sensitivity and specificity was maximized. A P-value < .05 was considered as significant.R language version 3.3.3  and T&F program ver. 1.7  was used for all statistical analyses. Data are expressed as mean ± standard deviation (SD) or median (Q1–Q3 quartile) for continuous variables. When variables were normally distributed, the mean difference between two sample groups was determined using Student's 33.1The enrolled patients were divided into three groups: 28 patients with diabetic kidney disease in the CKD 3-4 group, 14 patients with diabetic kidney disease in the CKD 5 group, and 7 controls. All patients with diabetic kidney disease were predialyzed. The baseline characteristics of the 49 participants are presented in Table 3.2Serum VEGF-D levels ranged from 3 to 150 pg/mL among the subjects in this study. VEGF-D concentrations in the CKD 3–4 group or CKD 5 groups were significantly increased compared to those in the control group Table . The CKD3.3To determine whether increases in serum VEGF-D levels were associated with serum creatinine and eGFR, we performed the correlation analysis. As shown in A and B, serum VEGF-D levels were positively associated with serum creatinine levels and negatively associated with eGFR. These findings suggest that elevated VEGF-D concentrations are closely associated with changes in renal function.3.4We assessed the correlation between serum VEGF-D levels with UPCR and UACR. Correlation analysis showed that there were statistical associations between serum VEGF-D levels and UPCR and UACR (C and D).3.5P = .001). This curve shows that serum VEGF-D is an excellent biomarker for discriminating CKD from healthy subjects.The results of the ROC analyses are presented in Figure 3.6We performed multivariate linear regression to assess the relationship between a model of independent variables (predictors) and the dependent variable. The variables including stages 3 to 4 group, stage 5, age, sex, BMI, total cholesterol, cerebral infarction, and myocardial infarction were selected as independent variables of serum VEGF-D. The analysis revealed that the stages 3 to 4 group, stage 5 groups were independently associated with serum VEGF-D levels . However, in contrast with our findings, Young et al showed that serum VEGF-D levels were significantly higher in patients with lymphangioleiomyomatosis (>600 pg/mL) than in those with CKD (39–90 pg/mL).We noted both similarities and differences between our findings and those of previous studies on serum VEGF-D concentrations.,24 Simil In patients with type 2 diabetes, serum endostatin levels can be a predictive marker of kidney disease progression and mortality.It has been shown that GDF15 is related to cardiovascular disorders such as endothelial dysfunction, heart failure, and atherosclerosis in DM.,28 In paThis study did not show the exact mechanism related to increased serum levels of VEGF-D in diabetic patients with decreased renal function. This study had several limitations. The total number of enrolled patients was small. However, because there were increases in serum VEGF-D levels, we could demonstrate the use of serum VEGF-D as a predictor of CKD progression in patients with diabetic kidney disease through this clinical study. A more dedicated study with a larger number of patients could confirm serum VEGF-D as a stronger biomarker for identifying prognosis, early diagnosis, and disease progression in diabetic CKD. Our major limitation is that we did not determine whether VEGF-D is a biomarker of kidney function or diabetes. Thus, further studies to compare the level of VEGF-D in healthy controls, patients with diabetes and CKD, patients with diabetes without CKD, and CKD patients without diabetes are needed. This study was not a prospective observational study that identified changes in VEGF-D according to the decline of renal function in patients with diabetic kidney disease. Therefore, prospective observational studies are needed in the future.In this study, serum VEGF-D levels in the CKD 5 group were significantly higher than those in the control group. However, serum levels were not significantly higher than those in the CKD 3-4 group Table . Our datIn conclusion, our data suggest that serum VEGF-D is closely related to a decline in renal function, albuminuria, and proteinuria in patients with diabetic chronic kidney disease.www.editage.co.kr) for English language editing.The biospecimens and data used in this study were provided by the Biobank of Jeonbuk National University Hospital, a member of the Korea Biobank Network, which is supported by the Ministry of Health, Welfare, and Family Affairs. All samples derived from the Korea Biobank Network were obtained with informed consent under institutional review board-approved protocols. We would like to thank Editage (This paper is a result of the cooperation and contributions of all authors. Conceptualization, W.K. and J.H.J.; Methodology, W.K. and H.K.; Software, T.T.U.N. and W.K.; Validation, W.K. and H.K.; Formal Analysis, Y.J.C., T.T.U.N, H.K., and W.K.; Investigation, H.K., Y.J.C., J.H.J., and W.K.; Writing – Original Draft Preparation, Y.J.C., T.T.U.N. and H.K.; Writing – Review & Editing, T.T.U.N, H.K., and W.K.; Supervision, W.K. and J.H.J.; Project Administration, W.K.; Funding Acquisition, W.K.. All authors read and approved the final version of the manuscript.Conceptualization: Jong Hwan Jung, Won Kim.Formal analysis: Thi Thuy Uyen Nguyen, Hyeongwan Kim, Yoon Jung Chae, Won Kim.Funding acquisition: Won Kim, Jong Hwan Jung.Investigation: Yoon Jung Chae, Jong Hwan Jung, Won Kim.Methodology: Hyeongwan Kim, Won Kim.Project administration: Won Kim.Software: Thi Thuy Uyen Nguyen, Won Kim.Supervision: Jong Hwan Jung, Won Kim.Validation: Hyeongwan Kim.Writing – original draft: Thi Thuy Uyen Nguyen, Hyeongwan Kim, Yoon Jung Chae, Won Kim.Writing – review & editing: Thi Thuy Uyen Nguyen, Hyeongwan Kim, Won Kim.


