Cardiovascular disease is a leading cause of death among kidney transplant recipients. Metabolic syndrome increases the risk for cardiovascular events and decreases graft survival. Lately, guidelines for management of the metabolic syndrome, primarily hypertension, diabetes mellitus (DM) and hypercholesterolemia have dramatically changed in an attempt to decrease cardiovascular risks among kidney transplant recipients. In the present study we examined whether these guideline changes had impact on our management of post-transplantation patients and the subsequent treatment outcomes for these diseases.Data were obtained from kidney transplant clinic files from two follow-up (FU) periods—between 1994–1997 and between 2008–2011. Demographic data, monitoring and screening frequency for cardiovascular risk factors, immunosuppression regimen, treatment for hypertension, diabetes and hyperlipidemia, treatment outcomes and graft function changes were compared between the two follow-up periods.There was a significant increase in the percentage of patients undergoing transplantation due to renal failure secondary to diabetes and/or hypertension. Patient monitoring and screening during the second FU period were less frequent, but more targeted, reflecting changes in clinic routines. Blood pressure was better controlled in the second FU period (p < 0.01), as was hypercholesterolemia (p < 0.001). High fasting glucose levels were more prevalent among patients in the second group (p < 0.005), although more patients received treatment for DM (p < 0.001). Significantly, fewer patients experienced deterioration of kidney functions during the second FU period (p < 0.001).We found that guideline changes had impact on clinical practice, which translated to better control of the metabolic syndrome. DM control is challenging. Overall, stability of kidney function improved. For kidney transplanted patients, graft failure is defined either as a need for a new renal replacement therapy or as patient’s death. Nowadays, about 50 % of graft losses are due to recipient’s death, a major cause for that being cardiovascular disease (CVD) , 2.Many of the risk factors for CVD are included in the metabolic syndrome, which was first described as a combination of central obesity, dyslipidemia, hypertension and fasting hyperglycemia . It has Understanding the importance of a balanced metabolic state for the general population has led to wide screening tests as well as early and aggressive interventions.During the mid-90’s formal guidelines were not as common as they have become in the last 2 decades, more so in special populations such as kidney transplant recipients . InsteadFew large-scale studies have looked at the kidney transplant recipients population, and though most suggested significant benefit in treating hyperlipidemia, diabetes (DM) and hypertension (HTN), evidence levels are not as strong as for the general population . EncouraHere we aimed to elucidate the impact of changes in guidelines on our clinical management of post-transplantation patients, and to test if improvement in controlling the metabolic syndrome evolved as reflected by patients’ blood pressure, fasting glucose levels, serum cholesterol and weights. We therefore compared patient’s monitoring frequency, treatments and treatment outcomes and graft function from 2 different periods representing patients treated under two different follow-up guidelines: 1994–1997 and 2008–2011. Indeed, we found that patient monitoring has changed markedly between the two periods, more patients achieved treatments goals, and graft function was more stable during the latter follow-up period.Data were obtained from files of the out-patient clinic for the follow-up (FU) of kidney transplant recipients at Hadassah Hebrew University Medical center from two time periods: 1994–1997 and 2008–2011. All patients who were under observation for the full time-period (i.e. had visits at least once a year through one of the study periods) were included. Demographic data, transplant specifics, immunosuppressive medications, patient’s weights, prevalence of screening/monitoring tests for metabolic syndrome, treatments for the different cardiovascular risk factors and the last test results were recorded at the end of the relevant FU period. As no data was available regarding patients’ height we were not able to consider BMI. Data regarding ESRD etiology was based on the diagnosis as recorded in patient file.The outcomes examined were glucose level, cholesterol levels and blood pressure measurements as indicative for control of the metabolic syndrome diseases. We also examined changes in serum creatinine during the FU period as a representation of kidney function. The incidence of new onset diabetes mellitus was also recorded. Glucose levels, cholesterol levels and blood pressure measurements were assessed as categorical values, in order to evaluate adherence to guidelines. As only patients under observation for the whole follow up time in each period were included, no graft survival could be calculated.With the ethic committee approval no informed consent was asked, as data were analyzed anonymously.2 test and the Fisher’s exact test were applied. The comparison of quantitative variables between two independent groups was carried out using the t test or the non-parametric Mann–Whitney test when the data was not normally distributed. The logistic multivariate model was applied (using the stepwise forward method), to simultaneously assess the effect of several variables on a dependent dichotomous outcome variable. We also conducted a two-pass analysis , receiving similar results to those achieved with the stepwise forward method. The multivariate linear regression model using the stepwise method was applied to quantitative dependent variables. All tests were two tailed and a p-value of 0.05 or less was considered statistically significant.In order to test the association between two categorical variables, the χThe following data were missing from patient records—weight was unavailable for 44 patients (15 and 29 in groups I and II respectively), pre-transplant DM was unavailable for 4 patients (3 and 1 in groups I and II respectively), last glucose was unavailable for 1 patient (from group I), last total cholesterol was unavailable for 21 patients (1 and 20 in groups I and II respectively), last LDL was unavailable for 60 patients (40 and 20 in groups I and II respectively), last TG was unavailable for 42 patients (24 and 18 in groups I and II respectively), last creatinine (and delta-creatinine) was unavailable for 6 patients . Only available data was used for statistical analysis.ESRD etiology was not clear for 41 patients (12 and 29 in groups I and II respectively) as they presented with ESRD. They are included in others . The prevalence of pre-transplant DM was significantly higher in group II , in accordance with the older age as mentioned of the recipients. Notably, serum creatinine levels at the beginning of the FU period were similar between the groups.Tacrolimus was not used in the earlier time period, while 61 % of patients in group II received this drug. Accordingly, cyclosporine use decreased drastically. Furthermore, cyclosporine mean blood levels were lower in the second group.As seen in Fig. 24-hour BP monitoring was more common in group II, though not statistically significant. During 2008–2011 only 8.4 % of the patients underwent the test, indicating it has not yet become standard practice.Lipid profile measurements were also more frequent in group I. We suspect that this difference is a result from a change in clinic practices, since in the second study period lipid measurements were ordered actively by the physician while in the first period they were done routinely at every clinic visit.We were not able to compare diabetes monitoring and screening frequency. Data regarding fasting status at glucose measurement during the second study period were missing, and HbA1C measurements were not available during the early period. Patients in group II had a mean of 1.3 measurements of HbA1C during the follow-up period. Patients already being treated for diabetes had a mean of 2.85 tests compared with 0.46 in patients not treated  was higher in group II . This might reflect the higher percentage of patients receiving tacrolimus and the older age of this group.Since HbA1C measurements were not available in the early period, we compared DM management between the patient groups by fasting glucose measurements. Glucose levels were assessed as a categorical variable, in order to differentiate controlled vs. uncontrolled diabetes . In group I more patients had a fasting glucose <7 mmol/L (e.g. as recommended) than in group II . Total cholesterol was better controlled at the second period Fig. d. Factor58.2 % of patients in group II had TG levels under 150 compared to 40 % in group I (p < 0.02). Levels above 500 were rare (only 1 patient in group I and none in group II).Table An important and encouraging finding is the difference noted between the groups regarding stability in kidney function. Serum creatinine levels were measured at the beginning and end of the FU period and delta-creatinine (creatinine level at the end of FU minus creatinine level at the beginning of FU) was calculated. Changes in kidney function were defined as follows: improvement = decrease in creatinine >50 μmol/l or return to normal range, deterioration = increase in creatinine 50–100 μmol/l, significant deterioration = increase in creatinine >100 μmol/L. The data show that only 5.1  % of patients in group II experienced a deterioration in kidney function during the follow-up period compared to 29.8  % in group I Table . FactorsIn this study, we aimed to determine whether changes in guidelines for monitoring and treatment of CVD risk factors have been implemented in our clinic and whether treatment outcomes of these risk factors have improved. We therefore examined records from 2 different periods representing patients treated under two different follow-up guidelines, and compared monitoring frequency and treatment outcomes.The two patient groups differed in many aspects, in accordance with trends seen in the transplantation world during the last years. Changes in patient demographics as ESRD etiology and age, increase in the percentage of living donors, emergence of new immunosuppressive drugs, subsequent change in treatment protocols and heightened awareness for the metabolic syndrome, can have an impact on the metabolic syndrome itself, and on graft function and survival, and therefore were taken into account when analyzing treatment outcomes.Our results show that patient monitoring has changed markedly between the two periods. While some tests were done more frequently during 1994–1997 due to automatic routines, during the second study period the clinic practices have become more methodical.DM is now the most common cause of ESRD leading to transplantation , is prevHypertension occurs in 60 to 80 % of renal transplant recipients, associated with an increased risk for chronic graft failure and CVD , 31. CauWe were pleased to see that BP improved dramatically between the two time periods. We believe this result from heightened physicians’ awareness and earlier and more aggressive treatment, as can be seen in the significant increase in number of medications used.Hyperlipidemia leads to increased risk of CVD after renal transplantation . In the The significant improvement in metabolic syndrome control between the groups results from evolution in patient treatment that occurred during the last two decades. It can be attributed to an increased awareness to monitoring and treatment of the metabolic syndrome components, but it might also be the consequence of other changes. Immunosuppressive drugs, among other factors, can contribute to the metabolic syndrome in transplant patients . For exaKidney function stability in the later follow-up period is probably multifactorial. It can be attributed, in part, to improvement in immunosuppressive regimen including the addition of tacrolimus. Another factor contributing to better graft survival might be an increased rate of living donors. However, as graft survival nowadays is highly affected by cardiovascular morbidity and mortality of the recipients, we believe that some of the change for the better in kidney function stability is related to a better control of the metabolic syndrome.Since the study was conducted in one medical center there may be a selection bias. However, as the population in our clinic is diverse and includes many different sub-populations, we expect this selection bias to be minimal. An additional limitation was the relatively small number of patients in the first time period, which might cause selection bias. The reason for a smaller group was partly because of lower total number of patients followed at the clinic at that time. Also, small number of patients were not included because they did not meet the inclusion criteria of a yearly visit through the whole period, some of them because they went back to dialysis. This might cause a bias decreasing the differences seen between the two groups regarding the kidney functions outcome, but also regarding the blood pressure. Also, the total percentages of patients having a metabolic syndrome could not be evaluated, as no data was available about patients’ height  or central obesity. Missing data was not a significant problem for data related to kidney function, glucose levels and blood pressure therefore not considered as potential source for bias. Cholesterol levels were absent for 20 out of 273 patients from the second period. As patients in this group had significantly much lower cholesterol levels, this could cause a bias by decreasing the improvements we found in controlling cholesterol levels.In conclusion, our results indicate that changes in guidelines for monitoring and treatment goals of the metabolic syndrome have had a great impact on management of kidney transplant recipients. The majority of the patients meet the treatment goals as defined by KDIGO, even though there is still a significant number of patients who require further efforts to achieve better clinical outcomes, especially regarding DM control. The significant improvement we saw in kidney function stability over time was most gratifying, as it demonstrates that overall, the various changes in management of renal transplant patients in the last decade, including among other things modification of immunosuprressive regiments and better control of blood pressure and cholesterol levels are associated with improvement graft function.


