Background. In Indonesia, hypertension treatment relies on primary health care services, and there are no current data on blood pressure control and hypertension treatment in Indonesia’s primary health care system.Methods. We conducted a cross-sectional study including all patients with hypertension (n = 273) who visited the Tegal Alur II Community Health Center in 2017. For all patients with hypertension, medical records containing the most recent blood pressure results and antihypertensive treatments were examined by the authors. The primary outcome in this study was optimal blood pressure control according to the Joint National Committee (JNC) VII guidelines.p = 0.022).Results. The mean systolic and diastolic blood pressures were 143.7 mmHg (SD 18.5) and 87 mmHg (SD 11.4), respectively. Calcium channel blockers were the most frequently used antihypertensive agents (58.6%). Of all patients with hypertension, 27.1% achieved controlled blood pressure. Bivariate analysis revealed a significant association between antihypertensive agents and blood pressure control (p = 0.009). Multivariate analysis showed that calcium channel blockers were the strongest predictor of blood pressure control, with an adjusted odds ratio of 1.9 (95% confidence interval CI [1.1–3.5], Conclusion. Controlled blood pressure was achieved by less than half of all patients with hypertension visiting the Tegal Alur II Community Health Center in 2017. The majority of patients with hypertension received single-drug therapy with calcium channel blockers, the most frequently used antihypertensive agents. There was a significant association between antihypertensive agents and blood pressure control.Funding. This study received no financial support from any specific funding agencies. Hypertension treatment in Indonesia relies on primary health care services. However, achieving controlled blood pressure is still challenging in Indonesia. According to the Joint National Committee (JNC) in 2003, controlled blood pressure refers to a blood pressure of <140/90 mmHg in people without diabetes and <130/80 mmHg in people with diabetes2. A previous study by Hussain showed that only 9% of adults with hypertension achieved controlled blood pressure in Indonesia3. A higher rate of controlled blood pressure was found in developed countries such as Denmark (29.1%)4. A previous hospital-based study showed that twice-daily administration of antihypertensive drugs was associated with blood pressure control5. To our knowledge, little is known about the association between antihypertensive agents and blood pressure control in primary health care. Therefore, it is hypothesized that antihypertensive agents have a significant association with blood pressure control in Indonesia’s primary health care system.The high prevalence of hypertension is still a global health burden. In 2013, according to Indonesia’s Ministry of Health, the prevalence of hypertension in Indonesia was 26.5%This cross-sectional study aimed to reveal the association between antihypertensive agents and blood pressure control among patients with hypertension at the Tegal Alur II Community Health Center. This primary health care centre is located in Tegal Alur Administrative Village, Kalideres Subdistrict, West Jakarta. This study was conducted from February 2018 to March 2018.The authors employed a total sampling method. Medical records of all adult patients (aged ≥18 years) with hypertension visiting the Tegal Alur II Community Health Center from January 2017 to December 2017 were included in this study.The authors obtained data from the medical records of all patients with hypertension who visited the Tegal Alur II Community Health Center during 2017. The following characteristics of patients with hypertension were recorded: sex, age, duration of hypertension, current blood pressure, comorbidities, antihypertensive agents, and combination of hypertensive agents. Age was categorized as <45 years, 45–65 years, and >65 years. The duration of hypertension was categorized as <1 year, 1–5 years, and >5 years. Comorbidities were divided into two categories: hypertension with diabetes mellitus and hypertension without diabetes mellitus. Antihypertensive agents that were used by physicians in the Tegal Alur II Community Health Center were categorized into the following drug classes: diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and beta blockers. The combination of antihypertensive agents factor was categorized as one drug and two drugs.Patients’ blood pressure at Tegal Alur II Community Health Center was measured with a periodically calibrated sphygmomanometer. The outcome measure in this study was blood pressure control, categorized as uncontrolled blood pressure and controlled blood pressure based on the criteria from JNC in 2003. These criteria define controlled blood pressure as <140/90 mmHg in individuals without diabetes and <130/80 mmHg in individuals with diabetes. Blood pressure control data was obtained from mean blood pressure of three latest visits. Primary health care providers in Indonesia adhere to these criteria.The categorical data, such as sex, age, duration of hypertension, blood pressure control, comorbidities, antihypertensive agents, and combination of antihypertensive agents, are presented as frequencies (n) and percentages (%). The numerical data, such as age, duration of hypertension, systolic blood pressure (SBP), and diastolic blood pressure, are presented as means and standard deviations (SDs). The multivariate analysis was performed to detect the differences in characteristics between men and women . A p-value of <0.05 indicated statistical significance. The distribution of patient characteristics according to comorbidity status (hypertension with and without diabetes mellitus) was also analysed. The bivariate analysis was performed to determine the relationship between treatment (antihypertensive agents and combination of antihypertensive agents) and blood pressure control. The multivariate analysis with a logistic regression model was performed to obtain age- and sex-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the influence of antihypertensive agents on blood pressure control. The statistical analysis was performed using SPSS version 20.0 .p = 0.001) than that of women . The largest age group in this study was 45–65 years (67.8%). Most patients had hypertension for less than 1 year (59.0%). The mean SBP in this study was higher than the blood pressure target recommendation . Controlled blood pressure (<140/90 mmHg for patients without diabetes and <130/80 for patients with diabetes) was achieved by 27.1% of the patients. Most of the patients did not have diabetes mellitus (95.6%). CCBs were the most frequent antihypertensive agents used by the subjects in this study (58.6%). Most of the patients received single-drug therapy (90.8%) as their hypertension treatment.In total, 273 patients with hypertension were included in this study. p = 0.009). The majority of patients in the uncontrolled blood pressure group and in the controlled group received single-drug treatment . There was an insignificant association between combination of antihypertensive agents and blood pressure control (p = 0.190).p = 0.022).3 in Indonesia, which stated that only 9% of patients with hypertension achieved controlled blood pressure. This result was also similar to the result from a study of Denmark’s primary health care system, in which 29.1% of all patients achieved controlled blood pressure4. This study showed that the rate of blood pressure control was the highest in patients with hypertension aged >65 years (35%). With the consideration that this study population was dominated by women (75.5%), a study by Llisterri et al.6 showed that 3 out of 10 women aged >65 years achieved controlled blood pressure, which was similar to this study’s finding for patients with hypertension aged >65 years. In this study, half of patients with hypertension and comorbid diabetes mellitus achieved controlled blood pressure. This frequency was higher than the rate of blood pressure control among hypertensive patients with diabetes in the Danish primary health care system7.In this study, 27.1% of patients with hypertension achieved controlled blood pressure. This finding was higher than that from a previous study by Hussain et al.8.The mean SBP of patients with hypertension and comorbid diabetes  and without diabetes  in this study was above the target blood pressure recommended by JNC VII. The mean SBP among patients with hypertension and comorbid diabetes in this study was higher than the mean SBP of 131 mmHg among patients with diabetes in a study of the Irish primary health care system8. The mean SBP in this study  was better than the result from a study by Didier and Guimaraes9 in Brazil . This evidence shows that patients in developed countries still more frequently achieve target blood pressure than patients in developing countries. However, few diabetes patients visit primary health care centres in Indonesia, as the majority of diabetes patients visit secondary and tertiary health care centres due to adverse clinical manifestations resulting from uncontrolled blood glucose and blood pressure.The mean SBP among patients with hypertension without diabetes mellitus in this study was also higher than the mean SBP of 136 mmHg among patients with hypertension without diabetes mellitus in the study of the Irish primary health care system10 in Japan, which showed that 50.3% of all patients with hypertension received CCBs. This result was also supported by Chia et al.11, who showed that the most frequently used class of antihypertensive agents in a Malaysian primary care setting was CCBs (62.6%). This result differed from that of a study in a primary care setting by Novello et al.12, which showed that the most frequently used class of antihypertensive agents was diuretics. Another study by Abegaz et al.5 also showed that diuretics (thiazide) were the most frequently used antihypertensive drugs in patients with hypertension. This study’s result was also different from the findings of a meta-analysis in Brazil, in which ACE inhibitors were the most frequently used antihypertensive agents in primary care practices13. Every primary care setting has its own preferred first-line treatment while still adhering to the recommendation by JNC VII2.The most frequently used class of antihypertensive agents in this study was CCBs (58.6%). This result was similar to the result from a study by Mori et al.14, in which ACE inhibitors were the antihypertensive agents most frequently prescribed to patients with hypertension and diabetes mellitus. This result is supported by the JNC VII guidelines, which state that the first-line treatment options for patients with hypertension and diabetes mellitus are thiazide, ACE inhibitors, beta blockers, CCBs, or ARBs2. However, the most beneficial antihypertensive agents for reducing the progression of diabetic nephropathy in diabetes patients are ACE inhibitors and ARBs2,15.This study showed that in patients with hypertension and comorbid diabetes, CCBs were the most frequently used antihypertensive agents (75%). The results of this study differed from those of the Malaysian primary care study by Cheong et al.16. A study by Cheong et al.14 also showed that the number of drug combinations had a significant positive association with blood pressure control. This evidence could explain the failure of the hypertension with diabetes mellitus group in this study to achieve a mean SBP below 130 mmHg, as 50% of the patients in this group had uncontrolled blood pressure.In this study, all patients with hypertension and diabetes mellitus received single-drug therapy. In contrast to this study’s finding, a recommendation by the American Diabetes Association stated that multidrug therapy should be used to achieve controlled blood pressure in people with diabetes17, which showed that CCBs had a lower rate of use among individuals with controlled blood pressure than among those with uncontrolled blood pressure , although that result was insignificant. After adjusting for age, sex, and comorbidities (diabetes mellitus), CCBs were the strongest predictor of blood pressure control at the Tegal Alur II Community Health Center. In contrast to this study, a study by Bronsert et al.18 showed that ACE inhibitors and beta blockers had significantly higher rates of blood pressure control than CCBs. Contrary to the findings in the study by Bronsert et al.18, which showed that multidrug therapy had better blood pressure control than single-drug therapy, the bivariate and multivariate analyses in this study showed no significant association between combinations of antihypertensive agents and blood pressure control.In this study, antihypertensive agents had a significant association with blood pressure control. CCBs were more frequently used by patients with controlled blood pressure than by patients with uncontrolled blood pressure . This result was in contrast to the result by Alba-Leonel et al.The limitation of this study was that there was no blood pressure change measurement to evaluate the effectiveness of antihypertensive agents in reducing blood pressure. Additionally, this study evaluated office blood pressure and did not produce conclusive results regarding the association of treatment type with blood pressure changes. Further study is needed to evaluate other determinants related to antihypertensive agents and blood pressure control, such as the treatment adherence and compliance of patients with hypertension. Nevertheless, this is the first study to evaluate the relationship between antihypertensive agents and blood pressure control in an Indonesian primary health care practice. General physicians in Indonesian primary health care settings are recommended to use CCBs and other first-line antihypertensive agents when treating patients with hypertension. Due to the difficulties in achieving controlled blood pressure in people with diabetes, ACE inhibitors or ARBs and a combination of antihypertensive agents are recommended treatments for patients with hypertension and comorbid diabetes.Controlled blood pressure was achieved by less than half of all patients visiting the Tegal Alur II Community Health Center in 2017. The majority of patients with hypertension received single-drug therapy with CCBs, the most frequently used class of antihypertensive agent. CCBs were the strongest predictor of blood pressure control at the Tegal Alur II Community Health Center. There was a significant association between antihypertensive agents and blood pressure control.This study protocol was approved by the Health Research Ethics Committee, Faculty of Medicine, Universitas Indonesia–Cipto Mangunkusumo Hospital with the reference number of the following: 0549/UN2.F1/ETIK/2018. Because this study used medical records as secondary data and had no direct contact with patients, informed consent was not obtained.All raw data of this study are included in this published article. The authors are keen to collaborate in answering further research questions and to participate in systematic reviews or metaanalysis. No additional data are available.The authors have no conflict of interest to declare.This study did not receive specific financial support from any funding organization.


Treatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support.We retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013–2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention.p = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension . Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min , 18 doses at 60 min , 16 doses at 90 min , and 17 doses at 120 min . Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus.The cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min (Hypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention. Paracetamol was introduced in the late nineteenth century and is currently one of the most common antipyretic, analgesic drugs used worldwide. The mechanism of action of paracetamol is unclear and may involve inhibition of the cyclooxygenase, cannabinoid, or nitric oxide pathways in the central nervous system . PerfalgComplementary data in the pediatric medical literature are sparse. A case report by Yaman et al.  describeThe aim of the present study was to evaluate the frequency, extent, and risk factors of hypotension associated with intravenous administration of paracetamol in children with septic shock supported with inotropic drugs.A retrospective chart review study design was used. The study was approved by the institutional review board. The cohort included all children hospitalized in the pediatric intensive care unit (PICU) of a tertiary pediatric medical center in 2013–2018 with septic shock  who wereiMDsoft, Tel Aviv, Israel). For the present study, the following data were collected from the medical charts: patient age and sex; underlying disease; amount of sedative drugs; Pediatric Logistic Organ Dysfunction (PELOD) score; hemodynamic parameters  immediately before paracetamol administration and 30, 60, 90, and 120 min after; and need for inotropic support or intravenous fluid bolus during the 4 h before and 2 h after paracetamol administration. The main outcome measures of the study were change in blood pressure, hypotension, and hypotension requiring intervention.All patient parameters at our center are continuously and automatically recorded in the individual electronic charts  vital signs chart . As for In addition, we calculated the differences between the systolic and diastolic blood pressure values and the respective normal means for age expressed as delta (Δ). A negative change of ≥ 15% in MAP after intravenous paracetamol administration was also evaluated, similar to previous studies , 9. Tempp value of < 0.05 was considered statistically significant.Statistical analysis was performed with ©2018 QuickCalcs software . Changes in blood pressures, heart rates, and VIS were analyzed using analysis of variance (ANOVA) with repeated measures. Potential baseline factors predicting a risk of hypotension after paracetamol treatment were tested by ANOVA. For all tests, a The cohort included 45 children who received a total of 105 intravenous paracetamol prescriptions (3 prescriptions were included in our earlier study of paracetamol ). Their p < 0.001). In 83 cases, patients were being mechanically ventilated at the time paracetamol was prescribed. Three children did not survive to pediatric intensive care unit discharge.The mean dose of intravenous paracetamol was 12 ± 3 mg/kg. The indications for treatment were fever in 83 (79%) prescriptions and pain in 22. Paracetamol treatment led to a decrease in mean temperature from 38.6 ± 0.6 to 37.5 ± 0.8 °C . The lowest systolic blood pressure value was 8 ± 17 mmHg higher than the lower limit of normal systolic blood pressure, adjusted for age. There was no statistically significant change in diastolic blood pressure (Table p < 0.001) than the pre-paracetamol value.For the whole cohort, mean systolic blood pressure before paracetamol administration was 113 ± 15 mmHg, and the lowest value after paracetamol administration was 108 ± 15 mmHg at 60 min. The difference between these values was statistically significant p = 0.00. The lowThere was no statistically significant change in VIS before and after paracetamol administration Table .MAP decreased by ≥ 15% from the pre-paracetamol value in 8 doses (7.6%) at 30 min (mean drop − 19 ± 4 mmHg), 18 doses (17.1%) at 60 min (mean drop − 20 ± 7 mmHg), 16 doses (15.2%) at 90 min (mean drop − 20 ± 5 mmHg), and 17 doses (16.2%) at 120 min (mean drop − 19 ± 5 mmHg). Mean arterial hypotension occurred after 34 doses of paracetamol (32.4%); in 23 doses, hypotension was recorded at 60 and 90 min after paracetamol infusion , and another 6 required fluid boluses to maintain systolic blood pressure or MAP within the normal range. Figure p = 0.49, ANOVA). Similarly, no statistically significant association was found between a drop in MAP to below normal and patient diagnosis  (p = 0.52), amount of sedative drugs , or indication (fever/pain) for paracetamol administration (p = 0.89). On stepwise logistic regression analysis, there was no association between these three variables  and a drop in MAP to below normal.There was no statistically significant association between baseline VIS and a decrease in MAP below the normal range , and warranting intervention in 12 patients in the form of a fluid bolus or an increment in inotropic support. Among patients who experienced a decrease in systolic blood pressure after intravenous paracetamol, the highest number of negative events occurred at 60 min (67 events), with a decrease of − 15 ± 12 mmHg from the mean pre-paracetamol value.The hypotensive effect of intravenous paracetamol is multifactorial and well recognized in the adult literature. More than 20 years ago, Brown  describeKelly et al.  reportedIn children with septic shock, two possible mechanisms may exaggerate the hypotensive effect of paracetamol. One is skin vasodilatation. Owing to the higher ratio of surface area to weight than in adults, skin vasodilatation occurring when temperature drops may exaggerate relative hypovolemia and facilitate hypotension. The other is the additive lowering effect of paracetamol on the already low cardiac output and myocardial depression characteristic of pediatric septic shock.Ray et al.  reportedHowever, since MAP and heart rate would be expected to decrease to normal range on relief of fever and discomfort, the definition of hypotension as a decrease of > 15% mmHg in MAP can be misleading. Therefore, to identify true hypotension, we not only presented the negative changes in systolic and diastolic blood pressures and MAP after intravenous paracetamol, but also calculated the difference (Δ) in the post-paracetamol values from the lower normal range and hypotensive limit for age. We found that despite the drop in mean systolic blood pressure, the mean difference from the systolic hypotensive value was in the safe range, and only 5 events were by definition systolic hypotension. Furthermore, in only 34 of the 59 events in which MAP decreased by ≥ 15% relative to baseline, MAP was below the normal age-adjusted value. Thus, we suggest that rather than defining hypotensive events after paracetamol administration by the change from baseline, we should consider the change in blood pressure values  relative to the normal range. Furthermore, since sedated children may experience low blood pressures, we suggest that low blood pressure together with the need for intervention is more clinically relevant than the change in pressure per se.The present findings do not agree with our recently published study of 100 consecutive children treated with intravenous paracetamol , whereinNone of the potential risk factors evaluated in this study, i.e., baseline VIS, underlying diagnosis, sedative drugs, and indication for paracetamol administration, was associated with the development of hypotension after intravenous administration of paracetamol.Our study has several limitations. First, although the data had been recorded electronically and continuously, they were collected retrospectively. Second, patients who received known hypotensive medications were excluded, but it is still possible that some patients experienced an unexpected hypotension event in response to some other medication that was given at the time of paracetamol administration. There are also other potential causes of hypotension in this setting, such as are unmet ongoing fluid loss and septic shock deterioration. Third, the cohort was relatively small, with some patients had more than one dose of paracetamol, and was not powered to identify all risk factors for hypotensive events after treatment.Clinicians should be alert to the occurrence of hypotensive events and the need for intervention following intravenous paracetamol administration in critically ill children with septic shock on inotropic support. Future prospective controlled studies are warranted to investigate below-normal blood pressures and the need to intervene and to further characterize the mechanisms and risk factors of paracetamol-induced hypotension in this patient group.