The long‐term goals of asthma treatment are to achieve well control of symptoms and to minimize the future risk of asthma exacerbation. Identifying biomarkers for uncontrolled asthma is important for improving the asthma outcome. This study aimed to investigate the association of the levels of eosinophil‐derived neurotoxin (EDN) with asthma control status in specific asthma phenotype, aspirin‐exacerbated respiratory disease (AERD), and aspirin‐tolerant asthma (ATA).4) level was measured using liquid chromatography–mass spectrometry (LC‐MS)/MS methods. Asthma control status was evaluated according to the GINA guideline, asthma control test and asthma control questionnaire scores.A total of 136 adult asthmatics, including 47 asthmatics with AERD and 89 asthmatics with ATA, were enrolled. Plasma, sputum, and urine were collected at enrollment and the levels of EDN were measured by the K‐EDN ELISA kit. Urinary leukotriene E4 (LTEp < 0.001); in patients with AERD, the sputum EDN levels showed significant correlations with ACT, ACQ, and AQLQ scores , while no differences were noted in patients with ATA. Sputum EDN level was the only significant factor for ACT, ACQ, and AQLQ scores in patients with AERD  in the multivariate analysis adjusting for age, sex, peripheral eosinophil count, and urine LTE4. The ROC curve analysis demonstrated that sputum EDN can predict uncontrolled asthma with 80% sensitivity and 88.2% specificity for ACT ≤ 19 ; 71.4% sensitivity and 86.7% specificity for ACQ ≥ 1.5  only in AERD patients.In the total study subjects, sputum levels of EDN as well as of urine and plasma EDN showed significantly higher levels in patients with uncontrolled asthma than in those with well‐controlled or partly‐controlled asthma (ANOVA, The level of sputum EDN may be a potential biomarker for identifying the asthma control status in patients with AERD. AERD represents a distinct endotype with dysregulation of arachidonic acid metabolism and upregulated TIn the present study, we prospectively enrolled asthmatics with AERD and ATA that showed various asthma control status to evaluate the association of the levels of eosinophil‐derived neurotoxin (EDN) with clinical and inflammatory parameters as well as asthma control status.22.1A total of 136 patients with asthma were prospectively enrolled at Ajou University Hospital . Asthma was diagnosed according to the Global Initiative for Asthma guideline (GINA) 2022 by the allergy specialists.1)% was decreased by more than 20% after the challenge. ATA was defined when subjects showed negative results to the Lys‐ASA BPT or denied any upper or lower respiratory tract symptom changes after ingestion of NSAIDs/aspirin. Asthma control status was evaluated according to the GINA guideline,AERD was defined by a typical clinical history (recurrent exacerbation of upper or lower respiratory reactions after ingestion of NSAIDs/aspirin) and/or a positive response to the lysine‐aspirin bronchial provocation test (Lys‐ASA BPT). The Lys‐ASA BPT was performed with increasing doses of Lys‐ASA solution up to 300 mg/ml using the method previously reported.2.2At the day of enrollment, peripheral venous blood, sputum, and urine samples were collected from the subjects between 8:00 a.m. and 11:00 a.m., when the patients had maintained on controller medications. Pulmonary function test, PC20 methacholine, FeNO measurement, and questionnaires survey using the ACT, ACQ‐6 , and asthma quality of life (AQLQ[S]) were performed on the same day of enrollment. Serum total immunoglobulin E level was measured using ImmunoCAP . All subjects gave written informed consent at the time of enrollment, and the study was approved by the Institutional Review Board of Ajou University Hospital (AJIRB‐BMR‐SUR‐15‐498).2.34) were analyzed by liquid chromatography–tandem mass spectrometry. LTE4‐d5  was used as a deuterated internal standard. Chromatographic separations were performed using the Waters Acquity UPLC system (Waters) with a Hypersil GOLD column  on a concentration gradient. Data acquisition was performed using an API5500 triple quadrupole mass spectrometer  equipped with an Electrospray ionization source. For the quantitative determination of creatinine in urine samples, 10 μl of urine sample was applied to the Creatinine Parameter Assay Kit .The samples of plasma, sputum, and urine were collected at enrollment and stored at −70°C. Levels of EDN in plasma, supernatant of sputum, and urine were measured using K‐EDN kit  as previously described.2.4t test, and Pearson's chi‐squared test were used for continuous and categorical variables, respectively. Analysis of variance (ANOVA) was performed for comparisons among the three groups. Multivariate logistic regression analysis was performed to determine significant factors affecting asthma control status. A receiver operating characteristic (ROC) curve analysis was performed to determine whether the EDN level help detect UA. All computations were performed using Statistical Package for the Social Sciences software, version 22.0 . GraphPad Prism 5.0 software  was used for the production of graphs.Student's 33.1p = 0.013). The number of atopic patients were higher in ATA patients (p = 0.004). There were no other significant differences between patients with AERD and ATA.A total of 47 patients with AERD and 89 patients with ATA were enrolled. Table p = 0.002 and p = 0.049). The sputum and plasma levels of EDN were significantly higher in the UA group than in the others (p = 0.046 and p = 0.006). The urine and plasma levels of EDN were significantly lower in the CA group than in the others (p = 0.030 and p = 0.041) , while no differences were noted in the urine and plasma levels of EDN. The levels of sputum EDN were significantly higher in AERD patients with UA than in those with CA or PA . Patients with ATA showed no differences in the levels of EDN according to asthma control status by the GINA guideline.In patients with AERD, sputum levels of EDN showed significant difference among the CA, PA, and UA groups . In patients with AERD, sputum EDN levels showed significant correlations with ACT, ACQ, and AQLQ scores , while no correlations were found in patients with ATA , sputum EDN levels showed significant correlations with ACT, ACQ, and AQLQ scores  in patients with AERD, while no correlations were found in patients with ATA.In subgroup analysis of eosinophilic asthma  ratio in asthmatic subjects, especially in patients with AERD , but not in those with ATA. In addition, urine, and plasma levels of EDN were significantly correlated with FEV1/FVC ratio in asthmatic subjects. However, ATA patients had no correlations