Purpose. To assess differences in translaminar pressure gradient (TPG) and neuroretinal rim area (NRA) in patients with normal tension glaucoma (NTG), high tension glaucoma (HTG), and healthy controls. Methods. 27 patients with NTG, HTG, and healthy controls were included in the prospective pilot study (each group consisted of 9 patients). Intraocular pressure (IOP), intracranial pressure (ICP), and confocal laser scanning tomography were assessed. TPG was calculated as the difference of IOP minus ICP. ICP was measured using noninvasive two-depth transcranial Doppler device. The level of significance P < 0.05 was considered significant. Results. NTG patients had significantly lower IOP (13.7(1.6) mmHg), NRA (0.97(0.36) mm2), comparing with HTG and healthy subjects, P < 0.05. ICP was lower in NTG (7.4(2.7) mmHg), compared with HTG (8.9(1.9) mmHg) and healthy subjects (10.5(3.0) mmHg); however, the difference between groups was not statistically significant (P > 0.05). The difference between TPG for healthy (5.4(7.7) mmHg) and glaucomatous eyes (NTG 6.3(3.1) mmHg, HTG 15.7(7.7) mmHg) was statistically significant (P < 0.001). Higher TPG was correlated with decreased NRA  in the NTG group. Conclusion. Translaminar pressure gradient was higher in glaucoma patients. Reduction of NRA was related to higher TPG in NTG patients. Further prospective studies are warranted to investigate the involvement of TPG in glaucoma management. Glaucoma is a progressive optic neuropathy leading to the retinal ganglion cell death and typical optic nerve head (ONH) damage . It remaRecently, researchers have emphasized not only IOP or vascular dysregulation, but also intracranial pressure's (ICP) role in glaucoma , 9. The However, the role of TPG still remains unknown, because only invasive ICP measurements are available within the contemporary medicine (lumbar puncture or punction of brain ventricles—for patients with severe brain injury). The ideas for noninvasive ICP measurement have been appearing since about 1980. Numerous methods for finding the objects or physiological characteristics of cerebrospinal system that would be related to the ICP and its monitoring have been sought by many authors. Most of the proposed technologies were based on ultrasound and were capable of monitoring blood flow in intracranial or intraocular vessels, cranium diameter, or acoustic properties of the cranium . Broad rThe aim of our study was to assess differences in TPG and NRA in patients with NTG, HTG, and healthy controls.27 patients with NTG (age 56.6 (10.4)), HTG (age 54.7 (15.6)), and healthy controls (age 51.9 (6.6)) attended prospective pilot clinical study. Kaunas Regional Biomedical Research Ethics Committee approved the study protocol and all participants provided written informed consent, according to the Declaration of Helsinki. Indiana University School of Medicine, Department of Ophthalmology, provided services as the analysis reading center site for RBF images. Study objectives and methods were explained to all patients prior to examination. All patients signed an informed consent. Only one eye per patient was included in the study. The eye with greater glaucomatous damage was selected in the glaucoma patients. In healthy individuals, the eye was selected randomly.Measurements included arterial BP, best-corrected visual acuity (BCVA), Goldmann applanation tonometry, confocal laser scanning tomography for optic nerve disc structural changes , and noninvasive ICP . TPG was calculated as the difference of IOP minus ICP.Noninvasive absolute ICP value was measured using two-depth TCD device that does not need an individual patient specific calibration and is based on simultaneous monitoring of blood flow velocity pulsations in intracranial and extracranial OA segments. The value of external pressure, when OA blood flow parameters in both segments are equal, was fixed and expressed automatically in absolute units mmHg. A head frame with fixed ultrasound transducer was added to close eyelid of a patient. Patients remained in the supine position. Special acoustic conducted gel was used for a better ultrasonic contact. An external pressure Pe has been produced by a small ring cuff placed over the tissues surrounding the eyeball. Pe was automatically increased gradually from 0 to 20 mmHg by pressure steps equal to 4 mmHg. In order to decrease ICP value sampling error the measurement was repeated with external pressure Pe increased by 2 mmHg pressure steps until 12 mmHg, if first measured absolute ICP value was lower than 10 mmHg . The durThe inclusion criteria were NTG/HTG patients over 18 years of age with diurnal IOP lower/higher than 21 mmHg, and willing to sign informed consent form prior to initiation of the study. Pregnant or nursing women, patients with uncontrolled systemic diseases, and patients with a history of allergy to local anesthetics, orbital/ocular trauma, or other diseases that could influence study results were excluded from the study. Patients were included in the HTG group if they were diagnosed with POAG by a glaucoma specialist and had characteristic OND changes, visual field loss consistent with glaucoma, and IOP higher than 21 mmHg. Patients were considered to have NTG if NTG was diagnosed by a glaucoma specialist and had characteristic OND changes, visual field loss consistent with glaucoma, and IOP always less than 21 mmHg before treatment. Current medical treatment, including topical IOP lowering drugs, was continued. The control group was composed of healthy adult volunteers with no history of glaucoma or other diseases that could bias the results.P < 0.05 was considered significant.Statistical analysis was performed using computer program SPSS 17.0 for Windows. All variables were defined by methods of descriptive statistics. The analysis of the quantitative variables included calculation of the mean and standard deviation (×(SD)). The hypothesis of equality among three groups was analysed using the Kruskall-Wallis test. Association between categorical variables or