Chronic renal failure, particularly end-stage renal disease, is a serious health problem associated with a high mortality rate. Uremic syndrome leads to increased oxidative stress, inflammation, and dyslipidemia.To examine superoxide dismutase isoenzyme gene expression in peripheral blood mononuclear cells of patients on hemodialysis and to determine the associations between superoxide dismutase isoenzyme gene expression, oxidative stress, and non-enzymatic antioxidative protection.Case control study.This study included 33 patients on hemodialysis  and 33 apparently healthy controls . Superoxide dismutase isoenzyme messenger ribonucleic acid levels were determined by real-time polymerase chain reaction. General biochemical parameters, high sensitivity C-reactive protein, total antioxidant status, thiobarbituric acid-reactive substances, and the superoxide anion radical were also determined.Normalized Cu/Zn superoxide dismutase and Mn superoxide dismutase messenger ribonucleic acid levels were significantly higher in patients than controls (p<0.001 and p=0.011). A significant negative correlation was detected between normalized Cu/Zn superoxide dismutase messenger ribonucleic acid levels and total protein, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total antioxidant status. Normalized Mn superoxide dismutase messenger ribonucleic acid levels were negatively correlated with total protein and total antioxidant status. A multiple regression analysis revealed independent associations between total antioxidant status and normalized Cu/Zn superoxide dismutase (p=0.038) and between total antioxidant status and normalized Mn superoxide dismutase messenger ribonucleic acid levels .The superoxide dismutase isoenzyme gene is expressed at a higher rate in patients with end-stage renal failure, probably due to increased oxidative stress and attenuated antioxidative defense. The plasma total antioxidant status is an independent predictor of normalized superoxide dismutase isoenzyme messenger ribonucleic acid levels. If not scavenged properly, it causes lipid peroxidation  with chronic kidney disease receiving hemodialysis were included in the study. The diagnoses were as follows: six patients had chronic glomerulonephritis, six had nephroangiosclerosis, four had chronic renal insufficiency, three had uric acid nephropathies, three had Good-Pasture syndrome, two had renal calculosis, two had vesicoureteral reflux, one had hypertension, one had atrophia renis segmentalis, one had lupus nephritis, one had endemic nephropathy, one had chronic pyelonephritis, one had renal tuberculosis, and one had renal vasculitis. Because their kidneys were unable to perform physiological roles, hemodialysis was substituted. Cessation of basic kidney functions and the hemodialysis process itself increases oxidative stress  reagent and frozen at -80 °C until total RNA isolation. Glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), triglycerides, total protein, urea, and creatinine were measured by routine enzymatic methods in plasma using the ILab 300+ analyzer  and Randox Laboratories reagents . High sensitivity C-reactive protein (hsCRP) was determined by an immunoturbidimetric method using a COBAS® c6000-Roche Diagnostics  analyzer.The control group was comprised of 33 healthy subjects . Inclusion criteria for the control group were the absence of a family history of cardiovascular disease, absence of hypertension (systolic blood pressure <140 mm Hg and/or diastolic blood pressure <90 mm Hg),  and/or t2.- (TM reagent according to an optimized procedure (TM Gene Expression Assays (primer sequences available upon request) according to the manufacturer’s instructions (Applied Biosystems). Gene expression data were calculated as follows: Normalized Cu/Zn SOD mRNA=Cu/Zn SOD mRNA/ β-actin mRNA; normalized Mn SOD mRNA=Mn SOD mRNA/β-actin mRNA. Negative controls for reverse transcription (without reverse transcriptase) and for real-time PCR (no complementary DNA) were included in all experiments.Thiobarbituric acid-reacting substances (TBARS) were measured as the quantity of malondialdehyde-TBA 1:2 adducts spectrophotometrically at 535 nm . The rat2.- . TAS was2.- . Total Rrocedure ,18. The The Shapiro-Wilk test was used to examine the data distributions of the examined variables. Data are shown as arithmetic mean ± standard deviation for normally distributed variables. Data that achieved a Gaussian distribution after logarithmic transformation are presented as geometric mean [95% confidence intervals (CIs)] . Skewed 2.- were significantly higher in patients compared with the controls, and TAS was significantly lower in the patients than the controls. These results indicate that the patients were in a state of oxidative stress. Normalized Cu/Zn SOD and Mn SOD mRNAs were higher in the patients than in the controls  determined in serum significantly predicted normalized Cu/Zn SOD mRNA in peripheral blood mononuclear cells . This result also demonstrated that model 1 was a good fit for the data. An adjusted R2 of 0.339 for model 1 demonstrated that 33.9% of the variation in the normalized Cu/Zn SOD mRNA in peripheral blood mononuclear cells was explained by model 1. Of all parameters, only TAS was independently associated with a decrease in normalized Cu/Zn SOD mRNA    . Urea anp=0.038)  were grop=0.018) . The pos2.-), such as when leukocytes contact the hemodialysis membrane. A decrease in blood antioxidants, which occurs because of their consumption during ROS neutralization and loss through the dialyzer membrane, additionally contribute to increase oxidative stress . TBARS and O2.- were positively correlated  (data not shown). Malondialdehyde, a component of TBARS, is the ultimate product of lipid peroxidation and an oxidative stress marker  are likely to be key inducers of Cu/Zn SOD and Mn SOD genes in peripheral blood mononuclear cells. Only TAS was an independent predictor of SOD isoenzyme gene expression in peripheral blood mononuclear cells.According to our results, elevated Cu/Zn SOD and Mn SOD gene expression in peripheral blood mononuclear cells from the patients  probablywith TAS . As TAS with TAS , 5. ModeSOD mRNA . This is


It is crucial to frequently inspect the proper operation of non-invasive electronic blood pressure monitors in various sites to prevent accidents from inaccurate blood pressure measurements, especially for large-scale hospitals. However, most conventional blood pressure monitor inspection devices are not suitable for such on-site investigation purpose. In this study, we propose a new single-pieced, fully air-driven pseudo blood pressure generator that is suitable for frequent on-site pre-screening tests of the blood pressure monitor by nurses.p < 0.05). Besides, during the experiments using ten commercial blood pressure monitors, the maximum error in average systolic blood pressure was 2.9 mmHg, the maximum standard deviation in average systolic blood pressure was 3.5 mmHg, and the maximum percentage error in average pumping rate was 3.2%, respectively.The proposed model comprises a rigid cylindrical body, two simulated brachial arteries, two air-pumps, an electronic controller, and a pressure sensor. Control algorithm based on polynomial curve fitting was implemented to generate various user-instructed systolic blood pressure and heart-rate conditions automatically. To evaluate the performance and clinical feasibility of the proposed model, various experiments were performed using ten commercial electronic blood pressure monitors. Experimental results demonstrated that the values of the Pearson coefficient between the reference pseudo-blood pressure waveforms and the actually generated pressure waveforms were 0.983, 0.983 and 0.997 at 60, 70 and 80 beats/min, respectively (We expect that the proposed model can give an easy and comprehensive way for frequent on-site investigations of the blood pressure monitors by nurses, and improve the safety of patients with abnormal blood pressure, especially in most large-scale hospitals. Blood pressure (BP) is a fundamental physiological signal to understand the physical status of patients with various symptoms and diseases; therefore, most hospitals repetitively gather BP information using non-invasive electronic BP monitors whenever the patient visits . When thIn large-scale hospitals (with hundreds or thousands beds), experts from the engineering department should periodically examine all of the BP monitors in the hospital using inspection devices; when the estimated error is beyond the permitted limit, they send it to the authorized inspection agency for fine-tuning. For this case, the best way to guarantee the proper operation of BP monitors is to inspect each device more frequently . However, in most large-scale hospitals, there are too many devices