between the levels of urine/plasma EDN and pulmonary function test results , SEC , and FeNO values  in asthmatic subjects.The EDN levels showed positive correlations with PEC , and urine LTE4 levels showed significant correlations with all types of EDN  in asthmatic subjects. Table 4 and EDN levels in asthmatics with AERD and ATA patients.LTE3.5p = 0.042, Exp 〔B〕 = 1.002〔1.000068 − 1.004〕, p = 0.017, Exp 〔B〕 = 1.001〔1.0002 − 1.002〕, respectively) in asthmatic subjects. Sputum EDN level was the only significant factor for ACQ and AQLQ scores  in asthmatic subjects; for ACT, ACQ, and AQLQ scores  in patients with AERD. Urine and plasma EDN levels showed no significant associations. The levels of PEC, SEC, urine LTE4, or FeNO were not a significant factor for ACT, ACQ, or AQLQ scores. All of these factors showed no statistical significances with asthma control status in patients with ATA.In the univariate analysis, PEC and sputum EDN level were significant factors for UA defined by the GINA guideline  in asthmatic subjects. Table 4. Sputum EDN level was the significant factor for ACQ and AQLQ scores in asthmatic subjects , and for ACT, ACQ, and AQLQ scores in patients with AERD , while no associations were observed in those with ATA.In the multivariate analysis adjusting for age, sex, PEC, and urine LTEp < 0.001 for all, Exp 〔B〕 = 0.998〔0.998 − 0.999〕, 1.004〔1.003 − 1.005〕, and 0.975〔0.971 − 0.980〕, respectively), while no associations were found in those with ATA.In subgroup analysis of eosinophilic asthma, sputum EDN levels were significantly associated with ACT, ACQ, and AQLQ scores in patients with AERD (p = 0.019), 71.4% sensitivity and 86.7% specificity for ACQ ≥ 1.5  in AERD patients, but not in ATA patients. The levels of PEC did not reach statistical significance for UA in ROC curve analysis.The ROC curve analysis demonstrated that sputum EDN can predict UA with 80% sensitivity and 88.2% specificity for ACT ≤ 19  and EDN levels. The present study aimed to investigate these associations according to specific asthma phenotype, comparing between AERD and ATA patients. LTE4 overproduction and type 2/eosinophilic airway inflammation are a major inflammatory pathway to present the phenotype of AERD. As early steps of this mechanism, epithelium‐derived cytokines, such as thymic stromal lymphopoietin, interleukin‐25, and interleukin‐33, activate mast cells and eosinophils and then leads to release cysteinyl leukotrienes.4 has been extensively studied as a reproducible biomarker determining the phenotype of AERD and reported to be elevated in patients with uncontrolled AERD.4. In the multivariate analysis sputum EDN remained as the only significant factor for poor asthma control in AERD patients. These results were consistently found, regardless of the outcome parameter used for the assessment of asthma control status including ACT, ACQ, or AQLQ scores. Several kinds of specimens have been used to analyze the levels of eosinophil degranulation products in asthma; however, there is no definite consensus on which sample is the most suitable to predict asthma control status. In the present study, EDN levels in sputum samples showed better predictability for UA, suggesting that EDN levels found in airway secretions (target tissues of asthma) may better predict airway inflammation and clinical outcome (asthma control status). The potential clinical implication of this observation warrants further studies.Eosinophils contain potent granule proteins including EDN, eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and the major basic protein (MBP).Meanwhile, we could not find statistical significance of PEC, SEC, or FeNO levels for predicting poor asthma control in the multivariate analysis. This is in agreement with the previous studies that showed better performance of EDN level to assess asthma control status than PEC.1% in patients with SA.As AERD is not fully understood by enhanced production of type 2 cytokines or cysteinyl leukotrienes, novel molecules related to activated eosinophils have been proposed to be implicated in AERD pathogenesis.RAB1A gene were associated with the risk of AERD and a greater decline in FEV1% after aspirin challenges.STX2, and RAB3B, were up‐regulated in patients with AERD. These genetic studies have demonstrated that degranulation‐related genes are strongly associated with the risk of AERD. These findings support significant correlations between the EDN levels and asthma control status/the degree of airflow limitation in AERD patients, not in ATA patients. In addition, when the predictability of EDN levels for UA was compared between the AERD and ATA groups, good predictability was noted in the AERD group. These findings may be explained by previous genetic studies on close associations between degranulation‐related genes and the risk of AERD. Collectively, it is suggested that EDN may be closely associated with a specific phenotype of asthma and serves as a good phenotypic biomarker of UA in patients with AERD.In addition, specific polymorphisms in the This is a cross‐sectional study; therefore, further studies with a longitudinal follow‐up study design are needed to assess the change and variability of EDN levels in AERD patients. The number of study subjects enrolled in the present study is small. Further studies with a larger sample size are needed to completely evaluate associations between EDN levels and asthma control status. Previous studies have implicated that genes associated with degranulation process may cause the increased levels of EDN in AERD patients with uncontrolled status; however, further functional studies on direct relationships among EDN, degranulation pathway, and clinical outcome are warranted in AERD patients.In conclusion, the sputum EDN level may be a potential biomarker for identifying the asthma control status in patients with AERD, regardless of anti‐asthmatic medications.Ga‐Young Ban: data curation (lead); formal analysis (lead); investigation ; methodology ; project administration ; resources ; software ; validation ; visualization (lead); writing – original draft (lead). Eun‐Mi Yang: data curation (lead); formal analysis ; investigation ; methodology (lead); resources (lead); software (lead). Young‐Min Ye: conceptualization ; data curation ; project administration ; supervision (lead); writing – review and editing (lead). Hae‐Sim Park: conceptualization ; funding acquisition (lead); investigation (lead); methodology (lead); project administration (lead); supervision (lead); validation ; writing – review and editing (lead)The authors declare that they have no relevant conflicts of interest.