abnormally distributed continuous variables was assessed by Spearman's correlation. The level of significance P > 0.05). Patients' characteristics are provided in 27 patients  with NTG, HTG, and healthy controls were included in the study (each group consisted of 9 patients). The study groups did not vary significantly in age (2), and retinal nerve fiber layer thickness (0.15 (0.07) mm), comparing with HTG and healthy patients, P < 0.05. ICP was lower in NTG (7.4 (2.7) mmHg), compared with HTG (8.9 (1.9) mmHg) and healthy subjects (10.5 (3.0) mmHg); however the difference between groups was not statistically significant (P > 0.05). The difference between TPG for healthy (5.4 (7.7) mmHg) and glaucomatous eyes (NTG 6.3 (3.1) mmHg, HTG 15.7 (7.7) mmHg) was statistically significant (P < 0.001).Changes in IOP, ICP, TPG, and optic nerve disc structure are shown in r = −0.83; P = 0.01) was observed in the NTG group .Correlations between NRA and IOP, ICP, and TPG in glaucoma patients and healthy subjects are shown in TG group , while nA pressure imbalance between the two circulating fluids of the nervous system may be the cause of glaucomatous damage to the optic nerve. Jonas and Budde showed that the optic disc appearance in NTG patients could be remarkably similar to the optic nerve head morphology in HTG patients . Recent In prospective study, Ren and colleagues found that in normal subjects CSF pressure is related to the systemic arterial BP and the IOP . AccordiThere are several limitations to acknowledge in our study. First, the number of patients in NTG, HTG, and control groups was small and therefore our data should be considered as a pilot study. Second, this study did not include a washout period and hypotensive agents could have possible effects on ICP, especially carbonic anhydrase inhibitors. Third, ICP was measured in the supine position, while IOP was assessed in the sitting position; therefore our calculated TPD is only a surrogate for the actual TPG. Fourth, it has remained unclear whether the lumbar CSF pressure is directly related to the CSF pressure in the orbit around the optic nerve. It is known that TPG is calculated as the difference of IOP minus orbital CSF pressure. Usually lumbar CSF pressure is used as surrogate for the orbital CSF pressure. It is also known that CSF column height measurement is the “gold standard” invasive ICP evaluation method. We used a novel noninvasive ICP measurement method in which sensitivity, specificity, and diagnostic value were proven with healthy subjects and patients with neurological diseases , 18.Translaminar pressure gradient was higher in glaucoma patients than in healthy controls. Reduction of neuroretinal rim area was related to higher TPG in NTG patients. Further prospective studies are warranted to investigate the involvement of TPG in glaucoma management.


Background: Healthy lifestyle and ineffective coping strategies are deemed significant variables among patients with hypertension. This study attempted to determine the status of these variables following intervention via the mindfulness-based stress-reduction program (MBSRP) in patients with hypertension.Method: This study was a randomized clinical trial. The study sample, consisting of 30 patients referring to the Hypertension Clinic of Imam Hossein Hospital in 2013, was assigned either to the intervention (recipient of the MBSRP and conscious yoga) or to the control group (recipient of yoga training). The intervention group had 8 training sessions over 8 weeks. Lifestyle and coping strategies as well as blood pressure were measured in the intervention group before intervention and then immediately thereafter and at 2 months' follow-up and were compared to those in the control group at the same time points.Result: The mean age of the patients in the intervention (40% women) and control (53% women) groups was 43.66 ± 5.14 and 43.13 ± 5.04 years, respectively. The results showed that the mean scores of lifestyle , emotion-focused coping strategies , problem-focused coping strategies , diastolic blood pressure , and systolic blood pressure  were significantly different between the intervention and control groups after the intervention.Conclusion: Applying an intervention based on the MBSRP may further improve the lifestyle and coping strategies of patients with hypertension. Achieving these goals requires the application of a multidimensional approach. Although drug therapy is important in blood pressure control, the patient's lifestyle is a factor exerting a significant impact on its control.3 Hypertension can lead to increased risk of heart disease, myocardial infarction, stroke, and kidney diseases.1, 4 In most cases, the actual cause of hypertension is unknown, but in general, diseases and lifestyle  have a major effect on decreasing the quality of life and increasing the incidence of the disease.3, 4 It seems that lifestyle and stress and its coping strategies are the factors correlated with the incidence and progression of hypertension.5Hypertension is the third cause of death in the world.6 Recent studies have shown that lifestyle can cause stress, anxiety, and mental pressure and consequently bring about a rise in the blood pressure and other chronic diseases.5, 7 Ariff et al.,5 believing that improving lifestyle components can help individuals to stay healthy and cope with daily stresses, posited that a healthy lifestyle can have an effective role in individuals' happiness and prevention of stress and depression. Health training focuses on lifestyle, seeking to change individuals' behaviors and motivating them to develop a healthy lifestyle.8 In this regard, Hung et al.6 demonstrated that lifestyle modification is considered one of the foremost therapeutic strategies in treating patients with hypertension. Indeed, research has demonstrated that lifestyle change is effective in improving or controlling chronic diseases such as hypertension.3Lifestyle is defined as a way of life that an individual chooses, with its foundation laid in family and