to manage  compared to the number of staffs in the engineering department. For example, seven engineering staffs should manage over 4000 devices in our hospital; among them, the number of BP monitors is over one hundred. As a result, the interval of periodic BP monitor inspection is generally once per a year, which may not sufficient to guarantee the proper operation because there are many error sources in actual circumstances such as scratch in the cuff, error in embedded pressure sensor or other electronic parts, and degradation of mechanical parts due to aging.To improve the quality of BP monitor maintenance in large-scale hospitals, it is necessary to encourage the nurses to frequently perform on-site pre-screening tests by themselves at various sites such as wards, outpatient clinics, and emergency room, and ask the engineering staffs for further inspection only when the accuracy of tested device is suspicious. However, the price of conventional inspection devices is generally high to equip plural devices at all needed sites. In addition, inspection protocol of conventional devices is somewhat complicated for untrained nurses; e.g., open the external case of BP monitor, connect an air-tube inside the inspection device to the BP monitor, output pre-determined pressure vibrations via the air-tube, disconnect air-tube from the BP monitor, and close the external case. To encourage such self-screening tests by nurses, it is required to develop a new inspection tool suitable for such purpose that is (1) comprehensive and straightforward for untrained nurses, (2) small, light and single-pieced to improve portability and user convenience, and (3) relatively cheap to manufacture.In this study, we propose a new technical model suitable for on-site pre-screening tests that can generate various pseudo-BP conditions through the cuff-inserted virtual brachial arteries, and verified the feasibility of the proposed model using ten BP monitors.PMAX when the value of PWM control register was adjusted from 0 to 240 with a step of 10 (R2 = 0.999 in Pearson correlation). Figure PRESP waveforms calculated by Eq. . Maximal errors between two curves were 4.9 BPM for 60 BPM, 4.7 BPM for 70 BPM, and 3.2 BPM for 80 BPM, respectively, and minimal errors between two curves were 0.1 BPM for 60 BPM, 0.0 BPM for 70 BPM, and 0.0 BPM for 80 BPM, respectively. Average errors between two curves were 2.3 BPM for 60 BPM, 2.3 BPM for 70 BPM, and 1.2 BPM for 80 BPM, respectively.Figure REF was 60, 70, 80, 90 and 100 BPM, respectively. In C2 test, average errors between the reference and the measured SBP/PR were 0.4/1.6, 0.1/1.6, 0.2/1.6, 0.9/1.6, and 1.9/1.6 mmHg/BPM when the SBPREF was 90, 100, 110, 120 and 130 mmHg, respectively. In C3 test, average errors between the reference and the measured SBP/PR were 2.4/0.7, 1.1/0.2, 1.2/1.6, 0.7/1.1, and 0.8/1.9 mmHg/BPM when the reference values of {SBP, PR} varied as {90, 60}, {100, 70}, {110, 80}, {120, 90}, and {130, 100}, respectively.Table Table p < 0.05); in contrast, there was no significant difference in the PR between two groups in HYPER and NORMAL conditions (p > 0.05). In HYPO condition, there was a statistically significant difference in the PR between two groups because the value of standard deviation was always zero before performance deterioration (p < 0.05).Table The purpose of this study is not making a new inspection device that assesses the accuracy of BP monitor; e.g., BP PUMP2 , AccuPulse , AccuSim-BP , SC-5 SimCube , and MS200  . For thiCompared to conventional inspection devices, the proposed technical model has several advantages as follows. First, the evaluation protocol is similar to the normal BP measurement; so, nurses can easily understand how to use it. Second, it is suitable for frequent on-site inspections because it is small, light, quick, single-pieced, and non-hydraulic. Third, its manufacturing cost is relatively low; thus making it possible to equip at various sites simultaneously with less financial burden. Besides, as shown in Table There have been a few reports that proposed cuff-insertion type BP monitor inspection devices. For example, Yong and Geddes proposed a surrogate arm that requires inserting a plastic cylindrical chamber that contains air/water mixture into the cuff . HoweverUnder the general regulatory guidelines for BP monitor, clinically permissible ranges of measurement error are (1) maximal average error in BP measurement ≤ 5 mmHg, 2) maximal standard deviation in BP measurement ≤ 8 mmHg, and (3) maximal average error in PR measurement ≤ 5%, respectively –11. As s maximal REF and DBPREF as 40 mmHg based on the assumption that when the accuracy of an embedded pressure sensor in the BP monitor deteriorates, both of the SBP and DBP measurements will become inaccurate simultaneously. Second, the current model cannot be applied to assess the accuracy of BP monitors directly because the operating mechanism of the proposed model is far from a standard approach of the conventional BP monitor inspection devices, and as a result, it should be verified through more well-designed validation processes in future studies. Third, there have been two main approaches for benchtop assessment of BP monitors—i.e., limb simulators and waveform generators—and it is generally known that the latter is more successful than the former [The limitations of the current study are as follows. First, as described above, the main purpose of the study was to make a single-pieced, fully air-driven, cuff-inserted technical model that can be used only for easy and simple on-site pre-screening purpose to detect error-suspicious devices before time-consuming official inspection. Therefore, we used a simple sinusoidal wave-profile as a reference to simplify the implementation, and fixed the difference between the SBPe former , 13. AltIn this study, we proposed a single-pieced, fully air-driven, cuff-inserted technical model for easy, simple, and quick on-site BP monitor pre-screening purpose before official inspection, and evaluated the performance and versatility of a proposed model using ten BP monitors. We expect that the proposed model can give a technical option to improve the quality of BP monitor management and the safety of patients with abnormal BP especially for large-scale hospitals.In standard oscillometric BP measurement, a BP monitor detects the vibration of cuff pressure due to the occlusion and re-opening of brachial artery in the cuff during the measurement, and then, calculates average, systolic and diastolic BPs and HR . To simuREF) for given BP and PR conditions as Eq. . Then, the reference waveform moved upward to match the values of local minima with the {SBPREF—20 mmHg}, and the responsive pressure in the closed air-loop (PRESP) that corresponds to the given SBPREF and PRREF was calculated by Eq.  values of the generated pressure waveform at each duty ratio conditions were recorded using a pressure gauge  that is also connected to the closed air-loop. Then, the relationship between the duty ratio (in %) and the PMAX (in mmHg) was extracted by applying the polynomial curve fitting, and finally, by substituting the PRESP in Eq.  the value of SBPREF was fixed to 120 mmHg, and (2) the value of PRREF was adjusted from 60 to 100 BPM with 10 BPM step (denoted as C1 test). Second, to verify the ability to adjust SBPREF while maintaining the constant PRREF, (1) the value of PRREF was fixed to 80 BPM, and (2) the value of SBPREF was adjusted from 90 to 130 mmHg with 10 mmHg step (denoted as C2 test). Third, to verify the ability to adjust both the SBPREF and PRREF simultaneously, (1) values of SBPREF and PRREF were initially set to 90 mmHg and 60 BPM, and (2) test condition {SBPREF (mmHg), PRREF (BPM)} was adjusted to {90, 60}, {100, 70}, {110, 80}, {120, 90}, and {130, 100} (denoted as C3 test). Each test condition was repeated ten times during the experiments.In this implementation, the operating ranges of PRREF, PRREF} = {150, 70} for hypertension (denoted as HYPER), {120, 60} for normal (denoted as NORMAL), and {80, 80} for hypotension (denoted as HYPO). All the tests were repeated 30 times during the experiments.Next, to evaluate the clinical usability of the proposed model, ten BP monitors that were used in our hospital were randomly selected as Table Next, to evaluate whether the proposed pseudo-BP generator can be used to discriminate the error-suspicious BP monitor whose measurement error is out of the permitted range, we opened the external case of an arbitrarily selected BP monitor (BPM-2) and adjusted the variable port in front of the embedded pressure sensor using a screwdriver to increase the velocity of air flow toward the sensor, which results in the elevation of the level of cuff pressure measurement (i.e., case of embedded sensor error; Fig.