Sublingual varices have earlier been related to ageing, smoking and cardiovascular disease. The aim of this study was to investigate whether sublingual varices are related to presence of hypertension.In an observational clinical study among 431 dental patients tongue status and blood pressure were documented. Digital photographs of the lateral borders of the tongue for grading of sublingual varices were taken, and blood pressure was measured. Those patients without previous diagnosis of hypertension and with a noted blood pressure ≥ 140 mmHg and/or ≥ 90 mmHg at the dental clinic performed complementary home blood pressure during one week. Those with an average home blood pressure ≥135 mmHg and/or ≥85 mmHg were referred to the primary health care centre, where three office blood pressure measurements were taken with one week intervals. Two independent blinded observers studied the photographs of the tongues. Each photograph was graded as none/few (grade 0) or medium/severe (grade 1) presence of sublingual varices. Pearson’s Chi-square test, Student’s t-test, and multiple regression analysis were applied. Power calculation stipulated a study population of 323 patients.p < 0.002). Mean systolic blood pressure was 123 and 132 mmHg in patients with grade 0 and grade 1 sublingual varices, respectively . Mean diastolic blood pressure was 80 and 83 mmHg in patients with grade 0 and grade 1 sublingual varices, respectively . Sublingual varices indicate hypertension with a positive predictive value of 0.5 and a negative predictive value of 0.80.An association between sublingual varices and hypertension was found (OR = 2.25, An association was found between sublingual varices and hypertension. Examining the lateral borders of the tongue is easily done, causes no harm and could be a valuable method for the dental profession to take active part in preventive healthcare. Hypertension is the primary risk factor for global disease burden  and causA major part of the population visits their dentist on a yearly basis. Approximately 80 % of Swedish grown-ups are in contact with a dental team by a recall system, and about 60 % visit the dental team yearly. Together with a long tradition of prophylactic work, the dental team could potentially be a good screening partner for hypertension by investigating the patient’s oral cavity.A common condition that may be found by the dentist is varicosities, a benign venous lesion. This condition can be found in several locations within the oral cavity; in the buccal mucosa, in the lower lip mucosa, and most often under the lateral borders of the tongue, i.e. sublingual varices .Sublingual varices are clinically characterised by small dilated veins under the lateral borders of the tongue. Their pathogenesis may be due to a change in the connective tissue or weakening of the venous wall, as a result of degeneration of elastic fibres related to the ageing process –5. The pThe aim of this study was therefore to investigate whether sublingual varices are related to presence of hypertension.This observational study was performed between May 2010 and February 2013 at the Public Dental Services, Varberg, Sweden.Patients above the age of 40 years were invited to participate in the study in connection to their regular yearly visit. They received both verbal and written information about the study. Those who accepted to participate provided written consent. Exclusion criteria were pregnancy, atrial fibrillation and renal disease . The stuPatients answered a questionnaire about background information  and health status . One intraoral digital photograph of each lateral borders of the tongue were acquired before the routine oral survey. Thereafter, the patient rested for at least 5 min in a quiet room. Blood pressure was measured in a sitting position, 2 times in each upper arm using the Korotkoff-Riva-Rocci method, using a cuff, a calibrated manometer and a stethoscope. If a patient had no previous diagnosis of hypertension and the measured average systolic blood pressure was ≥ 140 mm Hg, and/or the average diastolic blood pressure was ≥ 90 mm Hg, the patient was asked to use a home blood pressure device  for 1 week . The folIf the average home blood pressure was systolic ≥135 and/or diastolic ≥85 mm Hg the patient was referred to his ordinary primary health care centre , 12, wheThe two digital photographs of each patient were examined in a blinded fashion by 2 observers (one of the authors and one dentist not involved in the study) not having knowledge about the other’s results nor the patient’s blood pressure or health status. Both observers viewed the photographs using the same screen. All photographs were graded as none/few visible sublingual varices  were coded as dummy variables. All statistical analyses were performed using IBM SPSS Statistics version 20. Pearson’s Chi-square test, Student’s t-test, and multiple logistic regression analysis were applied. Correlation between observers was analysed using Cohen’s kappa coefficient. Descriptive statistics with index of validity, sensitivity and specificity were also used. All tests were two-sided and the significance cut-off was set at 0.05.The expected prevalence of hypertensive patients in a Swedish population above 40 years of age is 38 % . The preA total number of 454 patients were invited to participate in the study. Seventeen patients3.7 %) resigned from the study . Of the remaining 437 patients, 2 were excluded due to lack of photographs of the tongue, and 4 patients refused to visit the district nurse for follow-up after initial high blood pressure was observed at inclusion. In total 431 patients underwent the complete study protocol. The total dropout number was thus 23 patients . The gender distribution was 188 male and 243 female. The prevalence of smokers was 46 (10.7 %), and 202 (46.9 %) expressed heredity for hypertension. For 92 patients, previously known hypertension was reported (21.3 %) with a mean duration from diagnosis of 7.2 years (SD 7.2), and another 28 patients (6.5 %) had other cardiovascular disease  and 30 patients (7.0 %) had lower limb varices. During the study another 28 participants were identified having hypertension .The prevalence of sublingual varices was 26.5 % (114/431) in the study population, with 18.3 % among those having normal blood pressure, and 47.5 % among those diagnosed with hypertension (p = 0.005).The mean systolic blood pressure measured at inclusion at the dental clinic was 123.2 mm Hg (SD 17.3) in the group with grade 0 sublingual varices and 132.1 mm Hg (SD 19.3) in the group with grade 1 sublingual varices , and further to 43.6 % among those with stage 2 hypertension (p = 0.001).The prevalence of grade 1 sublingual varices increased with increasing blood pressure measured at inclusion at the dental clinic, from 21.8 % among those with normal blood pressure to 30.8 % among those with stage 1 hypertension (n = 28), the prevalence of grade 1 sublingual varices was 46.2 % and 53.3 % in patients with stage 1 hypertension and stage 2 hypertension , respectively.In the group with newly diagnosed hypertension at the primary health care centre  of 0.5, and a negative predictive value (NPV) of 0.80  in the current study population would identify 48 % of hypertensive patients, with a high specificity of 0.82.Based on the results of the current study, a patient above 40 years of age with sublingual varices has a 50 % risk of being hypertensive, and if also being a smoker the risk increases to 58 %. If sublingual varices are not present the chance of being normotensive is 80 %. The high positive predictive value for hypertension, combined with no discomfort for the patient and minor effort for the dentist, makes sublingual varices highly interesting as a clinical sign to note in the oral status.An association was found between sublingual varices and hypertension in patients over 40 years of age. With a sensitivity of 0.48, a specificity of 0.82, a PPV of 0.5, and an NPV of 0.80 the identification of sublingual varices is highly interesting as an indicator of hypertension. Examining the lateral borders of the tongue is easily carried out by a dentist, causes no harm to the patient, and could be a valuable method for the dental profession to take active part in preventive healthcare.