affected by the individual's culture, race, and economic and social status.9 Accordingly, alleviating stressful factors is an effective technique in reducing the blood pressure. Although the existence of stress is inevitable and having adequate levels of stress confers growth and development, high levels of stress or ineffective coping strategies are harmful. Learning effective coping strategies leads to the maintenance and promotion of health.10 There are two coping strategies applied by individuals when facing specific problems and diseases such as hypertension: the problem-focused coping strategy and the emotion-focused coping strategy.11 In the emotion-focused coping strategy, the objective is to focus on emotion and to control emotional distress. This strategy is more associated with physical exercise, care, expression of feelings, and seeking social support. In the problem-focused coping strategy, the objective for individuals is to perform a problem-solving activity; and if they believe that the situation is beyond their capabilities, they can apply the emotion-focused coping strategy.11 Ariff et al.5 reported that patients with hypertension tend to apply inefficient coping strategies and that the application of these strategies brings about excess stress and emotional instability and thus mental and physical damage.The results of previous studies have revealed that almost all diseases have psychosomatic components and that any kinds of diseases, particularly heart diseases and hypertension, are affected by stress and stressful events.5, 11 In previous studies, the psychological consequences of hypertension such as anxiety and depression were mostly considered, but there was less attention to coping strategies with psychological factors and intervention in the lifestyle of patients with hypertension. In this regard, the mindfulness-based stress-reduction program (MBSRP) is one of the treatment modalities deemed effective in individuals' health training against physical and psychological diseases. The MBSRP is based on the three components of avoiding judgment, enhancing awareness, and focusing on the present moment. Paying attention to the present moment helps individuals to process their cognitive, physiological, and behavioral activities. It happens because through the regular practice of mindfulness-based activity, individuals become aware not only of their daily activities but also of the automatic function of their mind in the past and future. Additionally, via the moment-to-moment awareness of their thoughts, feelings, and physical states, individuals will learn to control them and to release themselves from the automatic mind, which is focused on the traumatic past and future.12, 13 According to this approach, a judgmental mind increases the levels of stress, anxiety, and depression in that it tends to divide experiences into good and bad ones. A judgmental mind, therefore, seeks to struggle with or avoid experiences, both of which will result in stress and anxiety.14In general, previous research has demonstrated that controlling stress and using effective coping strategies can be useful in treating hypertension.15The most important component of mindfulness practices is the enhancement of awareness, which means commitment to the presence of mind such that the individual can move from one moment to another moment easily without yielding to the judgmental and non-reactive mind and without trying to get anywhere.15 Niazi et al. reported that mindfulness reveals internal and external realities freely and without distortion and shows a great capability in dealing with a wide range of thoughts, emotions, and experiences (both pleasant and unpleasant). They also suggested that mindfulness has a positive relationship with mental and psychological calmness and mental health in chronic diseases.16 The MBSRP has shown success in treating physical and mental symptoms such as generalized anxiety, panic disorders, eating disorders, and stress symptoms as well as in improving the quality of life in patients with breast and prostate cancer and fibromyalgia.13, 15, 17Mindfulness-based interventions with the aim of alleviating psychological symptoms and enhancing the quality of life are taken advantage of in psychological and physical health.15 showed that the MBSRP is an effective method to reduce stress and improve the quality of life in individuals with a diagnosis of different diseases. This meta-analysis study included patients with cancer suffering from psychiatric disorders, chronic pain, and cardiovascular diseases such as hypertension. The results of the Gloria et al.18 study, conducted to demonstrate the effectiveness of the MBSRP in patients with hypertension, showed that this program is an effective treatment both in reducing stress and anxiety in daily life and in reducing the symptoms of chronic diseases such as high blood pressure. Parswani et al.19 demonstrated that the MBSRP can reduce the symptoms of anxiety and depression in patients with coronary heart disease and hypertension. Additionally, the authors reported that after a 3-month follow-up, the treatment effects were still present.A meta-analysis by Bohlmeijera et al.Given the high prevalence of hypertension and its complications and treatment costs, it seems that a simultaneous combination of non-pharmacological therapies (both in treatment and in prevention) and drug treatment could at least reduce these undesirable effects and accelerate improvement. To that end, survey investigations are the first step toward planning appropriate non-pharmacological treatment strategies. We, therefore, sought to assess the effect of group MBSRP and conscious yoga on lifestyle, coping strategies, and systolic and diastolic blood pressures in patients with hypertension.20 with a confidence level of 95% and error of 5%. A significance level < 5% error rate rejected the null hypothesis. After obtaining written informed consent from all the patients, pre-test evaluations were conducted.This study was