After PS matching, no significant differences in perioperative recipient or donor graft parameters were observed between groups. Although the total amount of crystalloid fluid infused during surgery did not differ between groups, the proportions of main crystalloid fluid type used  did. The eGFR increased gradually during postoperative day (POD) 2 in both groups. However, the proportion of patients with eGFR > 60 mL/min/1.73 m2 on POD 2 was higher in the non-hyperchloremia group than in the hyperchloremia group. In this PS-adjusted analysis, hyperchloremia was significantly associated with poor graft recovery on POD 2. In conclusion, exposure to hyperchloremia may have a negative impact on early graft recovery in LDKT.The effects of hyperchloremia on kidney grafts have not been investigated in patients undergoing living-donor kidney transplantation (LDKT). In this study, data from 200 adult patients undergoing elective LDKT between January 2016 and December 2017 were analyzed after propensity score (PS) matching. The patients were allocated to hyperchloremia and non-hyperchloremia groups according to the occurrence of hyperchloremia  immediately after surgery. Poor early graft recovery was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m Acute kidney injury (AKI) is a common complication that increases the risk of poor graft outcome in patients undergoing kidney transplantation (KT). Kidney grafts seem to be vulnerable to poor early function recovery because of various types of acute perioperative damage, such as ischemia-reperfusion injury, immunological insult, medication toxicity, and surgical stress . In liviChloride is a major anion in extracellular fluid and an essential element for plasma tonicity. Chloride plays a role in maintaining aspects of homeostasis, such as acid balance, muscular activation, and immunological response . HyperchTo date, the effects of hyperchloremia on kidney grafts have not been investigated in patients undergoing LDKT. We investigated the association between hyperchloremia and early graft function recovery. In addition, postoperative outcomes, such as the requirement for renal replacement therapy (RRT), graft rejection, and mortality, were investigated according to the occurrence of hyperchloremia.This study was approved by the Institutional Review Board and Ethics Committee of Seoul St. Mary’s Hospital (KC19RESI0088) and was performed in accordance with the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective study design.The study population consisted of 330 adult patients  who underwent elective LDKT at Seoul St. Mary’s Hospital between January 2016 and December 2017. Pediatric patients , those undergoing deceased-donor or ABO-incompatible KT, patients undergoing multiorgan transplantation including the kidney, and those undergoing re-transplantation were excluded from the study because these patients require various and complex immunosuppression regimens or surgical technique application ,15,16,17The surgical technique for LDKT involved an initial hockey-stick  incision and exposure of the right pelvic fossa. After back table preparation of the graft, end-to-side anastomoses between the recipient external iliac artery/vein and the graft renal artery/vein were performed using Prolene 6.0 resorbable monofilament . Subsequently, ureteroneocystostomy was performed with insertion of a double-J stent  using the Lich-Grègoir technique ,19. AfteBalanced anesthesia was applied using 1–2 mg/kg propofol  and 0.6 mg/kg rocuronium , and maintained using 2.0–6.0% desflurane  with medical air/oxygen and continuous remifentanil  infusion at a rate of 0.1–0.5 μg/kg/min, as appropriate. The maintenance of appropriate hypnotic depth between 40 and 50 was ensured with a Bispectral Index™ instrument . Central venous pressure (CVP) was monitored using a central venous catheter  inserted before surgery. The optimal hemodynamic status was adjusted to a mean arterial pressure of ≥65 mmHg with infusion of dopamine  at a rate of 5–10 μg/kg/min. Mannitol  was used at doses of 20–50 g to promote urine flow [For intraoperative fluid therapy, an isotonic crystalloid fluid  or Plasma Solution-A ) was selected at the discretion of the attending anesthesiologist. The 0.9% normal saline  included sodium chloride . Plasma Solution-A  included magnesium chloride ). Baseline isotonic crystalloid infusion was based on the estimated fluid maintenance requirements, calculated from the patient’s weight and anticipated tissue trauma . AdditioIn the immunosuppressive regimen , the indThe baseline chloride level was estimated between the day after dialysis and the preoperative period, and serial chloride levels were measured 1 day before surgery, immediately after surgery, and on postoperative days (PODs) 1 and 2. The chloride level was analyzed by indirect potentiometry . The patients were divided according to the presence or absence of hyperchloremia  imme−1.154 × age−0.203 × 1.212 (if black) × 0.742  [2), stage II , stage IIIa , stage IIIb , stage IV , or stage V  [Kidney graft function was quantified based on the estimated glomerular filtration rate (eGFR), calculated using the Modification of Diet in Renal Disease formula: eGFR = 175 × standardized serum chloride female) . The bas1.73 m2) . 2 during the first 48 hours after surgery [In the present study, poor early recovery of kidney graft function, defined as eGFR < 60 mL/min/1.73 m surgery , was thePreoperative and intraoperative recipient and donor graft factors in the non-hyperchloremia and hyperchloremia groups were assessed by PS matching analysis. Preoperative recipient factors included age, sex, body mass index (BMI), comorbidities  and hypertension), dialysis history and duration, and laboratory variables . Intraoperative factors included the operation time, averages of vital signs , and total amounts of crystalloid infusion, urine output, and blood loss. Donor graft factors included age, sex, BMI, graft weight, total graft ischemic time, and human leukocyte antigen level. Postoperative clinical factors included RRT requirement, biopsy-proven graft rejection , and patU test and χ2 test or Fisher’s exact test, as appropriate. Wilcoxon’s signed-rank sum test and McNemar’s test were used for analysis of the pair-matched data. Postoperative changes in the proportions of patients with kidney graft function classified as eGFR ≥ 60 vs. 30–59 vs. < 30 mL/min/1.73 m2 were analyzed using Cochran’s Q test with the McNemar post hoc test. The association of hyperchloremia with poor early recovery of kidney graft function was evaluated by multivariable logistic regression analysis with PS adjustment. The values are presented as odds ratios with 95% confidence intervals. All tests were two sided, and p < 0.05 was taken to indicate statistical significance. All statistical analyses were performed using R software version 2.10.1  and SPSS for Windows .The normality of continuous data was assessed using the Shapiro-Wilk test. Continuous data are expressed as medians and interquartile ranges, and categorical data are expressed as numbers and proportions. PS matching analysis was applied to reduce the impact of potential confounding factors on intergroup differences based on hyperchloremia ,29. PSs 2. The incidences of DM and hypertension were 28.6% (n = 86) and 58.1% (n = 175), respectively. Dialysis was performed in 220 (73.1%) patients for an average duration of 30 ± 53 months. The average eGFR was 7.6 ± 3.5 mL/min/1.73 m2. A total of 295 (98.0%) patients had CKD stage V , five (1.7%) patients had CKD stage IV , and one (0.03%) patient had CKD stage IIIb .The total study population of 301 patients comprised 188 (62.5%) males and 113 (35.5%) females with an average age of 49 ± 11 years and average BMI of 23.1 ± 3.5 kg/mBefore PS matching, there were significant differences between groups in preoperative findings , intraoperative findings , and donor graft parameters  differed between the groups . With re2 increased significantly from immediately after surgery to PODs 1 and 2 in the non-hyperchloremia group  patients required RRT due to poor graft function, five (5.0%) patients suffered graft rejection, and two (2.0%) patients died. In the non-hyperchloremia group, two (2.0%) patients required RRT, one (1.0%) patient suffered graft rejection, and one (1.0%) patient died. These postoperative outcomes did not differ significantly between groups. 2 and decrease in the proportion of patients with eGFR < 30 mL/min/1.73 m2. The proportion of patients with adequate graft function  on POD 2 was larger in the non-hyperchloremia group than in the hyperchloremia group.The main finding of our study was that hyperchloremia was associated with poor early recovery of graft function after LDKT in an analysis adjusted for clinical factors related to kidney graft function by PS matching. Patients without hyperchloremia showed appropriate graft function recovery during POD 2, as indicated by the increase in proportion of patients with eGFR > 60 mL/min/1.73 mMany studies have examined the impact of hyperchloremia on AKI in critically ill patients, but debate persists regarding the relation between hyperchloremia and the occurrence of AKI ,23,30,31Patients with chronic kidney dysfunction and those undergoing RRT have been routinely excluded from many studies of AKI because the initial kidney status is one of the most critical factors contributing to the development of AKI after surgery or ICU admission . In contThis study had some limitations. First, although confounding factors were adjusted between patients with and without hyperchloremia by PS matching, hidden biases attributable to unknown factors could not be completely excluded. Second, we were not able to determine the amounts of chloride infused from the patients’ records, so the analysis was based on the serum chloride concentrations. Third, our observations did not elucidate the pathophysiology underlying the relationship between hyperchloremia and kidney graft function recovery. Fourth, because of the possibility of graft failure requiring RRT, such as arteriovenous fistula , we did Exposure to hyperchloremia may have a negative effect on the early recovery of kidney grafts injured by ischemia in LDKT. The infusion of large amounts of chloride-rich fluid seems to be a major factor contributing to increased serum chloride levels, and this chloride load may play a role in prolonging kidney graft recovery in the early postoperative period. Previous studies have shown that chloride loads cause renal vasoconstriction and interstitial edema, thereby decreasing renal blood flow and perfusion, and consequently reducing the GFR and urine output ,42. Howe