Introduction: Hypertension (HTN) is an independent risk factor for heart disease, stroke, and premature death. In 2017 there was a shift in the definition of HTN by the American College of Cardiology (ACC), as well as the American Heart Association (ACC/AHA), resulting in lower blood pressure (BP) readings meeting criteria for diagnosis. Our study aimed to explore the impact the change had on a single cardiology practice’s management of patients with HTN.Methods: We performed a retrospective chart review of a single cardiology practice. We separated the time into two categories: 12 months before and 12 months after the reclassification of HTN categories in November 2017. A paired t-test analysis was done comparing averaged blood pressures (BPs) in each of the two time periods, as well as the number of medications in each time period and several subgroup analyses.Results: A total of 441 patients were included in the final analysis. Patients were prescribed an average of 2.61 ± 1.20 medications at baseline, and 2.74 ± 1.22 medications post-reclassification (p < 0.0001). There was an average of 0.82 ± 1.28 medication changes per patient. The overall average BP was 133.7 ± 14.1/76.4 ± 9.5 at baseline, and 131.3 ± 13.1/76.7 ± 7.7 after the recategorization .Conclusion: The change in definition of HTN significantly impacted this single cardiology practice. There was a statistically significant increase in antihypertensive medications prescribed with an expected decrease in BP observed in this study. Hypertension (HTN) is an independent risk factor for heart disease, stroke, and premature death. In 2010, HTN was the leading cause of death and disability-adjusted life years worldwide .The American College of Cardiology (ACC), as well as the American Heart Association (AHA), have provided strong evidence-based guidelines to improve cardiovascular health since 1980. In 2017, the ACC and AHA released updated HTN guidelines to replace the Joint National Commission’s (JNC) VIII guidelines. These guidelines recommended new categorization of patients’ BP. This categorization differs from previous recommendations made in the JNC 7 report, with stage 1 HTN now defined as a systolic blood pressure (SBP) of 130-139 or a diastolic blood pressure (DBP) of 80-89 mm Hg, and with stage 2 HTN in the present document defined as SBP greater than 140 mmHg or a DBP greater than 90 mmHg . All patients were included if they were at least 18 years of age, had essential HTN, and had at least two visits in each of the two time periods (before and after the release of the updated guidelines). Patients were excluded if they did not have at least two visits in either time period.Blood pressure readings were averaged in each time period. The averages were then compared and overall change relative to guideline release was calculated. In addition to BP readings at each visit, the number and class of each medication were assessed. Furthermore, the numbers of medication changes were included. We accounted for both adjustments in dosage, as well as change in/additional class of medication. A paired t-test analysis was done comparing averaged BPs in each of the two time periods, as well as the number of medications in each time period. Subgroup analysis was also done based on whether a patient’s baseline BP was controlled. Further analysis was performed on the basis of number of medication changes that occurred during the post-guideline release time period. Medication changes were considered to be present if there was a dose adjustment, addition or subtraction of a medication class. A total of 898 patients were initially screened. There were 441 patients who met the inclusion criteria and were included in the final analysis. The average age of the patients was 70.4 ± 11.8 years old. 41.7% of the included patients were female. Patients were on an average of 2.61 ± 1.20 medications at baseline, and 2.74 ± 1.22medications post-guidelines (p < 0.0001). A total of 10 patients were not on any BP medications at baseline, while only four patients were not on medications after the guidelines were released. However, after excluding patients who had well controlled BP at baseline (as defined by the new guidelines), only six patients were not on medications at baseline, and all of them were placed on a medication following the release of the guidelines. The overall average SBP was 133.7 ± 14.1 at baseline, and 131.3 ± 13.1after the guideline release (p < 0.0001) , thiazide diuretics, and angiotensin receptor blockers (ARBs). Patients were on an average of 2.59 ± 0.99 medications in the post-guideline time period. There were an average of 0.96 ± 1.29 medication changes overall in this group. Of these, 0.45 ± 0.83 were due to medication dose adjustment, 0.36 ± 0.59 were due to addition of a new medication class, and 0.20 ± 0.51 were due to removal of a medication class.There were 128 (45.9%) of the above 279 patients who did not have any medications changed throughout the study time period. They had an average blood pressure of 139.5 ± 12.3/79.8 ± 8.45 at baseline pre-guidelines and 133.7±11.7/78.4±7.45 in the post-guideline period (Δ -5.78 (95% CI 3.70-7.86)/-1.33 (95% CI 0.08-2.58); p<0.0001 for systolic blood pressure and p = 0.0366 for diastolic blood pressure)  had one medication change during the study period. The average BP of this group was 140.6 ± 10.9/79.7 ± 9.76 at baseline and 134.3 ± 11.9/77.9 ± 8.43 in the post-guideline period . By the end of the study period, patients were taking an average of 2.69 ± 1.23 medications each (Table Thirty-four 12.2%) of the 279 patients with elevated BP at baseline had two medication changes during the study period. The average BP of this group was 142.8 ± 11.3/78.5 ± 10.7 at baseline and 135.6 ± 13.5/77.0 ± 7.13 in the post-guideline period . After one year of the guidelines being released, patients were on an average of 2.62 ± 1.28 medications (Table .2% of thThere were 27 (9.7%) of the 279 above patients with at least three and as many as seven medication changes during the follow-up period. The average BP of this group was 145.9 ± 13.8/80.2 ± 9.28 at baseline and 142.5 ± 15.2/78.9 ± 10.1 in the post-guideline period . After one year post-guideline release, patients were taking an average of 3.63 ± 1.04 medications each. When comparing this to the group that had no medication changes, this group did have significantly greater number of medications with p<0.0001. This was also true when comparing against the group with one or two medication changes . There was also a statistically significant increase in medications prescribed from the pre-guideline to the post-guideline release time frames. A number of the patients included in this analysis had relatively well-controlled BP at baseline, with SBP less than 130 mmHg and DBP less than 80 mmHg. As a result, we performed a subgroup analysis of all of the patients who had BP above these parameters to assess the impact on their BP control. This revealed a much more meaningful decrease in both SBP and DBP as compared with the overall aggregate group of patients.  