quasi-experimental study with a control group and featured pre-test, post-test, and follow-up. The blood pressure of each patient in the two study groups was measured three times. All the patients who referred to Imam Hossein Hospital in Tehran in 2013 with a diagnosis of hypertension were recruited in this study. Among these patients, 30 individuals who met the inclusion criteria, i.e. not receiving psychological treatment at the time of diagnosis, having blood pressure > 130/80 mmHg, having high school diploma or higher qualifications, age between 30 and 55 years, and having similar drug regimen, were included in the study. Patients with mental illnesses and physical diseases such as diabetes, renal disease, liver disease, and history of myocardial infarction were excluded from the present study. Also excluded were pregnant patients and those missing more than 2 intervention sessions. The study population was randomly assigned into experimental and control groups, each consisting of 15 individuals. The adequacy of the sample size was examined by basic statistical methods and the results of the previous studiesTools The Clinical Version of the Structured Clinical Interview for Axis-One Disorders in DSM-IV (SCID-I /CV)21 This form was translated and adjusted by Sharifi et al.21 in Iran, and its validity and reliability was confirmed.It is a standardized tool for evaluating major psychiatric disorders based on the DSM-IV definitions and criteria designed for clinical and research goals. The implementation of the SCID-I/CV needs clinical judgment of the interviewer about the answers of the interviewee; therefore, the interviewer should have enough knowledge and experience about psychological pathology. The validity and reliability of this instrument is reported to be acceptable in different studies. For example, it was reported higher than 0.7 in the diagnostic reliability of Kappa raters. According to a study, the validity of this instrument was confirmed by specialists and test-retest reliability of 0.95 was reported with a one-week interval.Demographic Information QuestionnaireThis questionnaire includes items such as age, education, and inclusion and exclusion criteria.Walker's Health Promoting Lifestyle Questionnaire (1997)22 Likert's range is used to answer the items. The scores for each item comprise never = 1, sometimes = 2, often = 3, and always = 4. In a study by Mohammad Zeidi et al.,23 the reliability of the questionnaire was confirmed. The reliability of the questionnaire was also calculated using Cronbach's alpha.23 Cao WJ et al.22 reported the reliability of this questionnaire based on documented exploratory factor analysis and its validity based on Cronbach's alpha. Cronbach's alpha coefficient is 0.86 for health responsibility, 0.85 for physical activity, 0.80 for nutrition, 0.86 for self-actualization, 0.87 for interpersonal support, 0.79 for stress management, and 0.94 for the entire questionnaire. The validity of the questionnaire in this study was confirmed using formal reliability and the comments of 2 health specialists. In the next step, the correlation between the scores of the subscales and the total score was calculated to further guarantee the reliability. The correlation coefficients between the total score of the Health Promotion Lifestyle Questionnaire and responsibility, physical activity, nutrition, self-actualization, interpersonal support, and stress management were calculated at 0.78, 0.70, 0.65, 0.71, 0.73, and 0.84, respectively.This questionnaire has 54 items. Its aim is to measure health promoting behaviors and has 6 dimensions .Lazarus' Coping Strategies Methods (WOCQ)24 Individuals answer the items based on Likert's 4-choice scale, which indicates the frequency of each of the used strategies. In this case, zero indicates "I have not used them."; 1 signifies "I have used them to some extent."; 2 denotes "I have used them most of the time."; and 3 implies "I have used them too much.". The items of Lazarus's Coping Strategies Questionnaire have formal validity because the described strategies are those that individuals report they use in coping with stressful situations.24 The reliability of the questionnaire and the use of internal consistency  was estimated at 84/0.This questionnaire has 66 items and is devised based on an inventory of the coping strategies proposed by Folkman and Lazarus. This instrument evaluates a wide range of thoughts and actions that individuals apply when they face internal or external stressful situations. This test consists of 8 subscales, namely direct coping, distancing, self-control, seeking social support reassessment, accepting responsibility, escape avoidance, planned problem solving, and positive reassessment. The 4 subscales of seeking social support, accepting responsibility, planned problem solving, and positive reassessment are problem-focused strategies and the 4 subscales of direct coping, distancing, self-control, escape avoidance, and self-control are emotion-focused coping strategies.The Research Implementation Process25This study was conducted in the Internal Diseases Division of Imam Hossein Hospital in Tehran by 2 holders of master's degree in psychology familiar enough with the planned intervention. The participants provided informed consent and received reassurances about the confidentiality of their information. The subjects in the experimental and control groups completed the questionnaires in 3 stages: before intervention (pre-test); after intervention (post-test); and 2 months post intervention (follow-up). Group treatment was implemented for 8 sessions, once a week for 90 minutes, based on the MBSRP. The control group received no treatment. Due to ethical issues, the participants in the control group were given CDs about yoga at the termination of the study. To assess the normality of the distribution of the scores and homogeneity of the variances, the multivariate covariance analysis with repeated measures was employed. For the statistical analyses, the statistical software SPSS (version 19.0) for Windows  was used. The contents of the MBSRP and conscious yoga treatment sessions are presented in The demographic characteristics of the study population are listed in The mean and standard deviation of the lifestyle, coping strategies, and blood pressure scores in the experimental and control groups in the three stages of pre-test, post-test, and follow-up are reported in First, the assumptions of using the model were studied. The K-S test results on the normal distribution of the data showed that the distributions of the dependent variables were equal to the theoretical distributions: K-S = 0.83, sig = 0.52 for the lifestyle component; K-S = 0.49, sig = 0.97 for the coping strategy component; and K-S = 1.42, sig = 0.09 for the blood pressure component. The results of the MBox test about the equality of covariance matrices demonstrated that the assumption of the homogeneity of the variance-covariance matrix was established and that the observed covariance matrix of the dependent variables was equal in the groups: F = 2.239; p value = 0.144 for the lifestyle component; F = 0.949; p value = 0.458 for the coping strategy component; and F = 1.949; p value = 0.311 for the blood pressure component. Also, by utilizing Levine's test for the equality of error variances, the assumption of the equality of variances was observed and the error variance of the dependent variable was equal in both groups: F = 2.77, sig = 0.10 for the lifestyle component; F = 1.41, sig = 0.22 for the coping strategy component; and F = 2.80, sig = 0.08 for the blood pressure component. Therefore, the assumptions of the multivariate covariance analysis were used.The results of Based on our statistical findings, it can be concluded that the MBSRP and conscious yoga in the experimental group, compared to the control group, in both post-test and follow-up had an effect on improving lifestyle in patients with hypertension. The results of the present study indicated that healthy lifestyle behavior training through the MBSRP and conscious yoga decreased blood pressure in the patients and this change was statistically significant . 26-29The findings of the present study are consistent with the results of previously published studies.27 showed that lifestyle modifications, including choosing a healthy diet, increasing physical activity, and reducing sedentary behaviors can be beneficial in the management of blood pressure. Additionally, physical activity may contribute to improvements in medication adherence in hypertensives. However, evidence for the effect of lifestyle modifications on lifestyle change and medication persistence is scarce, of poor quality, and suggests little clinically relevant benefit. The results of a study by Lochner et al.30 in Portland showed that pharmacotherapy combined with applied training in case of lifestyle change can lead to a reduction of 3 to 11 mmHg in the systolic blood pressure and reduction of 2.5 to 5.5 mmHg in the diastolic blood pressure. The results of a study by de Moraes et al.31 The results of a study by Pandit et al.31 in Chicago revealed that health training can increase the knowledge of patients with hypertension, but it has no significant effect on reducing their blood pressure. In contrast, our results showed that lifestyle training through the MBSRP and conscious yoga can reduce psychological symptoms , thereby reducing the patients' blood pressure. A study by Chen et al.29 demonstrated the effectiveness of lifestyle training, including sleep and rest, physical activity, and nutrition, in reducing depression, anxiety, stress, and diabetes. Additionally, the meta-analysis found that lifestyle intervention showed significant benefits in risk factors that are known to be associated with the development of cardiovascular disease in patients with type II diabetes. The results of the present study, however, do not chime in with those of some other studies.32-34 Najafi Ghezeljeh et al.32 reported that patients with hypertension use emotion-focused coping strategies such as escaping, avoiding stress sources, and refraining from expressing emotions when they face stress. The emotion-focused coping strategy is believed to be effective as a short-term coping strategy; still, in the long term, it endangers mental and physical health. In other words, the use of these strategies by patients with hypertension reduces their ability to solve the problem. Thus, this situation disrupts thought integration, brings about distress, and compromises physical health. In contrast, using problem-focused coping strategies like positive reassessment and emotional and social support strengthens patients against stress and helps them to experience low emotional stress levels. This mental calmness focuses all the abilities of patients on using cognitive skills and dynamics to cope with the problem better. Kabat-Zinn25 and Lind et al.33 showed that inefficient coping strategies have a negative correlation with mindfulness and that training and increasing mindfulness can decrease inefficient coping strategies. A significant reduction was observed in the post-test in our study population. This can be explained by the notion that judgment causes stress in hypertensive patients in many situations and as such increases the use of the emotion-focused coping strategy and the experiencing of negative emotions and stress. This vicious cycle can lead to an increase in diseases and disorders. To reduce the use of these strategies, it is necessary that patients try not to judge and understand the feelings and events as they are. Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity, and social functioning. However, the patients identified potentials for treatment improvements, and they needed further treatment to fully recover.Our findings demonstrated that teaching behaviors related to a healthy lifestyle in components such as stress management, interpersonal support, nutrition, and exercise based on the MBSRP and conscious yoga techniques  can reduce psychological symptoms  and thus lead to a reduction in the blood pressure in patients with hypertension. The mean of the problem-focused coping strategy in the experimental group had a significant difference with that in the control group in the post-test and follow-up. It can, therefore, be concluded that a combination of the MBSRP and conscious yoga is more effective in patients with hypertension, compared to the control group, in encouraging the use of the problem-focused coping strategy. These findings are consistent with those reported by some previous studies.19, 35, 36 Hughes et al.35 showed that the MBSRP is effective in a group consisting of 56 men and women diagnosed with borderline hypertension not requiring medication. The patients receiving the MBSRP enhanced their physical and mental health, which prevented their blood pressure from increasing. The Blom et al.36 study on the effectiveness of the MBSRP with yoga and meditation in decreasing hypertension demonstrated significant differences in the post-test and at 3 months' follow-up. The authors suggested that mindfulness techniques be practiced continuously throughout the life and be turned into a style in life. In a study by Yuchy et al. 37 the effects of the MBSRP on a group of first-year nursing university students in variables such as the systolic blood pressure and anxiety symptoms were examined and the results indicated the effectiveness of this treatment on reducing the blood pressure and anxiety symptoms. This finding can be explained by the notion that group MBSRP and conscious yoga, through meditation techniques and mindfulness, can increase self-awareness and self-acceptance abilities, and thus improve the quality of life in patients. Mindfulness techniques (automatic exercise and focus) and relaxation training  largely as a stress management skill must be practiced regularly and permanently in patients' lives.25 Studies have shown that mindfulness has been effective in improving mental and physical well-being and reducing physical symptoms.14 In explaining this finding it can be said that because mindfulness is a non-judgmental and balanced feeling of awareness that helps clarity and acceptance of emotions and physical phenomena,34 teaching its concepts to hypertensive patients who suffer from physical and mental problems will enable them to accept their feelings and physical symptoms better and as such reduce their level of sensitivity to the problem. In this regard, results show that emotional inhibition, as a negative emotion-regulating strategy, leads to cardiovascular diseases and hypertension, whereas cognitive evaluation of emotions, as a positive emotion-regulating strategy, leads to a reduction in the blood pressure.15 Another explanation for these results is that depression, anxiety, and stress are the main factors affecting patients with hypertension.7, 9 This finding can be explained by the notion that it causes a reduction in physical stress and produces epinephrine and norepinephrine hormones, thereby reducing stress and anxiety and, thus, the blood pressure in patients. Generally, mindfulness and emotion regulation are each reviewed, followed by a conceptual integration. Fundamental difficulties arising from the attempt to integrate the two domains are highlighted, especially as to the "reality" of thoughts, the relationship between thoughts and emotions, and the need to move beyond a valence model of emotion. Finally, a model is proposed outlining the likely critical processes and mechanisms that underlie "mindful emotion regulation.38 According to Park et al, mindfulness practices  lead to physiological changes and these changes are correlated with decreased activity of the sympathetic nervous system, they can reduce the blood pressure. The participants had a significantly lower respiratory rate during mindfulness meditation; however, in contrast to mindfulness meditation, controlled breathing alone did not reduce blood pressure, heart rate, or muscle sympathetic nerve activity. Mindfulness meditation acutely lowered blood pressure and heart rate in African-American males with hypertensive chronic kidney disease, and these hemodynamic effects might have been mediated by a reduction in sympathetic nerve activity. The respiratory rate was significantly lower during mindfulness meditation, but controlled breathing alone without concomitant meditation did not acutely alter hemodynamics or sympathetic activity in chronic kidney disease.39 Treatment in a group helps to enhance coping ability, sense of hope, and response to treatment; therefore, it can be argued that more therapeutic consequences are affected.29Another result of the present study indicated that the MBSRP and conscious yoga reduced the systolic and diastolic blood pressures in our hypertensive patients in the post-test and follow-up compared to the control group. This finding is another confirmation of the effectiveness of the MBSRP in treating hypertension and psychological factors associated with it. The results of the present study are consistent with those of some previously conducted investigations.In light of the results of the current study and similar ones, it can be concluded that the MBSRP and conscious yoga can be useful in reducing hypertension, promoting a healthy lifestyle, and encouraging the application of problem-focused coping strategies because of their emphasis on awareness and non-judgmental techniques. Nonetheless, it should be noted that the longevity of the effectiveness requires constant practice and expansion of mindfulness techniques throughout the life, such that this method can indeed become a lifestyle. The present study has some limitations, first and foremost amongst which are its relatively short follow-up period and its inability to perform a comprehensive sampling of all urban areas, limiting the scope to only one hospital. The MBSRP can promote a healthy lifestyle, encourage problem-focused coping strategies, and decrease the systolic and diastolic blood pressures in patients with hypertension.