This study aimed to compare the changes in kidney function and the association of tumor size and renal outcomes between patients with renal cell carcinoma (RCC) who underwent radical nephrectomy (RN) and those who underwent partial nephrectomy (PN).A retrospective cohort study was conducted for 557 patients with an RCC of ≤7 cm in diameter and normal contralateral kidney function who underwent PN or RN. PN was performed for 218 (39%) patients. Renal outcomes included the incidence of acute kidney injury (AKI), new-onset chronic kidney disease (CKD), and a ≥25% decline in eGFR 1 year after surgery.P <0.001) than after PN . According to the multivariable logistic regression analysis, RN was an independent risk factor for a ≥25% decline in kidney function after 1 year regardless of the tumor size, even after adjusting for various covariates.Serial changes in eGFR were compared during the 3 years of follow-up. Postoperative eGFR was significantly lower in patients undergoing RN than in those undergoing PN. The incidence of AKI and new-onset CKD was significantly higher in patients after RN (70.1% vs. 24.3%, respectively; Compared to PN, RN for even a moderate sized RCC leads to an increased incidence of AKI and new-onset CKD, and is a significant risk factor for kidney function decline. Therefore, PN should be considered as the choice of surgical treatment for RCCs that are ≤7 cm in diameter in order to preserve renal function postoperatively. Kidney cancer is the 13th most common malignancy worldwide and ranks 3rd among the leading causes of genitourinary cancers in Korea .Recently, the development and widespread use of imaging technologies have led to a decrease in the size and stage migration of newly detected renal cortical tumors. In the last two decades, increased detection of small renal masses has led to a greater utilization of partial nephrectomy (PN). In patients with small renal cortical tumors, radical nephrectomy (RN) is a significantly independent risk factor for the development of chronic kidney disease (CKD) than PN , 4. PresWe hypothesized that RN influences the risk for deleterious renal outcomes for acute or chronic state patients with small and moderate sized RCCs. The aim of this study was to compare the changes in kidney function and various renal outcomes as well as the association of tumor size and renal outcomes between patients with RCC undergoing RN and those undergoing PN. We hope that the findings of this study will help enhance surgical treatment and improve clinical outcomes for patients with RCC.2 (n = 1), a RCC >7 cm in diameter (n = 82), and those who had a nephrectomy for metastatic RCC (n = 1). A total of 557 patients were included in the final analysis. RN was conducted in patients with a tumor involving a more central position of the kidney, suspected lymph node involvement, and multiple tumors in a single kidney. Patients with a tumor of <7 cm in size underwent a PN when it was technically feasible. Otherwise, the surgical modality was chosen at the discretion of the surgeon. Cases of death were ascertained by data linkage of the national death certificate database of Statistics Korea and the regional cancer registries. The waiver of informed patient consent and approval of the study protocol were obtained by the Institutional Review Board of Chonnam National University Hospital in 2014. This study was conducted according to the principles of the Declaration of Helsinki.The electronic medical records were reviewed for all adult patients undergoing RN or PN for kidney cancer between December 2003 and December 2012 at the Chonnam National University Hospital. Among the 916 patients identified, we excluded patients with bilateral tumors and benign renal masses (n = 263), end-stage renal disease , an estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 mLaboratory data regarding the levels of serum creatinine (SCr), hemoglobin, and urine protein were obtained from the medical records and reviewed by a trained study coordinator. SCr levels were measured at 6 time points .Tumor stage was reassessed according to the American Joint Committee on Cancer and the International Union for Cancer Control tumor-node-metastasis classification . The FuhAcute kidney injury (AKI) was defined according to the Kidney Disease Improving Global Outcomes clinical practice guidelines. According to these guidelines, AKI is present when an abrupt reduction in kidney function results in an absolute increase in the SCr level by ≥0.3 mg/dL within 48 hours, a known or presumed ≥1.5-fold increase in the baseline SCr level within the prior 7 days, or a reduction in urine output (<0.5 mL/kg/h) for 6 hours . We did 2 3 months after nephrectomy in patients with a preoperative eGFR >60 mL/min/1.73 m2.New-onset CKD was defined as a decrease in the eGFR to <60 mL/min/1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation as follows: 141 × minimum α × maximum -1.209 × 0.993age × 1.018  × 1.159 (if black), where κ is 0.7 for women and 0.9 for men, and α is -0.329 for women and -0.411 for men [SCr levels were analyzed by the Jaffe method, which was calibrated by isotope dilution mass spectrometry. The eGFR  between RN and PN at various time points. We performed a two-way analysis of variance (ANOVA) with repeated measures to compare the mean changes of eGFR over time between RN and PN according to tumor size. Within-group comparisons for eGFR at 7 days, 3 months, and 3 years were performed using a general linear model-ANOVA followed by a Bonferroni’s correction applied to the post-hoc analysis for multiple comparisons using a pared t-test; a P value of 0.017 was considered statistically significant. Multivariable logistic regression analyses were performed to identify the independent predictors of adverse renal outcomes according to tumor size after nephrectomy. Age, sex, blood pressure (systolic and diastolic), body mass index, history of smoking, hypertension, and diabetes mellitus, urine protein levels, type of surgical procedure, and the pathologic stage were all included in the multivariable logistic regression analysis. All statistical tests were 2-tailed and P <0.05 was considered significant. The analyses were performed using the Statistical Package for Social Sciences software, version 17.0 .Continuous variables were presented as mean ± standard deviation and categorical variables were expressed as the number and percentage of patients. Comparative analysis was performed using Student’s 2. RN and PN were performed in 339 (61%) and 218 (39%) patients, respectively. The clinical characteristics of the patients with RCC are listed in Table 2 vs. 80.1 ± 17.6 mL/min/1.73 m2, respectively). However, there were no differences between the RN and PN groups for age, sex, body mass index, hemoglobin levels, degree of urine protein, and a history of hypertension, diabetes, coronary artery disease, cerebral vascular disease, and smoking. Apart from the tumor size and pathologic stage, there were no significant differences in pathological characteristics  between the RN and PN groups (Table P = 0.004). The overall recurrence rate was greater in the RN group than in the PN group . However, there was no difference in recurrence rate at the ipsilateral or contralateral kidney between the RN and PN groups .A total of 557 patients were included in the retrospective analysis. The mean age of the patients was 60.7 years, 393 (70.6%) patients were male, and the mean baseline eGFR was 81.5 ± 16.7 mL/min/1.73 mP <0.05), as determined using two-way ANOVA with repeated measure analysis. The RN and PN groups, categorized according to tumor size, also showed similar changes in eGFR after surgery, even though the baseline eGFR was not different between the 2 groups. The mean eGFR decreased from 80.1 mL/min/1.73 m2 before surgery to 56.2 mL/min/1.73 m2 at 3 months (P <0.001) and then increased to 59.0 mL/min/1.73 m2 3 years after RN (P = 0.001). However, there were no significant changes in eGFR over time  in patients with PN.Serial changes in the mean eGFR from before surgery to the time points following surgery  according to the type of surgery  and tumor size (≤4 cm and 4 cm < tumor size ≤7 cm) are shown in Figure P <0.001). Furthermore, the incidence of transient and persistent AKI was significantly higher in patients undergoing RN than PN. In addition, compared to the PN group, the RN group had significantly higher prevalence of new-onset CKD 3 months after the operation  and a ≥25% decline in the eGFR after 1 year , even after adjusting for age, sex, and proteinuria. All-cause mortality was significantly higher in patients undergoing RN than in those undergoing PN . Among these patients, there was 1 case of death in a patient undergoing RN, who died due to end-stage renal disease; no cases of deaths were observed in the PN group.As shown in Table P <0.001; OR = 12.6; 95% CI = 1.45–108.9, P = 0.022, respectively).We identified independent risk factors for the adverse renal outcomes that were categorized according to the tumor size after nephrectomy by using multivariable logistic regression analysis Table . Among tIn this study, we determined that the postoperative eGFR was significantly lower in patients undergoing RN than those undergoing PN during the 3 years follow-up period. Patients undergoing RN also had a higher risk of various adverse renal outcomes  compared to those undergoing PN. Furthermore, RN increased the risk for deleterious renal outcomes for patients with small (tumor size ≤4 cm) and moderately (4 cm < tumor size ≤7 cm) sized RCCs. Therefore, our hypothesis that RN increases the risk for deleterious renal outcomes for acute or chronic state patients with small and moderately sized RCCs is supported by the findings of the present study.2) after operation for localized renal tumors [RN is now recognized as an independent risk factor for the development of CKD when used as a treatment for small renal tumors , 10. Nevl tumors . Althougl tumors , 11, 18.l tumors . Researcl tumors –22. Furtl tumors . The canl tumors .Complete surgical excision by PN is recommended for patients with all clinical T1 kidney tumors  based on compelling data demonstrating that RN is associated with an increased risk of CKD , 26. IntA lower eGFR before surgery would affect the postoperative kidney function. Although the preoperative eGFR was significantly lower in patients undergoing RN than in those undergoing PN in the total cohort, which might be due to the fact that RN was performed more frequently in patients with RCC >4 cm in size, there was a correlation between increased tumor size and decreased preoperative eGFR . HoweverAccording to two retrospective studies, compensatory hypertrophy in the non-operated healthy kidney occurs between 7 days and 4 weeks after RN , 28. HowThe present study has several limitations. Firstly, our study was of retrospective nature and therefore, our findings may be affected by confounding factors or selection bias. Secondly, we could not evaluate the non-neoplastic kidney disease, which may have had an effect on kidney function decline in patients with RCC after nephrectomy. However, there were no differences in comorbidities  between patients undergoing RN and PN in this study. Thirdly, long-term renal outcomes could not be fully evaluated despite checking the eGFR at various time points after the operations.Despite these limitations, our study had some strengths. Firstly, we used the recently validated Chronic Kidney Disease Epidemiology Collaboration equation to calculate the eGFR, while most previous studies involved the Modification of Diet in Renal Disease equation that systematically underestimates GFR in individuals without known CKD . SecondlThe risk for the incidence of AKI, new-onset CKD, and kidney function decline in patients undergoing RN was higher than that of patients undergoing PN even for moderately sized RCC tumors. Therefore, PN should be considered as the surgical treatment of choice for RCCs up to 7 cm in size, which will allow for the preservation of renal function postoperatively.