In addition to the emphasis on medication management, the updated ACC-AHA HTN guidelines also stressed the importance of lifestyle changes in BP control. Our study indirectly confirms the impact this can make on improving SBP. This is highlighted by the fact that 128 patients had no medication changes, yet they still had a statistically significant decrease in both SBP and DBP.  We did find that with each additional medication change, there was a trend for a greater effect seen on BP control. This was true only up until three medication changes were done, however. There are several possibilities as to why this was the case. Firstly, the group with greater than three medication changes was limited by a small number of patients and may not carry enough statistical weight to show a true correlation. Another possibility is that these patients had a greater level of resistant HTN. This is supported by the fact that they were on a significantly greater number of medications (3.63 medications on average) and yet still had poorer BP control. Yet another potential explanation is that there may be a greater degree of medication non-adherence in this group.  For the overall population of patients screened, as well as the groups with two medications changed or greater than three medications changed, DBP improvement was not statistically significant. As previously mentioned, the study population was relatively older (70.4 + 11.8 years old) and is thus more likely to have isolated systolic HTN. This was indeed the case in our study population, with every subgroup having mildly elevated SBP, while DBP was at target. The pathophysiology behind this is related to loss of arterial wall compliance and stiffening of arterial walls with age. This in turn leads to increased cardiovascular risk . One interesting finding was the predilection for beta-blockers over other antihypertensive agents. This can likely be explained by the fact that the population studied was from a cardiology practice and thus has a much higher likelihood of comorbidities such as atherosclerotic CVD or heart failure, and thus an indication for beta-blockers over other medications. Our study is limited by the fact that it was done in a retrospective fashion, as well as by the relatively small numbers in the subgroup analyses. Another limitation is the fact that this is based on a single cardiology practice, which may reduce generalizability. The 2017 ACC-AHA guidelines for management of HTN did significantly impact this single cardiology practice evidenced by a significant reduction in BP. There were increases in medications prescribed in order to meet the standards set by the new HTN guidelines.


Objectives: Determine the changes in clinical, pharmacological and healthcare resource use parameters, between the 6 months prior to the lockdown and the 6 months following its end, in a population with hypertension who did not have a diagnosis of COVID-19.Methods: Real world data observational study of 245,979 persons aged >16 years with hypertension in Aragon (Spain). Clinical , blood creatinine, cholesterol, triglycerides and anthropometric measures); pharmacological ; and utilization of healthcare resources were considered. We performed the Student’s T-test for matched samples (quantitative) and the Chi-squared test  to analyze differences between periods.Results: SBP, DBP, parameters of renal function and triglycerides displayed a significant, albeit clinically irrelevant, worsening in women. In men only DBP and eGFR showed a worsening, although to a lesser extent than in women. Certain antihypertensive drugs and health-resource utilization remained below pre-pandemic levels across the 6 months post-lockdown.Conclusion: Changes in lifestyles, along with difficulties in access to routine care has not substantially compromised the health and quality of life of patients with hypertension. Cardiovascular diseases are the leading cause of morbidity and mortality globally, and in 2019 accounted for 17.9 million deaths, almost one third of the sum total .AHT is one of the most prevalent chronic diseases, affecting over one billion persons worldwide . In SpaiA number of chronic conditions, including AHT , have beGood management and control of blood pressure during the pandemic is fundamental to reduce both the burden of this disease, and any ensuing cardiovascular complications and worse prognosis among infected patients . Prior tFurthermore, AHT is strongly influenced by virus control measures . On 15 MThe implications of COVID-19 therefore go beyond the harm related with the infection itself. Less rigorous control of blood pressure, coupled with the adoption of unhealthy lifestyles during strict lockdown, could increase the likelihood of suffering some complication or cardiovascular event, something that would translate as an increase in the burden of these diseases in the medium term.The great majority of studies on AHT and COVID-19 have investigated the influence exerted by this disease on the prognosis of infected patients –10, as wn = 1,122,151). To ascertain the repercussions of lockdown measures on the health of the population with hypertension , we decided to include only those patients >16 whose EMR showed diagnosis of AHT as per the International Classification of Diseases 10th Revision  and other parameters, in accordance with the following formula:Taking into account the Anatomical Therapeutic Chemical (ATC) Classification System, we analyzed the following codes of the drugs of choice for treatment of this disease, as indicated by the Spanish Society for Family and Community Medicine (Sociedad Española de Medicina de Familia y Comunitaria – semFYC –) : CO3  visits for routine or continued care, at the health center or home; and number of patients and number of visits to other health center professionals, such as social workers, physiotherapists or midwives) and specialized services , and duration of such stays), for each of the periods covered.Owing to the large sample size, parametric tests were used for analysis purposes . We perfFor the clinical