Background. Functional abnormalities of high-density lipoprotein (HDL) could contribute to cardiovascular disease in chronic kidney disease patients. We measured a validated marker of HDL dysfunction, nitrated apolipoprotein A-I, in kidney transplant recipients to test the hypothesis that a functioning kidney transplant reduces serum nitrated apoA-I concentrations. Methods. Concentrations of nitrated apoA-I and apoB were measured using indirect sandwich ELISA assays on sera collected from each transplant subject before transplantation and at 1, 3, and 12 months after transplantation. Patients were excluded if they have history of diabetes, treatment with lipid-lowering medications or HIV protease inhibitors, prednisone dose > 15 mg/day, nephrotic range proteinuria, serum creatinine > 1.5 mg/dL, or active inflammatory disease. Sera from 18 transplanted patients were analyzed. Four subjects were excluded due to insufficient data. Twelve and eight patients had creatinine < 1.5 mg/dL at 3 and 12 months after transplantation, respectively. Results. Nitrated apoA-I was significantly reduced at 12 months after transplantation (p = 0.039). The decrease in apoA-I nitration was associated with significant reduction in myeloperoxidase (MPO) activity (p = 0.047). In contrast to apoA-I, nitrated apoB was not affected after kidney transplantation. Conclusions. Patients with well-functioning grafts had significant reduction in nitrated apoA-I 12 months after kidney transplantation. Further studies are needed in a large cohort to determine if nitrated apoA-I can be used as a valuable marker for cardiovascular risk stratification in chronic kidney disease. Cardiovascular disease (CVD) is the leading cause of death among patients with end-stage renal disease (ESRD), accounting for approximately half of all deaths –4. The mIt is possible that HDL's quantity and quality may explain some of the residual risks in patients with advanced CKD. Epidemiologic studies have shown that there is a gradual increase in the risk of CVD as HDL cholesterol decreases , 12. HowRecent studies are now focusing on assessing HDL function rather than measuring its traditional plasma concentration –17. In tBoth qualitative and quantitative changes in HDL have been described in patients with CKD . SpecifiDegree of nitration in apoA1-HDL has been evaluated by several methods such as mass spectrometry and Western blot analysis in different disease setting , 32, 33.μg/dL between pretransplant and 12-month posttransplant concentration of nitrated apoA-I at two-tailed type I error α of 0.05 using Wilcoxon signed-rank test [Seventy-eight subjects were recruited from outpatient clinics of SUNY Downstate Medical Center between November 2010 and June 2013. The study was approved by the Institutional Review Board under protocol number 441318-1. Written informed consent was obtained from all study participants. All participants were adults. Kidney transplant recipients were enrolled in the study unless they met exclusion criteria. Patients with the following criteria were excluded from the study: diabetes, HIV on antiretroviral therapy, active systemic rheumatologic diseases, nephrotic syndrome, protein : creatinine ratio >1, treatment with lipid-lowering agents, body mass index (BMI) > 35, creatinine >1.5 mg/dL or estimated glomerular filtration (eGFR) <60 mL/min by Modification of Diet for Renal Disease (MDRD) equation, steroid dose >15 mg prednisone or equivalent a month or more after transplantation, and treatment with sirolimus or everolimus. All these above selection criteria would eliminate most of important confounding factors that could interfere with lipid and lipoprotein metabolism. A sample size of 12 was estimated to provide 90% power to detect difference of 448 ank test , 35.Sera were collected from each transplant subject before transplantation and at 1, 3, and 12 months after transplantation. In total, sera from eighteen transplanted patients who were eligible and presented stable kidney function were retrospectively analyzed. Four patients were excluded due to incomplete time point data. At the end, among this group, twelve and eight patients had creatinine < 1.5 mg/dL at 3 and 12 months after transplantation, respectively.μg/mL) of purified human serum HDL and LDL, respectively . For this purpose, monoclonal antibodies against apoA-I and apoB were immobilized in 96-well plates . Bound HDL (apoA-I-HDL) and LDL (apoB-LDL) were detected with alkaline phosphatase-conjugated secondary antibodies and p-Nitrophenyl phosphate (pNPP) as substrate (1 mg/mL).Aliquoted sera stored at −70°C were thawed and concentrations of nitrated apoA1-containing HDL were measured using a well-established sandwich ELISA method . A similAbsorbance at 405 nm was measured and corrected to absorbance of control wells in which PBS-Tween was added instead of serum. Total serum apoA-I and apoB levels were determined as described previously , 35. AbsNon-HDL fraction was isolated from sera by precipitating (LDL/VLDL) with manganese chloride solution (1.06 M). After centrifugation, total cholesterol in the supernatants (HDLc) and in PBS-reconstituted precipitates (non-HDLc) was measured by colorimetric assay . Lipid peroxidation/oxidative stress were evaluated by measuring thiobarbituric acid reactive substances (TBARS) in sera. Briefly, the LDL/VLDL fraction was precipitated by 1.06 M manganese chloride and levels of TBARS were determined using OXI-TEK TBARS assay kit . MPO was measured by colorimetric activity assay kit .p < 0.05 was considered statistically significant.Only results for those with creatinine < 1.5 (those with successful transplant) are mentioned. Data for continuous variables (means ± SD) and medians (interquartile ranges) were reported. All analyses were performed using the Prism GraphPad 5.0 and Statistica 10.0 softwares. Paired values of percent nitrated apoA-I or nitrated apoB before and after transplantation were compared using nonparametric Wilcoxon signed-rank sum test. In addition, linear regression and Pearson's correlation coefficient were used to assess associations between variables. μg/mL LDL added and between 0 and 100 ng/mL HDL added  12 months after transplantation. In contrast, there were no significant changes in nitrated apoB at 3 months and 12 months after transplantation  at 3 months and 12 months after transplantation, respectively. For each subject, we compared paired values of percent nitrated apoA-I and apoB before kidney transplantation and 3 months and 12 months after kidney transplantation. Analysis of the twelve patients that had creatinine < 1.5 mg/dL at 3 months after transplantation showed no difference in nitrated apoA-I . At 12 m Figures . Like app = 0.047). Lipid peroxidation as measured by TBARS assay was unchanged at 3 months and 12 months after transplantation.The decrease in apoA-I nitration 12 months after transplantation was associated with a significant reduction of MPO activity levels  probably due to absence of lipid-lowering treatment in these patients and possible effect of immunosuppressive drugs. Unlike apoA-I, good kidney function did not affect degree of apoB nitration at 3 months and 12 months after transplantation Figures . These dOne major limitation of our study is the small sample size due to strict patient's exclusion criteria setting. Nevertheless, none of our patients had received lipid-lowering therapy that could affect outcome of the study. Another limitation is lack of suitable normal control group (donors) for this particular setting protocol. These findings need to be confirmed in a large prospective study in order to validate the usefulness of nitrated apoA-I as independent predictor marker for CVD risk in CKD patients. More focused research is warranted to elucidate whether modified HDL in advanced CKD participates in very similar cellular processes of atherosclerosis such as foam cell formation, proliferation and migration of smooth muscle cells, and, most importantly, plaque destabilization.In summary, we have demonstrated that patients with well-functioning kidney transplants had significant reduction in nitrated apoA-I-HDL 12 months after kidney transplantation without any major changes in nitrated apoB-LDL. Given the high cardiovascular burden of kidney transplant recipients, nitrated apoA-I may serve as valuable marker for population stratification and perhaps as a possible target for novel therapeutic strategies.