Chronic Kidney Disease (CKD) is a major global health problem. CKD is one of the most common complications of diabetes mellitus and hypertension and carries a risk of cardiovascular morbidity and mortality and progression to end-stage kidney disease.This study sought to use the 2012 Kidney Disease Improving Global Outcomes (KDIGO) definitions to establish the prevalence and risk factors for CKD among a high risk population in the Sekondi-Takoradi metropolis.Cross sectional study.Effia-Nkwanta regional and the Takoradi Government hospitals in South Western Ghana.Two hundred eight consecutive adults with diabetes, hypertension or both.Serum creatinine and urine albumin-creatinine ratio respectively. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) was used to estimate glomerular filtration rate (GFR).CKD was classified according to KDIGO.The prevalence of CKD was 30 %: 27 % in patients with diabetes, 22 % in patients with hypertension only and 74 % in patients with both diabetes and hypertension. GFR category G3a CKD was most prevalent stage (9 %). Albuminuria was highest among people with diabetes (39 %).A convenience sample of patients attending clinics.CKD was prevalent in these high-risk patients. Chronic Kidney Disease (CKD) is defined as abnormalities of kidney structure or function, present for more than 3 months, with implications for health , 2. It iChronic kidney disease (CKD) is one of the most common complications of diabetes mellitus  and hypeSeveral studies within sub-Saharan Africa have examined the prevalence of CKD in people at high risk, including those with diabetes and hypertension. Janmohamed et al.,  recorded2 and is located in the South-Western part of Ghana and about 242 km west of Accra, the capital city of Ghana.A cross-sectional study was conducted at the outpatient diabetes and hypertension clinics of the Effia-Nkwanta Regional hospital (ERH) and the Takoradi Government Hospital (TGH) in the Sekondi-Takoradi metropolis between December 2012 and May 2013. These serve as the major healthcare facilities in the metropolis providing primary, secondary and tertiary healthcare services for a population of 445,000. The healthcare system is accessible to those who contribute or pay the minimum of GH 20.0 yearly premium, equivalent to about three times the daily minimum wage of GH 6.0; about 66 % of the population is covered. In Ghana, patients with diabetes or hypertension receive specialized care in teaching, regional or municipal hospitals since they are the only facilities with the capacity to diagnose and manage this condition. Sekondi-Takoradi is the administrative capital of the Western Region. It has a land area of 385 kmWe enrolled eligible adult (>18 years) outpatients receiving medical care at the diabetes and hypertension clinics of the hospitals during the study period. Patients diagnosed with high blood pressure or on anti-hypertensive drugs, diabetes or both hypertension and diabetes were included in this study. We excluded patients with other kidney diseases , those undergoing peritoneal or hemodialysis, and those with inflammatory bowel disease or rheumatoid arthritis. We also excluded people with known hepatitis B or C and HIV/AIDS.We screened 382 consecutive patients with diabetes, hypertension or both who visited the outpatient department of the two hospitals for routine evaluation. Diabetes was defined as a diagnosis of diabetes or taking a hypoglycaemic drug, and hypertension as a diagnosis of hypertension or taking an anti-hypertensive drug. Information on age, gender, fasting blood glucose, body mass index (BMI), systolic blood pressure and diastolic blood pressure, medication used, duration on medication, and duration of diabetes was obtained using a pre-tested questionnaire and the patient medical records.Trained personnel used a mercury sphygmomanometer  with a standard or a large cuff, appropriate to the patient’s size, to measure blood pressure after patients rested for 5 min, in accordance with recommendations of the American Heart Association Council on High Blood Pressure Research . We repo2), and categorized according to WHO criteria into normal weight (BMI 18.5–24.9), underweight (<18.5), overweight (25.0–29.9), obese (30.0–39.9) [Height (nearest centimetre) and weight (nearest 0.1 kg), without shoes and in light clothing were measured. Participants were weighed on a bathroom scale  and their height measured with a wall-mounted ruler. BMI was calculated by dividing weight (kg) by height squared (m.0–39.9) .A 4 ml venous blood sample was collected from each participant and 1 and 3 ml were dispensed into a fluoride oxalate tube and a serum gel separator tube respectively. After centrifugation at 1500 g for 3 min, the plasma and serum were stored in cryovials at −80 °C until assays were performed.Plasma fasting blood sugar (FBS), serum urea and creatinine were estimated using automated chemistry analyzer (Selectra JR). Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation using the coefficients for black ethnicity in all .Urine protein was quantitatively estimated using the method of . Estimatwww.graphpad.com). Two-sample Student’s t test and chi-squared or Fisher’s exact test, as appropriate, and one-way analysis of variance (ANOVA) were used to compare groups. A P-value ≤0.05 was considered statistically significant.Analysis was performed using Graphpad prism version 5.0  and the committee of ethics of TGH and ERH. Written informed consent was obtained from all participants.Study procedures including collection of clinical data and the laboratory tests were funded by the authors.We screened 382 consecutive patients, of whom 76 were less than 18 years, and 67 declined to participate: of the 239 consenting participants, 208 provided both blood and urine samples  and are the subject of this report. Mean age was 60 and 71 % were female .Overall, 13 of 208 participants (6.2 %) had GFR less than 30, and 50 (24 %) had eGFR less than 60 mL/min/1.73 mTable Multivariable predictors of the presence of CKD were diagnosis category and duration on medication, both with odds ratios around 10, but not age, gender or BMI Table .Table 4MWe identified a prevalence of CKD in patients with hypertension of 22 % and in patients with diabetes of 27 %. In patients with both hypertension and diabetes, the prevalence was 74 %, and 26 % had category G4 CKD. Clinical factors associated with a greater risk of CKD were the presence of both hypertension and diabetes, and duration on medication (antidiabetic and antihypertensive).Osafo and colleagues  reportedOsafo and colleagues  observedGood blood pressure control and ACE inhibitors are known to have a reno-protective effect, particularly in people with albuminuria . In our Our study has several limitations. First our findings cannot be generalized to other low income and low resource countries because it was not community based and was conducted within a population at risk of developing CKD with genetic and cultural differences. Further, there may be differences in the practices that lead to a patient being identified as having hypertension or diabetes, and differences in access to treatments for, and monitoring of those conditions. The study was conducted in the Sekondi-Takoradi metropolis. It is likely that there would be significant variation in prevalence rates in other urban and rural towns in the Western region and across Ghana as a whole. This study is also limited by the small sample size, use of the single measurement of serum creatinine , and by our lack of standardization of serum creatinine to isotope mass dilution spectrophotometry (IMDS). Third, although the CKD-EPI eGFR equation has been used in previous studies in this population , 18, 19 CKD was detected among 30 % of this high-risk population. Further research is needed into optimal approaches to screening and treatment, including research on the effects of lowering economic barriers to known effective treatments. This is particularly important in resource-constrained practice settings such as ours, because the impact of the development of end-stage renal disease when dialysis cannot be provided is so much greater.