variables we calculated the mean and standard deviation (SD) of the parameters for each of the study time points (pre-lockdown and post-lockdown) by sex. If there was more than one measurement of the same parameter for the same individual, the median and interquartile range (IQR) were calculated. To compare differences in means between the baseline measurement and the measurement at 6 months post-lockdown, we used the Student’s T-test for matched samples.To determine variations in clinical parameters, the proportion of people who had maintained, worsened or improved their BP values were calculated. People who had remained stable were defined as those who: 1) before and after lockdown presented values in range (I-I) or 2) before and after lockdown presented values out of range (O-O). Those who presented values in range before lockdown and after it presented values out of range were considered as worsening (I-O). Lastly, we considered as improvements those who had values out of range before lockdown and values in range after lockdown (O-I). Values greater than 140 and 90 mmHg for systolic and diastolic blood pressure, respectively, were considered out of range.We use Chi-squared test for calculate the proportion of people who had maintained, worsened or improved by sex.To ascertain variations in drug use, we calculated the DHD of the study population for each period, and transformed it into its annual equivalent.To compares differences in the utilization of healthcare resources, we used the Student’s T-test for matched samples in the case of quantitative variables, and the Chi-squared test in the case of qualitative variables. For those variables with less than 100 observations, a Wilcoxon rank test was used.Six months after the end of strict lockdown in Aragon, a total of 245,979 persons over the age of 16 years with diagnosis of AHT in their EMR did not have a diagnosis of COVID-19 during the study period.The descriptive analysis showed that: 52.1% of the population were women, mean age 70 years (SD: 13.6); over two thirds (68.1%) had an income of under 18,000 euros per year, and a little over half (51%) lived in urban areas. 95.2% of patients with AHT presented with some associated comorbidity, with the category of three related comorbidities being the one that embraced the highest number of individuals (17.9%). Among the chronic comorbidities, the most prevalent were dyslipidemias (53.6%), dorsopathies (30.6%), anxiety and depression (29.2%), neoplasms (28%), and diabetes (23.3%) .Of the 259,808 patients older than 16 years with a diagnosis of hypertension 13,829 were not included in the study. 4,485 because they had a diagnosis of COVID-19 during the study period and 9,344 because they died. Of these 4,352 died in the 6 months preceding the declaration of the state of emergency (14 September 2019 through 15 March 2020), and a further 4,992 in the 6 months following the end of lockdown (03 May 2020 through 04 November 2020). Taking into account the Aragon population in the middle of the period in each of the two measurement moments, the mortality rate per 1000 individuals was 3.3 (95%CI 3.2–3.4) and 3.7 (95%CI 3.6–3.9), respectively.p < 0.001 (95%CI: −0.69 to −0.37)], DBP [p < 0.001 (95%CI: −0.78 to −0.59)], eGFR [p < 0.001 (95%CI: 1.62–2.35)] blood creatinine [p < 0.001 (95%CI: −0.04 to −0.03)] and triglycerides [p 0.016 (95%CI: −4.64 to −0.48)] showed a slight, though significant, worsening with respect to the baseline measurement. In men only DBP [p 0.010 (95%CI: −0.24 to −0.03)] and eGFR [p < 0.001 (95%CI 0.83–1.64)] showed a worsening, although to a lesser extent than in women. For the rest of variables  both sexes appeared to undergo a slight but equally significant (p < 0.001) improvement. The same trend was observed in HDL only in women [p < 0.001 (95%CI: 0.52 – 1.11)] and in triglycerides in men [p 0.001 (95%CI 2.19 – 7.95)].Changes in clinical parameters observed on comparing the baseline measurement with the measurement in the 6 months post-lockdown by sex, can be seen in Number and percentage of women and men with a stable evolution, deterioration or improvement in clinical parameters at 6 months is shown in With respect to drug use , in the p < 0.001). Only the number of patients who received home nursing visits (routine care) rose in comparison with the previous 6 months (p < 0.001).In terms of health-resource utilization, as p < 0.05), a decrease that was only significant in terms of the number of home nursing visits made to provide continued care . With respect to the number of visits to other health center professionals, these fell solely in the case of physiotherapists , and rose in the case of midwives  and social workers .p < 0.001, 95%CI: −0.08 to −0.02), while the number of control visits to these same services fell across the same period .When it came to the number of visits to specialized care, opposite but statistically significant trends were in evidence. Among patients with AHT, the number of first visits to specialized care rose in the 6 months after the end of lockdown (p < 0.05).In comparison with the previous 6 months, the number of X-rays, ultrasound, blood count, biochemistry, immunology and urine tests decreased among patients with AHT. In contrast, the number of resonances, CAT scans, microbiology and coagulation tests increased among these patients in the 6 months after the end of lockdown, with all these variations being statistically significant  and the number of hospitalizations  also decreased, with no statistically significant differences being found between the number of ICU admissions and the duration of hospital stay.Lastly, the number of visits to emergency services  , 34. SomThe nationwide lockdown imposed by the government to halt the propagation of the novel virus, has had an important impact, not only on people’s psychological wellbeing, but also on their lifestyles and daily routines , 39. TheControl and follow-up of patients with hypertension after the introduction of drug treatment was already inadequate well before the pandemic, according to some studies , 46. TheWith respect to use of antihypertensive drugs in the 6 months following the end of lockdown, the reduction observed in the total number of DHD dispensed at pharmacies might be partly accounted for by difficulties in access to drug treatments, especially during the first wave . FurtherSix months after the end of lockdown, PC services continue to receive fewer patients with hypertension than they did in the previous 6 months. Only those patients who received a home visit by their nurse (routine