Background: Hypertension is a main risk factor for premature death. Although blood pressure is a complex trait, we have shown that the activity of the ATP-generating enzyme creatine kinase (CK) is a significant predictor of blood pressure and of failure of antihypertensive drug therapy in the general population. In this report, we systematically review the evidence on the association between this new risk factor CK and blood pressure outcomes. Method: We used a narrative synthesis approach and conducted a systematic search to include studies on non-pregnant adult humans that address the association between plasma CK and blood pressure outcomes. We searched electronic databases and performed a hand search without language restriction. We extracted data in duplo. The main outcome was the association between CK and blood pressure as continuous measures. Other outcomes included the association between CK and blood pressure categories . Results: We retrieved 139 reports and included 11 papers from 10 studies assessing CK in 34,578 participants, men and women, of African, Asian, and European ancestry, aged 18 to 87 years. In 9 reports, CK was associated with blood pressure levels, hypertension (vs. normotension), and/or treatment failure. The adjusted increase in systolic blood pressure (mmHg/log CK increase) was reported between 3.3 [1.4 to 5.2] and 8.0 [3.3 to 12.7] and the odds ratio of hypertension with high vs. low CK ranged between 1.2 and 3.9. In addition, CK was a strong predictor of treatment failure in the general population, with an adjusted odds ratio of 3.7 [1.2 to 10.9]. Discussion: This systematic review largely confirms earlier reports that CK is associated with blood pressure and failure of antihypertensive therapy. Further work is needed to address whether this new risk factor is useful in clinical medicine. Hypertension is the main risk factor for cardiovascular disease, chronic kidney disease, and premature death worldwide . Global Raised blood pressure is estimated to cause 7.5 million deaths, about 13% of the total of all deaths and around 60% of cardiovascular mortality, accounting for 57 million disability adjusted life years (DALYS), or around 4% of total DALYS. Blood pressure levels have been shown to be positively and continuously related to the risk for stroke and heart disease, with the risk starting as low as 115/75 mmHg systolic/diastolic blood pressure. Complications of raised blood pressure further include heart failure, peripheral vascular disease, renal impairment, retinal hemorrhage, and visual impairment, which could largely be prevented by reducing blood pressure to 139/89 systolic/diastolic blood pressure or lower [Blood pressure is a complex trait, affected by environmental and psychological, as well as biological factors, including education and income levels, psychosocial stress, genes, fetal and early childhood nutrition and growth, and nutrition and body mass in later life . In 2000Creatine phosphate + MgADP ↔ Creatine + MgATPWe proposed that high CK activity promotes hypertension through enhanced vascular contractility and sodium retention in the kidney  Figure . SubsequWe systematically reviewed the evidence on the association between CK and blood pressure in humans with standardized methods designed to conduct reviews of etiology . As a coWe used a framework with 4 elements to characterize the narrative synthesis based on Rodgers et al. , (a) PreBased on the protocol presented here, we sought to identify, through systematic searching, all studies which provided original data in non-pregnant adult humans on the association between tissue or plasma CK and systemic blood pressure in population (sub) groups. We excluded case reports. We critically appraised the retrieved studies in duplo and synthesized the evidence found, including the following aspects: Population, exposure (CK), and outcome (blood pressure-related outcomes) . We alsoSystematic searches were conducted in February 2019, in electronic databases , African Index Medicus, and IndMED), from their inception through to February 2019. Databases differed in technical search options, but a typical search strategy was, “(Creatine kinase OR Creatine phosphokinase OR HyperCKemia) AND (hypertension OR blood pressure OR Cardiovascular)”. We intended to include only studies providing original data on the association between CK and blood pressure measures and not studies merely reporting both parameters. Therefore, in developing this search strategy, we searched on title words where technically possible for a more relevant search yield, since a large majority of papers on CK and heart disease are on myocardial infarction. Search yields from the different databases were considered and analyzed separately to prevent merging errors and to enhance the retrieval of reports. We took further care in preventing bias in retrieval and inclusion of studies, by including reports without language restriction, and in performing a hand search. Data were extracted independently by two authors (LB and FK). Where relevant, European, African, Asian, or other descents (ancestry or ethnicity) were defined as, respectively, of European, sub-Saharan African, or Asian heritage, as indicated by the authors of the eligible papers. The main outcome was the association between CK as a continuous measure and blood pressure as a continuous measure, as reported by the authors. Other outcomes included the association between CK and blood pressure categories . We also assessed important determinants of plasma CK activity, such as physical exercise and the method of CK assessment. Plasma CK increases after exercise, in particular during the first 3 days, and this may dilute the association of CK with blood pressure . TherefoPredefined subgroups were based on sex, ancestry group, and geographical location. We expected heterogeneity in the participants’ characteristics, CK comparisons, and outcomes and therefore planned to describe the findings as reported by the authors. Data in square brackets are 95% confidence intervals and in parentheses are standard errors, unless indicated otherwise.The study flow is depicted in n = 4) [n = 5) among hypertensives and controls [The studies assessed CK in 34,578 participants, men and women of African, Asian, and European ancestry, aged between 18 and 87 years. The included studies were population studies with relatively large sample sizes (n = 4) ,14,17, ocontrols ,16,18,19controls . CK was estimated under resting conditions (to control for exercise-induced hyperCKemia) in 4 out of 10 studies (2 population studies) ,17,18,19® device , or treatment failure (vs. controlled hypertension) . AlthougUnlike the other included papers, the methodology of the report by George et al. was not designed to address the association of CK with blood pressure. The authors associate hypertension by sex with dichotomized CK levels at the cutoff point provided by the manufacturer, at 334 for men and 199 for women. This is remarkable, as the authors report in the same paper that these upper limits of normal (ULN) levels are incorrect. The authors report ULN for CK (IU/L) of 1001 for black men, 382 for white men, 487 for black women, and 295 for white women. The authors do not explain why they chose to dichotomize CK at 334 for men and 199 for women.The study of Mels et al.  also onlNotably, George and Mels et al. were the only studies that used a Beckman UniCel DxC800  to estimate CK. Mels et al. additionally used the Konelab 20I Sequential Multiple Analyzer Computer . Both devices have been associated with suboptimal performance, in particular in CK estimations ,22,23,24The association between blood pressure and CK was reported in European ,7,11,19,In this systematic review, we confirm the hypothesis , and subNormal tissue releases CK proportionate to the intracellular CK concentration, a physiologic process that occurs without tissue damage, as summarized by Brewster et al. . Therefo+-ATPase, Na+/K+-ATPase, and myosin ATPase, where it rapidly provides ATP in situ. In skeletal muscle, high CK Type II muscle fibers display reduced cytoplasmic uptake of glucose and fat, which is a risk factor for glucose intolerance, insulin resistance, and obesity [High tissue CK is thought to lead to a phenotype with greater vascular contractility and enhanced sodium retention through greater ATP buffer capacity at ATPases involved in ion transport and contractile responses ,28,29,30 obesity .Thus, based on the existing evidence, the high CK phenotype might carry a greater risk for hypertension, as well as bleeding risk and obesity . None ofThe main strength of this narrative review is that it summarizes and discusses the existing evidence on the biologically plausible association of CK with blood pressure, indicating that after the initial report in 2006 [We used rigid systematic review methodology ,9 and to® devices scored well in quality tests [®, but two studies used a Beckman UniCel DxC800 device, of which the performance was reported suboptimal in independent quality assessments [A further limitation of the included studies is that we are not well informed regarding the comparability and quality of the CK assays ,22,23,24ty tests ,22,23,24essments ,22,23. Tessments ,22,23,24essments ,22,23,2431P-magnetic resonance spectroscopy [Furthermore, only 4 studies standardized CK assessments to resting conditions ,17,18,19troscopy  of the cIn summary, the majority of studies included in this systematic review confirm the association between CK and blood pressure. The association is based on evidence that ATP-buffer capacity is relevant for the generation of blood pressure. Relatively high CK activity may carry the risk for hypertension that is difficult to treat, and reported links of CK with obesity and bleeding risk are also biologically plausible. However, the lack of information regarding the comparability and quality of the CK assays used in the included studies is a limitation of this review. Further studies will need to address the usefulness for clinical medicine of this new and emerging field of CK related-hypertension and cardiovascular disease, which has recently been substantiated by experimental evidence providing evidence of a causal relationship ,28,30,35