Subjects reported feeling significantly more “relaxed” and “natural” according to the Semantic Differential (SD) method. Profile of Mood State (POMS) negative mood subscale scores for “tension-anxiety,” “confusion,” and “anger-hostility,” as well as the Total Mood Disturbance (TMD) score were significantly lower following forest therapy. These results highlight that forest is a promising treatment strategy to reduce blood pressure into the optimal range and possibly prevent progression to clinical hypertension in middle-aged males with high-normal blood pressure.Time spent walking and relaxing in a forest environment (“forest bathing” or “forest therapy”) has well demonstrated anti-stress effects in healthy adults, but benefits for ill or at-risk populations have not been reported. The present study assessed the physiological and psychological effects of forest therapy (relaxation and stress management activity in the forest) on middle-aged males with high-normal blood pressure. Blood pressure and several physiological and psychological indices of stress were measured the day before and approximately 2 h following forest therapy. Both pre- and post-treatment measures were conducted at the same time of day to avoid circadian influences. Systolic and diastolic blood pressure (BP), urinary adrenaline, and serum cortisol were all significantly lower than baseline following forest therapy ( While technology and modern city life offer unparalleled economic opportunities, conveniences, and comforts, urban environments are also stressful ,2, whichet al. reported the relaxation and stress management effects of forest environments by several questionnaire-based studies [A variety of physiological indices show that humans are more relaxed in forested environments ,5,6,7,8. studies  as well  studies . In psyc studies .However, previous studies have only investigated the physiological and psychological responses to forest bathing in healthy young adults, while such effects may be even more beneficial to middle-age subjects in the early stages of age-related diseases such as hypertension. Moreover, it is generally accepted that effects of treatment on blood pressure may vary between healthy normotensives and subjects with higher blood pressure, so studies on the latter population may be of greater clinical relevance. Therefore, the aim of this study was to measure the physiological and psychological effects of forest therapy on middle-aged males with high-normal blood pressure.Nine Japanese males ranging in age from 40 to 72 years  participated in this experiment. Potential participants who were taking medication for chronic conditions such as diabetes, hyperlipidemia, and hypertension were excluded. All participants had high-normal blood pressure (systolic 130–139 mmHg or diastolic 85–89 mmHg) as measured at Nagano Prefecture Kiso Hospital. Systolic blood pressure ranged from 124.5 to 137.5 mmHg (131.8 ± 4.1 mmHg) and diastolic blood pressure from 65.7 to 86.7 mmHg (77.3 ± 7.1 mmHg).At the beginning of the experiment, subjects gathered in a waiting room at Nagano Prefecture Kiso Hospital and were fully informed about the study aims and procedures involved. After receiving a description of the experiment, the subjects all signed an agreement to participate. To control for the effect of alcohol, subjects did not consume alcohol during the entire study period. This study was approved by the Ethics Committee of Nagano Prefecture Kiso Hospital and the Center for Environment, Health and Field Sciences, Chiba University, Japan, on 19 August 2013 and performed according to the Declaration of Helsinki .The forest therapy phase was conducted in Akasawa Shizen Kyuyourin , Agematsu, Nagano Prefecture  on 7 September 2013. Distance from the waiting room at Nagano Prefecture Kiso Hospital to the forest was 21.6 km, and it took 52 min to drive by car. The weather was cloudy, with a temperature of 21.5 °C (19.1 °C–25.0 °C) and humidity of 80.4% (62%–92%) on the day of forest therapy.Systolic and diastolic blood pressure readings were obtained from the right arm using a portable digital sphygmomanometer . Urine and blood samples were also obtained for the measurement of adrenaline, creatinine, and cortisol, respectively. All procedures were performed between 15:14 and 15:35 on the day before and a few hours after forest therapy to control for circadian effects. Participants were not allowed to talk each other during the measurement.The Semantic Differential (SD) method, Profile of Mood State (POMS) subscale scores, and combined POMS Total Mood Disturbance (TMD) score were used to evaluate psychological responses to forest therapy. These questionnaires were completed by participants on the day before and soon after the experiment between 15:05 and 15:35. The SD method uses three pairs of adjectives anchoring seven-point scales: “comfortable to uncomfortable,” “relaxed to awakening,” and “natural to artificial” . The POMParticipants spent the previous night in their respective homes. In the morning of the forest therapy day, participants gathered in the same meeting room at 9:00 a.m. and participated in the forest therapy program as a group with a guide. They were not allowed to communicate with each other during forest therapy, except during lunch time and designated rest periods, and they were not permitted to carry cell phones. Participants walked around their assigned area and then sat and lay on their backs in the forest on waterproof sheets laid on the ground; this program, comprising multiple actions, was performed for 4 h and 35 min .Energy expenditure for the activity was assessed . Tobacco and all drinks  were prohibited during forest therapy. They had the same lunch, which was made at lunch time from local ingredients. The subjects walked around their assigned areas and then sat and lay on their backs for 4 h and 45 min. Subjects then returned to a waiting room and completed the post-treatment measurements and questionnaires. These results were then compared with the data obtained on the day before.p < 0.05 (one sided) was considered statistically significant.We used paired sample t-tests to compare physiological indices and the Wilcoxon signed-rank test to compare psychological test results before and after forest bathing. All statistical analyses were performed using SPSS 20.0 . Data are expressed as mean ± standard error (mean ± SE). For all cases, p < 0.01) in middle-aged males with high-normal blood pressure (p < 0.05) (p < 0.01)   and seru < 0.01)  were sigp < 0.01) and “natural” (p < 0.05) after forest therapy as compared with baseline (p < 0.01) , “confusion,” and “anger-hostility” and the TMD significantly lower after forest therapy (p < 0.05). Significantly higher semantic differential (SD) scores were observed for the adjectives “relaxed” , we provide evidence for both physiological and psychological benefits in middle-aged patients at risk for hypertension. Regular forest therapy may thus prevent progression to clinical hypertension, a possibility warranting further investigation.This study assessed the physiological and psychological benefits of forest therapy on middle-aged Japanese men with high-normal blood pressure. Japanese guidelines for the management of hypertension 2014)  classify014  clasAs blood pressure and many other physiological indices show a circadian rhythm, we paid special care to conduct pre- and post-treatment measurements at the same time (mid-afternoon) on successive days. Thus, circadian variation did not contribute to the changes reported. Forest therapy  reduced systolic blood pressure, urinary adrenaline, and serum cortisol. Blood pressure is under dual regulation by the sympathetic and parasympathetic nervous systems, with sympathetic activity increasing and parasympathetic activity reducing blood pressure . SympathAccording to the SD and POMS questionnaires, participants felt more “comfortable,” “natural,” and “relaxed” after forest therapy. In addition, negative emotions were significantly reduced. Similarly, younger healthy subjects reported being significantly more comfortable and calm after walking in a forest compared to urban walks .The risks of all cardiovascular diseases, strokes, myocardial infarction, chronic kidney disease, and associated risks of mortality increase in parallel with blood pressure above the optimum . Thus, eFrom the viewpoint of public health, it is necessary to shift blood pressure downward in the entire population and not only in high-risk hypertensive patients . BecauseThe present study provides evidence of physiological and psychological benefits of forest therapy for middle-aged males with high-normal blood pressure. However, the limitations of the present study include a lack of a control group performing similar activities in an urban environment. Furthermore, these results cannot yet be extrapolated to females or hypertensive adults. Studies examining health benefits in these groups are warranted in future study.Our study revealed that forest therapy elicited a significant: (1) decrease in systolic and diastolic blood pressure; (2) decrease in urinary adrenaline and serum cortisol levels; (3) increase in “relaxed” and “natural” feelings as assessed by the modified SD method; and (4) decrease in POMS negative subscales “tension-anxiety,” “confusion,” and “anger-hostility” as well as the TMD score in middle-aged males with high-normal blood pressure. Forest therapy may prevent progression to hypertension, thereby reducing associated risks of cardiovascular and renal diseases in this patient group.


To describe postextubation noninvasive positive pressure ventilation use inintensive care unit clinical practice and to identify factors associated withnoninvasive positive pressure ventilation failure.This prospective cohort study included patients aged ≥ 18 yearsconsecutively admitted to the intensive care unit who required noninvasivepositive pressure ventilation within 48 hours of extubation. The primary outcomewas noninvasive positive pressure ventilation failure.We included 174 patients in the study. The overall noninvasive positive pressureventilation use rate was 15%. Among the patients who used noninvasive positivepressure ventilation, 44% used it after extubation. The failure rate ofnoninvasive positive pressure ventilation was 34%. The overall mean ± SDage was 56 ± 18 years, and 55% of participants were male. Demographics;baseline pH, PaCO2 and HCO3; and type of equipment used were similar betweengroups. All of the noninvasive positive pressure ventilation final parameters werehigher in the noninvasive positive pressure ventilation failure group. The mean intensive care unit length of stay waslonger (24 versus 13 days), p < 0.001, and the intensive care unit mortalityrate was higher (55 versus 10%), p < 0.001 in the noninvasive positive pressureventilation failure group. After fitting, the logistic regression model allowed usto state that patients with inspiratory positive airway pressure ≥13.5cmH2O on the last day of noninvasive positive pressure ventilation support arethree times more likely to experience noninvasive positive pressure ventilationfailure compared with individuals with inspiratory positive airway pressure <13.5 .2O on the last day of noninvasive positive pressureventilation support are three times more likely to experience noninvasive positivepressure ventilation failure.The noninvasive positive pressure ventilation failure group had a longer intensivecare unit length of stay and a higher mortality rate. Logistic regression analysisidentified that patients with inspiratory positive airway pressure ≥13.5cmH Despite conflicting scientific evidence regarding many indications for itsuse, NIPPV has become a part of routine care in the majority of ICUworldwide.-8 In these cases, NIPPV can be applied immediately as apreventive,,10 after failure of a spontaneous breathingtrial or after extubation ofhigh-risk patients.This approach has some different nuances, mainly based on timing. Some studies haveincorporated NIPPV into the weaning from invasive mechanical ventilation, meaning thatNIPPV is applied immediately after extubation as part of a continuousprocess.others have shown that it does not seem to diminish the reintubation rate and may evenincrease the mortality rate.In other hand, the use of NIPPV after the development of acute respiratory failure (ARF)after extubation has presented conflicting results. While some studies have found thatNIPPV may prevent reintubation,From a clinical point of view, NIPPV is indispensable in the ICU, and information aboutits use in practice may raise some important issues not identified in randomizedclinical trials. The present study was undertaken to describe post-extubation NIPPV usein ICU clinical practice and to identify factors associated with NIPPV failure afterextubation.Hospital das Clínicas of the Faculdade de Medicinaof the Universidade de São Paulo, located in the cityof São Paulo, Brazil. The study was carried out in eleven ICU (140 beds). Thisstudy was approved by the hospital Ethical Committee (number 0327/07), and therequirement for informed consent was waived because data were collected from patients’records, and no intervention was performed.Between May and December 2007, a prospective cohort study was conducted atAll adult patients (age ≥ 18 years) consecutively admitted to the ICU who usedNIPPV within 48 hours of extubation were included. Patients were excluded if there wasany relevant information missing from the charts.Data were collected from medical charts and directly from the ICU staff. All decisionsabout NIPPV use were exclusively made by the ICU team; researchers did not intervene inany way. Patients were analyzed as success NIPPV group and failure NIPPV group. Thefollowing data were collected: demographics ; day and time of intubation; reasonfor invasive mechanical ventilation ; day and time of extubation; and dayand time of the start of NIPPV.