care) experienced an increase in the following 6 months. Fear of becoming infected and a possible worse prognosis, or the collateral effects of lockdown on the health status of older patients with hypertension may have hindered or prevented them from visiting the health center .Similarly, 6 months after the end of strict lockdown, the number of visits to healthcare services  and the performance of diagnostic tests on patients with hypertension, have still not reached pre-pandemic levels. These results are consistent with those published by the WHO in its survey of national capacity for the prevention and control of non-transmissible diseases, in which 53% of the countries surveyed reported total or partial interruptions in hypertension-management services as a consequence of the pandemic .With reference to the number of visits to other health center professionals, other studies , 54, sugAs regards the increase in observed mortality in the second 6 months of the study period, the interruption in healthcare services for cardiovascular diseases during the pandemic could have delayed referral, diagnosis, and treatment of these diseases, thus contributing to the excess deaths .Our study has some limitations. First, its large sample size means that small variations in these parameters may prove statistically significant.Second, it is not known whether measurement of BP was exclusively made during nursing visits or whether, in contrast, it was combined with arterial self-measured blood pressure (SMBP) monitoring, something that would allow for a more accurate diagnosis to be made.Thirdly, we only know the number of patients without a diagnosis of COVID-19, which is different from the number of patients without the disease . Moreover, in the case of some clinical variables, there are very few records. To be able to access these, a GP must validate the data. What this means in the context of this study is that we only had access to measurements which had been validated by GPs.Furthermore, our study did not include self-reported data on the lifestyles  followed by the population with hypertension during the months of lockdown. Hence, undertaking studies which included qualitative data and information on lifestyles would make it possible to better ascertain the effect of lockdown on the maintenance of daily routines and control of hypertension.Lastly, it would be of interest to ascertain the trend in the clinical parameters of this disease over a longer period of time .This study contributes, from a longitudinal standpoint, to knowledge of the consequences of lockdown on a sample of patients with AHT but without a diagnosis of COVID-19 infection, by simultaneously considering clinical, pharmacological, and health-resource utilization variables.The results of our study suggest that the COVID-19 pandemic has hindered access to routine care by patients with chronic diseases such as hypertension. However, the cancellation of medical visits and tests, coupled with changes in lifestyles induced by the pandemic, has not substantially compromised the health and quality of life of these patients.


The association between oral dysbiosis and chronic kidney disease (CKD) has gained increasing attention in recent years. Diabetes and hypertension are the most common conditions in CKD. However, a case–control study with matched confounding variables on the salivary microbiome in CKD and the influence of diabetes and hypertension on the microbiome has never been reported.In our study, we compared the salivary microbiome profile between patients with CKD and healthy controls (HC) using 16S ribosomal DNA sequencing and examine its association with diabetes, hypertension, and immunity.Lautropia and Pseudomonas, and decreased Actinomyces, Prevotella, Prevotella 7, and Trichococcus. No difference in the bacterial community between the CKD patients complicated with and without diabetes, and between those with and without hypertension. Prevotella 7 declined in CKD patients with/without hypertension with respect to HC, while Pseudomonas increased in CKD patients with/without hypertension. Pseudomonas was negatively associated with immunoglobin G in CKD patients. Both CKD patients with positive and negative antistreptolysin O had declined Prevotella 7 and Trichococcus compared to HC, whereas increased Pseudomonas.We observed that the bacterial community was skewed in the saliva of CKD, with increased Our study identifies a distinct bacterial saliva microbiome in CKD patients characterized by alteration in composition. We unravel here that the co-occurrence diseases of diabetes and hypertension are not associated with specific bacterial alterations, suggesting that bacterial dysbiosis in saliva plays a role in renal damage regardless of the occurrence of diabetes and hypertension.The online version contains supplementary material available at 10.1186/s12967-022-03602-5. Neisseria accompanied by depletion of Veillonella and Streptococcus in CKD patients , urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, and structural abnormalities detected by imaging [2, current illness including diabetes and hypertension, and acute or chronic infections, were excluded from the HC group.This study was approved by the Institutional Review Board of Wuxi Second Hospital of Nanjing Medical University Ref. 2018051). All participants gave written informed consent before participation, and the study was carried out in accordance with the ethical standards in the Declaration of Helsinki. The inclusion criteria for the groups of CKD and HC were as follows: To be a participant,  ≥ 18 years, no antibiotic use for  ≥ 1 month before sampling, without acute intercurrent disease and infections/diarrhea/kidney transplantation/pregnancy/breastfeeding, have not been administered medications such as antibiotics/probiotic/immunosuppression within 1 month before enrollment. The diagnosis of CKD was based on the criteria: either kidney damage or Egfr  < 60 ml/min/1.73 m imaging . Kidney 18051. AlWe collected demographic and health status information through face-to-face interviews and medical review. Fasting blood glucose, HbA1c, and blood pressure were assessed on the day of recruitment. An immunoturbidimetric test was used to assess serum immunological parameters on the day of sample collection by Freelite test .To investigate the influence of co-occurrence of diabetes and hypertension in CKD on the salivary microbiome, we divided the CKD patients into subgroups of diabetic CKD (DM-CKD) and non-diabetic CKD (nonDM-CKD), and subgroups of hypertensive CKD (HTN-CKD) and