A sociodemographic and clinical characterization questionnaire and the Risk Assessment Scale for Perioperative Pressure Injuries were used. Descriptive, bivariate and logistic regression analyses were applied. the majority of patients (56.5%) presented a high risk for perioperative pressure injury. Female sex, elderly group, and altered body mass index values were statistically significant (p < 0.05) for a higher risk of pressure injuries. In 77% of the patients, there were perioperative pressure injuries. most of the participants presented a high risk for development of perioperative decubitus ulcers. The female sex, elderly group, and altered body mass index were significant factors for increased risk. The Risk Assessment Scale for Perioperative Pressure Injuries allows the early identification of risk of injury, subsidizing the adoption of preventive strategies to ensure the quality of perioperative care. Despite technological advances, pressure injuries (PI) caused by surgical positioning still represent a challenge for clinical practiceVarious incidence rates of perioperative PI are described in the literature. A systematic review of 17 studies published from 2005 to 2011 that evaluated the incidence of these lesions found results ranging from 0.3% to 57.4%International researchers also investigated the incidence of perioperative PI derived from surgical positioning and found the following rates: 12.2% in PortugalSurveys in Brazil reported the occurrence of perioperative PI in comparison with other countries: 25% in Paraná-Effective interventions to prevent skin lesions involve pressure relief during and immediately after the patient lies on the surgical table, on a standard mattress. Examples of more effective devices to prevent this type of injury are: micropulse air mattress, viscoelastic dry polymer mattress cover and gel pads,--The incidence of these PI varies significantly according to the clinical environment and the individual and clinical characteristics of the patientDespite the existence of high technology preventive devices and the widespread use of the Braden scale in clinical nursing practice, gaps remain on the identification of factors critical to the occurrence of perioperative PI.In this scenario, given the scarcity of intraoperative risk assessment scales of decubitus ulcers and the need to recognize the risks for elaborating individualized care plans that guarantee safe and quality perioperative care, the application of the Risk Assessment Scale for Perioperative Pressure Injuries (ELPO), a valid and reliable instrument, is recommendableThe ELPO, developed and validated in Brazil, evaluates the risk of developing injuries resulting from surgical positioning. The score ranges from 7 to 35 points: the higher the score, the greater is the risk of the patient developing pressure injuries. The scale is based on recent evidence and includes factors recommended by scholarsIn addition to ELPO, the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients It is understood that the knowledge of possible contributing factors could support the planning of perioperative nursing care in the process of PI prevention because it would aid to identify patients at risk of developing perioperative PI. In view of this, the following questions were formulated: do patients submitted to elective surgeries have a high ELPO score (score ≥ 20)? Is there any association between sociodemographic variables , clinical variables , and risk according to the ELPO score? What is the incidence of perioperative PI?Thus, the purpose of this study was to evaluate and classify patients according to the ELPO score, verify the existence of associations between sociodemographic and clinical variables and the risk score in the ELPO scale, and identify the occurrence of perioperative PI.This is an observational, longitudinal, prospective and quantitative study carried out in the surgical center of a large teaching hospital.Patients aged 18 years and older, of both sexes, undergoing elective surgeries were included in the study. Patients who underwent cardiac surgeries through deliberate hypothermia during the surgical procedure and those who presented at least one of the defining characteristics of Impaired Physical Mobility according to the Nursing Diagnoses Definitions and Classification, which prevented weight and height measurements in the immediate preoperative period, were excluded from the study.For sampling calculation, the following parameters were adopted: incidence of perioperative PI of 50%, accuracy of 5% and 95% confidence interval, for a finite population of 1000 surgeries, in a total of 278 participants. The recruitment process was non-probabilistic.For data collection, we used an instrument addressing sociodemographic variables  and clinic variables  of the patient. The Risk Assessment Scale for Perioperative Pressure Injuries (ELPO) is composed of the following variables: duration of the surgery, type of anesthesia, surgical positioning, support surface, positioning of upper and lower limbs, comorbidities and age of the patientPrior to data collection, a pilot test was conducted with 12 patients to verify the applicability and suitability of the instrument, but there was no need for alterations. The researchers participated in a training moment for consensus in data collection.Data collection occurred between February and May 2017, in three moments: preoperative, intraoperative and postoperative. In the immediate preoperative period, sociodemographic variables  were obtained by means of information provided by the patients at the time of admission to the hospital. Hemoglobin values were consulted in the pre-anesthetic evaluation card or on the Web system of the laboratory of the hospital that was the field of this study. The variable presence of comorbidities was obtained through a verbal report of the patient and confirmation in the physical record. The weight and height of the patient were also collected by means of a digital scale and a vertical stadiometer  to calculate the BMI.2), eutrophic (BMI ≥18.5 and < 25 kg/m2), overweight ≥ 25 and < 30 kg/m2) and obesity (BMI ≥ 30 kg/m2). The Lipschitz classification was adopted for the elderly: low weight for BMI < 22 kg/m2, eutrophy for BMI 22-27 kg/m2, and obesity for BMI > 27 kg/m2 were: low weight  until his/her transfer to the post-anesthetic recovery room. The ear temperature was measured in the same ear canal  with a G-TECH PremiumFinally, the patient was evaluated by skin inspection and palpation in the immediate postoperative period (T3), at the time of transfer from the surgical table to the stretcher, and in the first (24 hours), second (48 hours) and third (72 hours) day  after the surgery in the bed of the hospitalization unit. The identified PI were classified according to the National Pressure Ulcer Advisory Panel (NPUAP) practice guidelinesThe NPUAP classifies pressure lesions in stages 1, 2, 3 and 4, unstageable pressure injury, deep tissue pressure injury, medical device related pressure injuries, and to mucous membranes related pressure injuries. PI stage 1 shows intact skin with non-blanchable erythema. PI stage 2 is characterized by Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. In LPP stage 3 there is full-thickness loss of skin, in which granulation tissue and is often present and slough and/or eschar may be visible. The stage 4 pressure lesion is characterized by full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone, and there is slough and/or devitalized tissue. Unstageable PI shows full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Resulting from friction or shearing, deep tissue PI presents intact or non-intact skin, localized dark red, brown or purple, persistent and non-blanchable area or with separation from the epidermis revealing a dark wound bed or blood-filled blisterThe data collected were analyzed using the SPSS  for Windows, version 22. Absolute and percentage frequency distributions were calculated for categorical variables and measures of central tendency (mean and median) and variability (amplitude and standard deviation) for quantitative variables. A bivariate analysis was used to verify the association between sociodemographic, clinical and anesthetic-surgical variables and the risk of developing perioperative PI according to the ELPO scale. The analysis included measures of association in contingency tables  followed by logistic regression, adjusting for other potentially relevant variables. The inferential analyses considered a level of significance of 5% (α = 0.05).This study is part of a larger project approved by the Research Ethics Committee of the Federal University of the Triângulo Mineiro under the Certificate of Presentation for Ethical Assessment (CAAE) 63030316.9.0000.5154 and Opinion number 1.916.567 / 2017.Between February and May 2017, a total of 869 patients were submitted to elective surgical interventions at the hospital under investigation. Of these, 278 were included in the study and 591 were excluded, according to The majority of the participants were female , white  and adults , and the mean age was 48.7 years, with a minimum of 18 and maximum of 90 years .Regarding body mass, the mean weight was 73.1 kg (SD = 17.3), with a minimum of 41.6 and maximum of 142.5 kg. The mean height was 1.62 m (SD = 9.3), with a minimum of 1.41 and maximum of 1.88 m. The mean BMI of the participants was 27.7 (SD = 5.9), with a minimum of 17.3 and maximum of 49.1. As for the nutritional classification of the 203 adults, there was a predominance of overweight , followed by obesity , while among the 75 elderly, 36 (12.9%) were eutrophic.Only 69 (24.8%) patients presented altered hemoglobin levels, with a mean value of 3.2 g/dl, a minimum of 8 and a maximum of 18 g/dl. Regarding physical status, the majority  was classified as ASA II. The mean atrial temperature at the beginning of the anesthetic induction reached 36.4 °C, with a gradual decrease as the anesthetic time increased, so that, after 240 minutes of the onset of anesthesia, it fell to 35.1 °C.Regarding the type of support surface, cushions in the elbows (right and left) predominated , followed by cushions in the occipital region  and calves .Regarding the risk for the development of perioperative PI according to the ELPO scale, the majority  of the patients evaluated presented a high risk for the event. The mean ELPO score was 20.09 points (SD = 3.63), with a minimum of 13 and a maximum of 29 