®, BIPAP ST/d Respironics®, Downs flowgenerator - Vital Signs®, or double function mechanical ventilator);time from extubation until NIPPV initiation (0 or ≥ 1 day); NIPPV parameters;type of NIPPV interface; arterial blood gas test prior to NIPPV use; mask leakage;intolerance to NIPPV; need for airway suctioning; NIPPV complications; reintubationrate; reasons for reintubation; NIPPV failure rate (defined as reintubation after NIPPVuse); ICU mortality rate; and ICU length of stay.Data related to NIPPV collected in the study included the indication for NIPPV; theperiod of NIPPV use; type of equipment used  or the median and interquartile range (IQR).Categorical variables were presented as proportions. The predictive capacity ofquantitative variables for NIPPV failure was assessed with receiver-operatingcharacteristic (ROC) curves; the area under the curve (AUC) and optimal cutoff values were calculated.The logistic regression model was fitted using NIPPV failure as a dependent variable.The following steps were taken: independent variables were selected based on theirclinical relevance and were dichotomized based on cutoff values calculated by ROCcurves. After that, all independent variables were submitted to univariate analysis.Odds ratio and Fisher’s exact test were applied to identify possible associationsamong independent variables and NIPPV failure. The odds ratio of each independentvariable was calculated based on 2 x 2 tables to define which variables wouldcomprise the initial model of logistic regression. The variables with p-values above0.30 were not included in the initial model. Multi-collinearity was evaluated byvariance inflation factors. The Hosmer-Lemeshow test was applied to verify thegoodness of fit model.During the study period, 2,773 patients were admitted to the ICU. NIPPV was used on 407(15%) of them. After excluding 15 patients due to missing data, the study population was392 patients. Those who used NIPPV only after extubation accounted for 44%, or 174patients . Baselin® and continuous positiveairway pressure flow generators were the most commonly used equipment. The maininterface was the orofacial mask.The main reasons for the use of mechanical ventilation prior to the use of NIPPV werehemodynamic instability (33%), acute respiratory failure (24%) and surgery (18%). Themedian (IQR) time of use of invasive mechanical ventilation was 4 (1 - 8) days.Noninvasive pressure ventilation features are presented in NIPPV after extubation was applied in three situations: a new acute respiratory event[46 cases (26%)], early weaning [17 cases (10%)], andpreventive NIPPV application [111 cases (64%)]. The time from extubationto initiation of NIPPV was recorded in days. A total of 121 patients (69%) receivedNIPPV support on the same day as extubation, and 53 (31%) received NIPPV between one andtwo days later.® (32%). However, on the lastday of NIPPV, BIPAP Vision® was more frequently used (42%).During NIPPV support, the equipment was changed in some cases. At the beginning ofNIPPV, the most commonly used device was a continuous positive airway pressure flowgenerator (45%) followed by BIPAP Vision2O (p = 0.015), expiratory positiveairway pressure: 10.0 versus 8.9cmH2O (p = 0.027), and FiO2: 41versus 33% (p = 0.014)]. The mean intensive care unit length of stay was longer(24 versus 13 days), p < 0.001, and the intensive care unit mortality rate was higher(55 versus 10%), p < 0.001 in the noninvasive positive pressure ventilation failuregroup.All of the noninvasive positive pressure ventilation final parameters were higher in thenoninvasive positive pressure ventilation failure group , a higher ICU length of stay , and a higher ICU mortalityrate .Independent variables were selected based on their clinical relevance, and continuousvariables were dichotomized based on cutoff values calculated by ROC curves. Thepredictive power of all variables was not high. Area under the ROC curves, sensitivityand specificity calculated values are presented in Possible associations between the explanatory variables and dependent variables werealso investigated. For this reason, the odds ratio of each variable was calculated, aspresented in 2O), inspiratory positiveairway pressure (IPAP) level on the last day of NIPPV (IPAP < 13.5 or ≥13.5cmH2O), fraction of inspired oxygen (FiO2) level on thelast day of NIPPV (FiO2 < 0.37 or ≥ 0.37), and time from extubationto NIPPV start (on the same day or ≥ 1 day). The Hosmer-Lemeshow test found agood model fit (p = 0.999). After fitting, the logistic regression model allowed us tostate that patients with IPAP ≥ 13.5cmH2O on the last day of NIPPVsupport are three times more likely to experience NIPPV failure compared withindividuals with IPAP < 13.5 .The variables selected to comprise the initial logistic regression model were need fornasotracheal suctioning (yes or no), age (< 60 or ≥ 60 years old), SAPS IIscore (< 36.5 or ≥ 36.5), expiratory positive airway pressure (EPAP) level onthe last day of NIPPV . In acohort study over six years, Harris et al. concluded that the rate of NIPPV use has increased over time. Aswe observed, the use of NIPPV after extubation is also high. In our study population,NIPPV after extubation accounted for almost half of all NIPPV use. The literature onthis issue has presented conflicting conclusions. In summary, randomized clinical trialswith a preventive approach had better results, with lower NIPPV failure or reintubationrates, as shown in some studies,12,17-20 that had reintubation rates from 8 to 11%. On the otherhand, Esteban et al. found thatNIPPV was not effective for averting ARF after extubation, as they observed areintubation rate of 48%. Few meta-analyses have focused on NIPPV after extubation.Burns et al. and Zhu etal. concluded that NIPPV hadpositive effects on mortality and ventilator-associated pneumonia. They also found thatthere is insufficient evidence to definitively recommend the use of NIPPV to avoidextubation failure and suggestedthat the benefits of NIPPV on the weaning process need to be elucidated. Glossop et al. concluded that NIPPV reduces the ICUlength of stay and instances of pneumonia when used in post-surgical patients and as aweaning method. In addition, they found that it reduces the reintubation rate and lengthof hospital stay in post-surgical patients, suggesting that NIPPV could be useful forpatients who may deteriorate after major surgery. Lin et al. corroborates that NIPPV is not beneficial in thosecases, while early NIPPV application after planned extubation decreased thereintubation, ICU mortality and hospital mortality rates.The use of noninvasive ventilation after planned extubation is part of clinical practiceworldwide.We estimated that the NIPPV failure rate after extubation was high (34%) and the maincause of NIPPV failure was a new event of ARF. NIPPV failure after extubation did notdiffer according to NIPPV indication . showed a high reintubation rate, but we noticed that the inclusioncriteria differed from other studies; specifically, patients were included after ARFinitiation. All other randomized clinical trials had a preventive approach and obtainedlower reintubation rates. In cohort studies, we observed a reintubation rate of 40% intwo studies.,23 We noticed that, except for the study by Esteban etal., randomized clinicaltrials have presented lower reintubation rates than observational studies. During theperiod of data collection, the intensive care units included in our study did not have astandardized protocol of weaning or NIPPV use after extubation, and we did not observeany difference between reintubation rates in a group of patients who used NIPPV at anearly stage or immediately after extubation.In randomized clinical trials, we observe that the reintubation rate is lower than inobservational studies. Esteban et al.such as reintubation in the case of a respiratory rate over 25 breaths per minute,peripheral oxygenation under 90% with high FiO2 and pH < 7.25. However,these parameters were not controlled across the units.Because there was not a standardized protocol of weaning, clinical decisions regardingNIPPV parameters, target physiological parameters and reintubation were made by the ICUteam. In the hospital where the study was carried out, the ICU team usually follows therecommendations in the literature, observed thatthere are many risk factors for NIPPV failure in ARF and found that a SAPS II score≥ 35, the presence of acute respiratory distress syndrome and pneumonia wereindependent factors of failure.Antonelli et al.2O are associated with NIPPVfailure. Rana et al. did not findany association between IPAP and EPAP levels and NIPPV outcome. They studied a group ofacute lung injury patients in a tertiary care center. However, the IPAP and EPAP levelswere not high, with a median IPAP of 12 to 13, and EPAP of 5 to 5.5cmH2O.NIPPV parameters were collected from charts during the study course, but we could notidentify how that information was managed. Other studies concerning NIPPV afterextubation did not evaluate these parameters. Our results showed that failure group patients presented higherlevels of NIPPV parameters at the last day of NIPPV use, suggesting that patients withhigher NIPPV pressure levels were more likely to fail.We estimated that levels of IPAP > 13.5cmH2Ois a cutoff value for NIPPV failure. The heterogeneity of the study population anddesign are not appropriate to answer this question. On the other hand, these resultsraise some important questions, such as whether it is possible to identify cutoff valuesof NIPPV parameters to prevent poor NIPPV outcomes, such as late reintubation.The elevated IPAP levels might indicate that those patients presented unfavorablepulmonary condition, such as poorer respiratory mechanics, muscle inefficiency, higherrespiratory work of breathing, higher dead space, or even systemic manifestations thatwould increase ventilator demand, including metabolic acidosis and shock, although thesevariables were not controlled in our study. We suggest that IPAP might be a good markerfor NIPPV outcome, but our data do not support that IPAP ≥ 13.5cmH and Su et al.are similar. The authors did not find any difference in outcomes, but there was a highNIPPV failure rate (48%) in the study by Esteban et al. and a low extubation failure rate in the study by Su etal., which was 13% in thecontrol group and 14.9% in NIPPV group. In both studies, we do not observe anyadvantages of NIPPV, and, obviously, there was no impact on clinical outcomes. On theother hand, the studies that estimated NIPPV efficacy showed improved ICU outcomes.Girault et al. showed that NIPPVreduced the duration of weaning; Ferrer et al. estimated that NIPPV improved the 90-day survival and reducedreintubation rates, and Trevisan et al. found that the use of NIPPV when weaning patients with spontaneousbreathing trial failures reduced the pneumonia rate and the need for a tracheostomy.We observed that patients who experienced a NIPPV failure after extubation presentedpoorer ICU outcomes, such as a higher tracheostomy rate, longer ICU length of stay andgreater mortality rate. Data from the literature are conflicting on this issue, but thestudies that we researched have some interesting features that can explain thesefindings. The results of Esteban et al.2O on the last day ofnoninvasive positive pressure ventilation support are three times more likely toexperience noninvasive positive pressure ventilation failure, and that some pointsshould be considered for future research, such as the identification of a reliablecutoff to better indicate noninvasive positive pressure ventilation discontinuation,based on noninvasive positive pressure ventilation parameters and the patient’sseverity, to avoid delayed reintubation and the poor outcomes associated with thisprocedure.This study was performed at a single university hospital in Brazil, and we believe thatour results may not be generalizable. Our results indicate that patients withinspiratory positive airway pressure ≥ 13.5cmH