non-hypertensive CKD (nonHTN-CKD).https://github.com/picrust/picrust2) to predict functional gene abundance with Kyoto Encyclopedia of Genes and Genomes (KEGG) orthologs.1 mL saliva was collected into an RNA-free sterile container after the participants refrained from eating, drinking, smoking, and brushing at least 1 h before saliva collection. The samples were added to 500 μL lysis buffer and stored at −80 ℃ until DNA isolation. The procedures of DNA extraction, 16S rRNA quantitative PCR, qualitative 16S targeted metagenomic sequencing, and bioinformatic analysis are described in our previous study . In addit-tests and categorical variables using Chi-square or Fisher’s exact tests, when appropriate. One-way analysis of variance was employed to compare quantitative variables among the number of groups  ≥ 3. The Wilcoxon rank-sum test/Kruskal–Wallis one-way test was applied to compare bacterial diversity and the relative abundance of bacterial taxa  between/among groups, and a Benjamini Hochberg false discovery rate (FDR)-corrected P-value was calculated for comparative tests. A P < 0.05 was used as a cut-off for comparative statistical tests. SPSS (v. 24.0) was used to compare the demographics between/among groups.Descriptive statistics for demographics and clinical and immunological parameters of groups are presented. To compare demographics and clinical characteristics between the groups, continuous variables were assessed using independent P < 0.05 was used as a significant cut-off correlation analysis. For categorical variables, such as anti-streptolysin O (ASO), we separated the CKD patients into subgroups of ASO positive CKD samples (ASOPOS-CKD) and ASO negative samples (ASONEG-CKD), and compared the bacterial microbiome among the groups of ASOPOS-CKD, ASONEG-CKD, and HC.Next, we examined associations between the bacterial genus that exhibited a significant difference between the groups of CKD and HC and the levels of serum immunological profiles. For continuous variables, we used Pearson analysis, and a P < 0.05). Also, the patient group had increased levels of serum C-reactive protein, κ FLC, and λ, FLC (P < 0.05), and decreased levels of C3 and C4. Among the CKD patients, ASOPOS subjects accounted for 58%  level.P < 0.05; Fig. P > 0.05; Fig. PCoA for the significantly differential ASVs indicated that the bacterial community in CKD patients’ saliva was different from that in the HC group (Streptococcus (30.50% in CKD and 28.45% in HC). Firmicutes was followed by Proteobacteria (26.61% in CKD and 22.40% in HC), and its bacterial genus such as Neisseria was accounted as the second most abundant bacteria in both CKD and HC . Actinobacteria exhibited a decline in the CKD group (10.77%) compared to HC (13.77%). Also, Rothia, a bacterial genus belonging to Actinobacteria, showed a decreasing trend in the CKD (6.99%) relative to HC (8.37%).As Fig. When the bacterial phylum was compared between the groups of CKD and HC. Significantly decreased abundances of Actinobacteria and Bacteroidetes were observed in CKD group, whereas Proteobacteria increased in CKD  antibody was negatively associated with the abundance of Pseudomonas. IgG is a major component of humoral immunity [Pseudomonas indicates that the salivary microbiome plays a role in regulating CKD patients’ immunity.The enrichment of immunity . Accordiimmunity . The negLautropia increased in CKD patients. Enrichment of salivary Lautropia might indicate an unhealthy state in the human oral cavity, as several previous studies demonstrated that Lautropia increased in various diseases. For example, Yu F and his group reported that oral lichen planus patients with erosive lesions had a higher level of Lautropia than those without erosive lesions and healthy subjects [Lautropia can be listed as a diagnostic biomarker for patients with Barrett’s esophagus [Lautropia could be used for the diagnosis of hepatitis B patients [We observed that subjects . Snider sophagus . Also, Lpatients .Trichococcus in CKD patients might be associated with an unhealthy state in the oral cavity. A previous study also demonstrated a decrease of Trichococcus in pediatric patients with obstructive sleep apnea [Trichococcus using animal models is necessary.The depletion of ep apnea . A furthWhen comparing the metabolic pathway data of the salivary microbiome, we found several metabolic pathways were associated with CKD. The upregulation of the pathway of lipid metabolism is inconsistent with a previous oral study on CKD patients , while tPseudomonas as a biomarker of CKD in saliva suggests that we should make detailed investigations in clinical settings.Like previous studies on the human salivary microbiome, 5, our Although therapeutic interventions aimed at restoring bacterial flora in the saliva in CKD patients may be future targets, current salivary microbiome study in a single-center is limited, necessitating further research. Further multi-center studies correlating the salivary microbiome with the gut microbiome, intestinal permeability markers, inflammatory markers, epigenetic factors, and various etiologies of CKD are needed to better interpret the salivary microbiome as a potential diagnostic biomarker and to investigate the diagnostic value and therapeutic effect in CKD patients. When the diagnostic value is confirmed by several large and multi-center studies, salivary microbiome transplantation should be investigated to replace the treatment option of fecal microbiome transplantation for CKD. As saliva is more easily collected using sterile collection tubes from healthy donors comparing to fecal samples.Our present study has some limitations. First, only local community participants were involved in this study. Human microbiome studies demonstrated that sampling a broad population of humans representing different cultural traditions offers an opportunity to discover how our microbiomes vary between populations . Thus, mIn our study, we identified a distinct bacterial saliva microbiome in CKD patients characterized by alteration in composition. Meanwhile, we unravel here that the co-occurrence diseases of diabetes and hypertension are not associated with specific bacterial alterations, suggesting that bacterial dysbiosis in saliva plays a role in renal damage regardless of the occurrence of diabetes and hypertension.Additional file 1:Table S1. Characteristics of groups of DM-CKD, nonDM-CKD and HC.Additional file 2:Table S2. Characteristics of groups of HTN-CKD, nonHTN-CKD and HCAdditional file 3:Table S3. Characteristics of groups of ASOPOS-CKD, ASONEG-CKD and HC