points.As for the association between sociodemographic and clinical variables and the ELPO score of the patients submitted to elective surgeries, the female sex, elderly group, and altered BMI were related with a statistically significant greater risk for the development of perioperative PI, with differences .It was observed that 77% (214) of the patients presented pressure injuries due to the surgical position, most of them in stage 1, and only one participant presented stage 2 PI, and another presented deep tissue PI.The majority of the patients submitted to elective surgeries included in this study were white. The structure of the skin varies between the different colors; in the black race the structure of the stratum corneum is more compact, providing greater resistance to the skin in the face of chemical irritations and/or trauma. The white skin, in turn, is more vulnerable to the occurrence of pressure injuries,Studies have demonstrated that the nutritional status indicated by albumin levels ≤ 3 g/dL and changes in BMI  may also influence the occurrence of perioperative PIIn the present sample, approximately 25% of the patients had altered hemoglobin levels. Low levels of hemoglobin deserve attention because they imply less transport of nutrients and oxygen to tissues, and consequently become a significant factor involved in the maintenance of skin integrityMost of the patients in this study were classified as ASA II with respect to physical status, corroborating the results of another investigation, whose participants classified as ASA II and III presented higher risk and incidence of perioperative PI when compared to those classified as ASA I-It was found that the atrial temperature decreased gradually as the anesthetic time increased, reaching a mean of 35.1 °C (95.1 °F) 240 minutes after anesthesia. Studies have shown that hypothermia in the intraoperative and postoperative periods occurs in about 60 to 90% of surgical patients and that factors such as anesthetic agents, length of stay in the operating room and duration of the anesthetic-surgical procedure cause a decrease in body temperature,One of the most significant risk factors for the occurrence of perioperative PI is the duration of the anesthetic-surgical procedure because long periods of immobilization and exposure to pressure cause anoxia, tissue necrosis and consequent skin injuryAnother important risk factor in the intraoperative phase is the type of anesthesia. This aspect influences the degree of nervous system depression, pain receptors depression, and relaxation of muscles, so that the patient’s defense mechanisms do not offer protection against pressure, leading to susceptibility to pressure injury and painSeveral surgical positions were analyzed in this study. The Trendelenburg, supine and lithotomy type were the more frequent. Of the several positions and their variations frequently used in anesthetic-surgical procedures, lithotomic position is the one that offers the greater risk of complications. In the supine position, complications only occur in cases where the patient is inadequately positioned and/or when the patient remains in this position for an extended time, favoring the increase of pressure points against the surgical tableThe correct and safe positioning of the patient implies the use of supports and cushions, soft bandages, lowering of the height during the raising of the legs and, especially, adequate support surfaces (SS)SS are specialized devices, overlays, mattresses or integrated systems manufactured for pressure redistribution, control of shear or frictional forces on tissue, microclimate maintenance or other therapeutic functions. They should be chosen according to the specific needs of the patient and the type of surgery,Studies have shown that the non-use of support surfaces during the intraoperative period increases the risk of perioperative PISome of the objectives of nurses in the intraoperative period involve reduction, relief and redistribution of pressure. These are the three guiding principles to minimize the risk of perioperative PI. Nurses may implement them by using support surfaces to alleviate the pressure as much as possible, considering the specific needs of each patient,Regarding the presence of comorbidities, diabetes mellitus is considered one risk factor for the occurrence of perioperative PI because its pathophysiology includes a decrease in blood flow that causes tissue perfusion impairment and healing problems due to the difficulty to replace endothelial cellsA longitudinal study of patients undergoing major surgeries in northern Italy showed that diabetes mellitus as well as cardiac and vascular diseases are significant risk factors for the development of decubitus ulcersThe early identification of perioperative PI risk through the use of risk assessment scales such as ELPOThe present study showed that 56.5% of the patients presented a perioperative PI risk, while another study a majority (53.2%) of participants with ELPO score ≤ 19 points, that is, a lower risk for this type of injury-This study revealed that the variables female gender, elderly group, and altered BMI presented statistically significant results, that is, they were significant contributing factors for a greater risk of perioperative PI. Another study identified a higher perioperative PI rate among men than among women,Regarding the association of age group with risk of developing perioperative PI, the literature is in line with the present findings in the sense that this group being the one under highest risk for the development of PI. Researchers have shown that the elderly are the group at higher risk because their skin goes through a physiological process inherent to aging that causes reduction of skin elasticity and texture, muscle mass, inflammatory response, albumin levels, and subcutaneous tissue, making the skin more susceptible to pressure and, consequently, to the development of tissue damagePerioperative complications increase with age. The elderly are, therefore, more exposed to the risk of perioperative PI,In contrast to these results, other studies showed that elderly patients did not present a higher risk of developing perioperative PI when compared to adults2 was a predisposing factor for the occurrence of PI (p < 0.001)Regarding the nutritional status, a study corroborated the results of the present research in the sense that BMI was associated with greater risk for the development perioperative PI. In the said study, BMI > 30 Kg/mResearchers from a recent literature review found that overweight and low weight increased the perioperative PI riskThe incidence of perioperative PI deserves to be mentioned in this study. It is noteworthy that 77% of the patients submitted to selective surgeries developed this type of lesion at one of the operative moments evaluated. A study of a cohort of 3225 patients submitted to surgical interventions found that 383 (12%) of these people had this type of lesionIt is important to understand that the incidence of these injuries remains high due to the absence of preventive measures. Moreover, non-compliance or non-observation of norms and/or clinical guidelines and protocols is the main contributory factorDue to the variety of surgeries and the peculiarities of each patient, nurses are responsible for assessing the risks to which individuals are exposed in the preoperative phase, as well as the tools and devices available for the implementation of safe and effective actions to prevent complicationsDeveloping a strategic plan to address risk factors throughout the perioperative period by determining the causes of injury, identifying any barrier that compromises patient safety, and investigating possible interventions that reduce the incidence of this complication may be the key to prevent PIA limiting factor in this study was the non-evaluation of the microclimate (heat and moisture of the skin) and the non-follow-up of patients in the postoperative period. However, this did not compromise the reliability of the results. Another limiting factor was the design of the study; descriptive studies do not allow the establishment of cause-and-effect relationship.This research contributes to the construction of knowledge about the nursing practice in the care of patients in the perioperative period of elective surgeries. Factors that contribute to the greater risk of developing perioperative PI were highlighted. Inserting nurses in care improvement processes is essential because these professionals play a key role in the prevention of perioperative complications. The ELPO scale is a management tool for the clinical practice of nurses and its application can improve the quality of care, patient safety, the evidence-based decision-making process of nurses, and the reduction of pressure injuries arising from surgical positioning.The results of this study showed that the majority of the participants were female, white, adult, overweight, with normal hemoglobin values and classified as ASA II. Regarding intraoperative aspects, most surgeries lasted from one to two hours, and regional anesthesia and Trendelenburg position were the most adopted. Intraoperative hypothermia was observed in 82.4% of the patients. The most used support surface was the surgical table with foam mattress and cotton cushions.Regarding the risk for the development of perioperative PI, the majority of patients presented a high risk. Besides the factors present in the ELPO scale, the variables female sex, elderly group, and altered BMI were statistically significant and represented important risk factors for the occurrence of perioperative PI. Finally, regarding the occurrence of injuries, most of the participants presented perioperative PI. As these injuries are avoidable complications, the importance of quality work on the part of professionals of the perioperative team in the prevention of these lesions stands out.The present study contributed with the provision of important evidence on the risk of perioperative PI. However, for the generalization of these results, further research is necessary. Additionally to the variables present in the ELPO scale, the correlation with other factors eventually associated with the occurrence of pressure perioperative injuries such as albumin and blood pressure levels has to be investigated. It is suggested that a longitudinal study with an extended follow-up be performed with patients in the postoperative period.