Robot-assisted laparoscopic radical prostatectomy (RALP) is a minimally invasive surgical procedure for prostate cancer. During RALP, the patient must be in a steep Trendelenburg (head-down) position, which leads to a significant increase in intraocular pressure (IOP). The association of RALP with visual field sensitivity, however, has not been prospectively studied. The purpose of this study was to evaluate prospectively the visual field, retinal nerve fiber layer (RNFL) thickness, and optic disc morphology in 50 normal eyes of 25 male patients that underwent RALP.The subjects were 25 males among 33 consecutive patients who underwent uneventful RALP under general anesthesia in our hospital. Visual field tests using the Humphrey visual field analyzer 30-2 SITA-standard program were performed before, 7 days after, and 1-3 months after RALP. IOP was measured before, during, and after RALP; and ophthalmologic examinations, including slit-lamp, fundus examination, and optical coherence tomography (OCT), were scheduled before and 7 days after surgery.IOP was significantly increased during RALP up to 29.4 mmHg (P<0.01). Postoperative local visual field defects were detected in 7 eyes of 7 subjects dominantly in the lower hemifield without abnormal findings in the optic nerve head or retina, and the visual field recovered to normal within 3 months after surgery. General factors associated with RALP, IOP, RNFL thickness, or optic disc parameters did not differ significantly between eyes with and without postoperative visual field defects, and parameters of OCT measurements were not altered after surgery.Transient but significant unilateral visual field defects were found in 28% of the subjects examined. The probable cause are the increased IOP and altered perfusion during surgery and ophthalmologic examinations are therefore suggested before and after RALP. Robot-assisted laparoscopic radical prostatectomy (RALP) is commonly performed in many countries, with more than 114,000 cases performed worldwide in 2013. Prostate cancer is one of the most common cancers in men, and RALP, as a relatively new surgical treatment, has several advantages, including less blood loss and pain.  are obseThe influence of the RALP procedure on visual function has not been studied in detail. There are two reported cases of posterior ION (PION) with bilateral permanent visual field defects or loss of light perception after minimally invasive prostatectomy, one of them performed using RALP.  On the oThe purpose of the present study was to evaluate the effect of RALP on the visual field in normal eyes. Visual field, RNFL thickness, and optic disc morphology were evaluated before and after RALP using static automated perimetry and optical coherence tomography (OCT). IOP was also measured during the procedure.This single-center, prospective, non-randomized study was conducted according to the tenets of the Declaration of Helsinki and received approval by the Institutional Review Broad of Asahi General Hospital. Written informed consent was obtained from each subject after explanation of the study protocol. A total of 33 consecutive male patients who underwent RALP under general anesthesia in Asahi General Hospital from February to December in 2013 were initially included, but 8 were excluded for reasons described below, and thus 25 patients were the subjects of the study.The paired t-test was applied to examine differences in the values before and after surgery, and an unpaired t-test was applied otherwise. Repeated-measures analysis of variance and a paired t-test were applied to examine the changes in IOP. A P value <0.05 was considered statistically significant after Bonferroni’s correction for multiple comparisons. All statistical analyses were carried out using SPSS software .RALP was performed by a single surgeon and the indication criteria for the surgery were the same as for conventional prostatectomy . Patients with a history of cerebral infarction, cerebral hemorrhage, and abdominal surgery  were excluded from the study.2) concentration and airway pressure. The head-down position was set to 25° or 30°, according to the physical constitution of the patient and surgeon preference. To avoid facial compression, face masks specifically intended for use in the prone position were used. Blood pressure was measured via an arterial cannula inserted into the right radial artery or a cuff on the left brachium.The anesthesia protocol was standardized for all subjects . No pre-medications were used. The patients were anesthetized with propofol  or desflurane (3–5%), in combination with continuous infusion of remifentanyl (0.1–1.0 μg/kg/min) to maintain blood pressure, heart rate, and bispectral index. Rocuronium was continuously (20 mg/h) or repeatedly administrated for muscle relaxation. The lung was mechanically ventilated to maintain end-tidal carbon dioxide  test, IOP measurement using the Goldmann applanation tonometer, slit-lamp biomicroscopy, indirect funduscopy under pupil dilation with topical tropicamide and phenylephrine , and static automated visual field measurement using the Humphrey visual field analyzer (HFA) with the 30–2 SITA-standard program . Circumpapillary RNFL thickness was also analyzed by OCT  and fundus photographs  were obtained under pupil dilation. Exclusion criteria included best corrected visual acuity <20/20, ocular hypertension (IOP >21 mmHg), abnormal visual field test results (described later), presence or history of any eye diseases that might affect IOP or visual field testing , or history of intraocular surgery (except uncomplicated cataract surgery) or refractive surgery. Patients with a history of intracranial and/or central nervous system disease, such as cerebral infarction or hemorrhage, were also excluded.An abnormal visual field was defined as a cluster of three or more points in a pattern deviation plot within a single hemifield  with P values <5%, one of which must have a P value <1% according to Anderson and Patella’s criteria.  When a sAll the examinations mentioned above were conducted 0–2 months before RALP and repeated again approximately 7 days  after the procedure. Only patients whose both eyes fulfilled the criteria were included in the study.IOP of both eyes was measured using the Tono-pen XL  8 times in each subject throughout the study period under topical anesthesia of a singular drop of 0.4% oxybuprocaine if conscious . IOP wasAll IOP measurements were obtained by the same examiner for each subject. The tonometer was calibrated according to the manufacturer’s guidelines before the measurements and the mean value of four reliable measurements with standard error ≤5% was adopted at each time point. In all eyes, the difference in IOP measured using the Tono-pen XL and Goldmann applanation tonometer obtained in the sitting position before RALP was 2 mmHg or less.Ocular perfusion pressure was calculated as mean arterial pressure minus IOP. Mean OPP value or time-integrated value during the surgery was used in the analyses.Each subject underwent static automated perimetry twice using the HFA 30–2 SITA-standard program at 0–2 months before RALP. Due to the learning effect, we adopted the results of the second test. If the test result was unreliable , it was discarded and a re-test was administered on the same day. Visual field test was repeated in the same manner at approximately 7 days after RALP, and the test result was confirmed with another test within 1 week if a reliable postoperative visual field result was not obtained. Eyes with a significant postoperative visual field defect underwent another visual field test 1–3 months after RALP, and further tests were scheduled every 3 months after that until the visual field returned to normal.Mean deviation (MD), pattern standard deviation (PSD), foveal threshold, and the mean value of total deviation (TD) in all test points in the superior or inferior hemifield were calculated and analyzed.RNFL thickness was measured using the Cirrus HD-OCT 0–2 months before and 7–10 days after RALP. Images with signal strength ≤5 were discarded and re-examined. Among the retinal parameters, average RNFL thickness, superior RNFL thickness, and inferior RNFL thickness were included in the analyses. Disc area, rim area, average C/D ratio, and cup volume were also included as parameters of optic nerve head morphology.Of 33 patients that underwent RALP during the study period, 8 were excluded after the ophthalmologic examinations due to unilateral and bilateral abnormal visual fields in 4 and 1, respectively, with large optic disc cuppings suggesting pre-existing glaucoma, blood vein occlusion, or other pathologic changes. Visual acuity was <20/20 and/or reliable visual field or OCT results were not available for the other 3 patients, due to significant cataract. There were 3 other eyes with clusters of abnormal points in the pattern deviation plots, but these were judged as normal visual fields because their total deviation plots and Glaucoma Hemifield Test results were normal and the initial postoperative pattern deviation plots had been normal.Fifty eyes of 25 subjects aged 52–74 years were finally included in the study and their characteristics are shown in Seven eyes of 7 subjects showed significant visual field defects in the initial postoperative examinations. All 7 eyes showed clusters of three or more abnormal points in the pattern deviation plot and four of them also showed Glaucoma Hemifield Test results of “Outside normal limits”. Five patients had a visual field defect in the lower hemifield . PION may occur after RALP  and invoIOP was significantly increased during RALP in this study as previously reported. ,4,9 AccoThe pathogenesis of ION after systemic surgery may be associated with severe arterial hypotension under general anesthesia or massive blood loss, hemodilution by overinfusion of intravenous fluid, or increased orbital pressure.  RALP is In this study, 25 subjects underwent RALP and 7 eyes of 7 subjects  showed significant visual field defects one week after surgery. None of the subjects were aware of the visual field loss, and none complained of any ocular symptoms, including visual acuity loss or anorthopia. The visual field returned to normal within 3 months after the surgery in all cases. Normal optic disc, macula, and clear optic media were confirmed by detailed ocular examinations in each eye. There were no abnormal findings in RNFL thickness or optic disc morphology measured using OCT or detailed funduscopy before and after RALP, and it is thus unlikely that those transient visual field defects were due to retinal pathologic changes, including macular edema or glaucoma.2 were 35.2±2.2 and 35.9±2.2 mmHg during the surgery in the subjects with and without postoperative visual field defects, respectively, and not significantly different between the two groups. The difference in blood loss was not significant between them even after standardization by body weight of each subject (P = 0.34). The blood loss remained in relatively small amount (mean of 267 ml and maximum of 695 ml) in the subjects of the current study, and it may still be possible that massive blood loss cause visual impairment. Correlations of the possible risk factors with the visual field were also analyzed in the both eyes of the all subjects using a linear mixed-effects model. Dependent variables were differences in MD or PSD between preoperative and initial postoperative visual field tests, and age, BMI, amount of blood loss, or time-integrated OPP during the surgery did not show any significant correlations. There was a trend for greater deterioration in postoperative MD with older age, however, this did not reach statistical significance (p = 0.063).Among the several risk factors of ION after surgical procedures,  amount oRecently, it has been reported that propofol has less influence on IOP than sevoflurane during RALP.  In the sSlight or moderate periocular swelling and chemosis were observed in all cases at the end of RALP (typical appearance shown in Among the seven eyes with postoperative visual field defects, five had visual field defects in the lower hemifield and two had more centered visual field defects in both upper and lower hemifields . Visual In summary, we conducted a prospective study in 25 patients who underwent RALP. IOP significantly increased during the surgery and significant, but symptomless, visual field defects were detected by static perimetry in 7 eyes of 7 subjects 1 week later. There were no abnormal findings in the fundus, RNFL thickness, or optic disc morphology analyzed using OCT, and the impaired visual field recovered to normal 3 months after the surgery, suggesting ION or other ischemic factors as a possible mechanism. Operation time, blood loss, intraocular pressure during RALP, or optic disc parameters were not associated with the development of visual field defects. The results of the present study suggest that transient but significant visual field defects are a possible complication after even uneventful RALP. Predictive risk factors were not clear, however, indication for RALP should be cautiously considered in patients with risks of optic nerve perfusion, such as glaucoma or diabetic mellitus, and detailed ocular examinations are suggested before and after the surgery.


Anemia is a common comorbidity in patients with chronic heart failure (CHF) and is frequently treated with erythropoiesis-stimulating proteins (ESPs). Previous studies, however, have been relatively short in duration and have not provided conclusive data on the safety or clinical efficacy of ESP treatment. The aim of this study was to explore the safety and therapeutic effects of ESPs in patients with anemia and CHF. A systematic literature search in EMBASE and MEDLINE from their inception to July 2013 was performed, and clinical studies that evaluated the effects of ESPs among patients with CHF were identified. Randomized clinical trials comparing the effects of ESP treatment with those of placebo treatment or usual care regimes in anemic patients with CHF were included. Nine randomized, controlled trials were identified, comprising 750 patients with CHF and anemia receiving ESP treatment for between three months and one year. ESP treatment had a significantly lower risk of CHF hospitalization  and a moderate reduction in mortality risk . Treatment with ESPs in patients with symptomatic CHF and anemia resulted in significant improvements in hemoglobin, hematocrit and brain natriuretic peptide levels, as well as exercise capacity, renal function, New York Heart Association class and left ventricular ejection fraction. In conclusion, this study found that treatment with ESPs exerts beneficial effects against CHF and is not associated with a higher mortality rate or adverse effects. These outcomes support the instigation of a trial evaluating the treatment of anemia with ESPs in patients with chronic CHF. Anemia is a common comorbidity in patients with chronic heart failure (CHF) –4 and isA number of preliminary studies have reported that the correction of low Hb concentrations using erythropoiesis-stimulating proteins (ESPs) may improve cardiac and renal function and reduce the requirement for hospitalization and diuretics in patients with CHF –10. ErytMost interventional studies conducted in patients with CHF and anemia have shown an improvement in exercise tolerance and functional status in response to treatment; however, these were uncontrolled studies or controlled studies without a placebo. Furthermore, these studies were relatively short in duration and not designed to provide conclusive data on the safety or clinical efficacy of ESP treatment. In addition, the small sample sizes produced underpowered results. In this study, a meta-analysis was performed to explore the safety and therapeutic effects of ESPs in patients with anemia and CHF.www.embase.com) and MEDLINE (www.ncbi.nlm.nih.gov/pubmed) were searched from their inception to July 2013, and clinical studies that evaluated the effects of ESPs among patients with CHF were systematically identified. No language restriction was applied. Search terms included ‘heart failure’ or ‘congestive heart failure’ or ‘chronic heart failure’ or ‘CHF’ combined with ‘recombinant erythropoietin’ or ‘darbepoetin’ or ‘erythropoietin’ or ‘erythropoiesis’. The titles and abstracts of studies identified in the automated search were scanned to exclude any irrelevant articles. The full texts of the remaining articles were read to determine whether they contained relevant information on the topic of interest. Cited references of retrieved and review articles were assessed to confirm that the assembled list of relevant publications was complete.The databases EMBASE  Study name (with first author’s name and year of publication); (ii) journal name; (iii) location; (iv) study design; (v) study population (case and control); (vi) inclusion criteria; (vii) exclusion criteria; (viii) range for follow-up; (ix) end-points. Two separate lists from two independent authors were compared, and disagreements were resolved by consensus. Relative risks (RRs) were recorded or calculated.Each study was evaluated for quality according to the guidelines provided by the United States Preventive Task Force. The following characteristics were assessed: (i) Duration of follow-up (>6 months); (ii) adequacy of follow-up (reporting loss rate of follow-up); (iii) definition of anemia; (iv) full specification of outcome; (v) study sample representative for the unexposed population; (vi) full specification of clinical and demographic variables; (vii) explanation of sample selection; (viii) clear inclusion and exclusion criteria. Studies were graded as ‘poor’ quality if they met <5 criteria, ‘fair’ if they met 5–6 criteria and ‘good’ if they met >7 criteria. Outcomes assessed were mortality and CHF hospitalization rate.To compute a summary RR with a 95% confidence interval (CI), a study-specific, most-adjusted RR and its 95% CI was used in all analyses. Publication bias was assessed by visual inspection of the funnel plots created by plotting the RR to standard error (SE) for all nine studies.2 statistics. The I2 statistic assesses the percentage of variability in the effect estimates that is due to heterogeneity rather than chance. A fixed-effects model was used if P<0.10 or I2 >50% for heterogeneity, otherwise a random-effects model was utilized. The RR was transformed to a natural log scale and the SEs were calculated. The analysis was performed using RevMan 5.2 software .Inter-study heterogeneity was examined using Cochran’s Q and IFollowing the exclusion of duplicates, 561 potentially relevant studies were reviewed, with nine clinical studies meeting the inclusion criteria and subsequently being analyzed . The bas2=9%, P=0.36), and there was no obvious indication of publication bias.Eight of the nine studies reported detailed CHF hospitalization. Of the 398 patients with CHF in the ESP treatment group, 50 were admitted to hospital (12.6%), whilst 82 of the 330 placebo-treated patients were hospitalized (24.8%). A significantly reduced hospitalization risk was identified for patients with CHF treated with ESPs compared with those treated with placebo  . With re2=0%, P=0.71), and there was no obvious indication of publication bias.Eight of the nine studies reported details of CHF mortality rate. Of the 397 patients with CHF in the ESP treatment group, 23 patients succumbed during the study (5.8%), compared with 29 of the 329 placebo-treated patients (8.8%). This resulted in a moderate reduction, without reaching statistical significance, in mortality risk for patients with CHF treated with ESPs  compared with those treated with placebo . No statThe baseline and achieved Hb and Hct levels and red blood cell count of the different studies are shown in EPO receptors are expressed in both hematopoietic and nonhematopoietic cells. ESPs, which are clinically used exclusively for erythropoiesis in patients with anemia, demonstrate potential in the treatment of pathological conditions of nonhematopoietic organs, including the brain and heart . Furtheret al (Patients with CHF together with anemia experience higher rates of hospitalization than those without anemia. A prior meta-analysis by van der Meer et al  of sevenet al .In the present pooled analysis of patients with HF, it was found that the anemia of patients with CHF improved with ESP treatment. The majority of the changes in the anemic condition occurred together with increases in Hb and Hct; however, the most significant improvements were observed after one year. A moderate reduction in mortality risk was also observed for patients with CHF treated with ESPs, compared with those treated with placebo. This may be due in part to the improved oxygenation and reduced oxidative stress caused by the improvement in the anemia or due to the direct effects of the drug. Another meta-analysis including >150,000 patients with CHF identified that low Hb levels increased the risk of all-cause mortality over a six-month to five-year follow-up period, irrespective of whether CHF was due to systolic or diastolic dysfunction . Other rBNP levels are a reflection of ventricular stretching and are accepted as an effective marker of the presence and severity of CHF, since high levels of BNP are independent predictors of adverse clinical outcomes in CHF . NeurohoIn conclusion, treatment of patients with symptomatic CHF and anemia with ESPs results in significant improvements in hospitalization rate, Hb, Hct and BNP levels, mortality, exercise capacity, renal function, NYHA class and LVEF. These results support the instigation of larger trials investigating the safety and efficacy of ESPs for the treatment of anemia in anemic patients with symptomatic CHF.