The present study compared short- and long-term prognostic values of red blood cell distribution width (RDW) with those of hemoglobin (Hgb) among patients with acute congestive heart failure (CHF) in a cardiac care unit. The cross-sectional study examined data from 521 patients with acute CHF who were admitted to a cardiac care unit and followed up for 24 months (median). Mean Hgb levels in patients who succumbed (DIH) or remained alive (AIH) were 11.0±1.8 and 11.8±2.6 g/l (P>0.05), respectively. Median values of RDW were 16.2% and 14.4%, respectively (P<0.0001). During the 24-month follow-up, mean levels of Hgb in groups with and without endpoints were 11.4±2.5 and 12.5±2.4 g/dl (P<0.0001), respectively. Median RDW values were 14.9 and 13.8%, respectively (P<0.0001). Logistic regression analysis showed that in-hospital mortality was significantly associated with RDW (P=0.044), New York Heart Association (NYHA) functional class IV (P=0.0037), estimated glomerular filtration rate (eGFR) (P=0.042) and C-reactive protein (P=0.0044), but not with Hgb (P=0.10). The multivariate Cox proportional hazard model selected RDW , left ventricular ejection fraction , age  and NYHA functional classes III/IV  as independent predictors of long-term outcomes after adjustment, but not Hgb . Higher RDW values in acute CHF patients at admission were associated with worse short- and long-term outcomes and RDW values were more prognostically relevant than Hgb levels. Congestive heart failure (CHF) is often accompanied by high mortality rates. Therefore, accurate risk stratification is critically important in identifying high-risk patients who may benefit from advanced treatment –4. A numAnemia is a common feature of patients with CHF and it has important implications for the prognosis and treatment of CHF –17. A caThe present study therefore investigated whether RDW is useful for risk stratification in patients hospitalized with acute exacerbation of CHF and analyzed the prognostic value of RDW compared with that of Hgb levels and anemia status.Patients with acute onset of CHF were consecutively enrolled in an observational study between January 2007 and December 2009. All patients were hospitalized at the cardiac care unit (CCU) of Juntendo University Hospital . Demographic and clinical information, as well as age, gender, New York Heart Association (NYHA) functional class, history of cigarette smoking, ischemic heart disease, hypertension, hyperlipidemia, atrial fibrillation, diabetes mellitus, chronic renal failure, hemodialysis and medications taken upon admission were obtained from medical records. Body mass index was calculated from height and weight data. Cardiac structure and function was assessed by echocardiography using a hematology analyzer .The patients were followed up by telephone, personal interviews and by reviewing electronic medical records. The endpoint for short-term outcomes was in-hospital mortality. Mortality from all causes and readmission to hospital with the onset of CHF were long-term endpoints. The end of the follow-up was June 2010. The current study was performed according to the ethics policies of Juntendo University Hospital and was approved by the internal review board. Informed consent was obtained from the patient.2) = 186 × [serum creatinine (Scr)]−1.154 × (age)−0.203 ×  where Scr is the serum creatinine level in mg/dl.Blood samples were obtained immediately upon admission to the CCU and analyzed as quickly as possible in the clinical chemistry laboratory. Anemia was defined as Hgb <12 g/dl in women and <13 g/dl in men, according to the World Health Organization (WHO) criteria. Renal function was evaluated as the estimated glomerular filtration rate (eGFR), calculated according to the simplified modification of diet in renal disease (MDRD) equation: eGFR  and the Wilcoxon or Kruskal-Wallis one-way ANOVA test. Univariable correlations were examined using the Pearson’s correlation coefficient in the context of normality, whereas correlations among non-normally distributed variables were examined using the Spearman’s rho test. Variables with a retention P-value of 0.10 in the univariate analysis were entered into a multivariable linear regression model. Variables with non-normal distributions were log-transformed prior to being entered into this model.Discrete variables were presented as frequency counts and ratios (%). Continuous variables were analyzed based on a normal distribution using the Shapiro-Wilk test. They were expressed as mean ± SD when normally distributed, or as medians with inter-quartile ranges (IQRs) if not. Proportions and means or medians were compared using the χIndependent predictors of short- and long-term outcomes were identified using the logistic regression and Cox proportional hazard models, respectively. Kaplan-Meier accumulated survival curves were constructed and log-rank values were calculated to assess their statistical significance.All data were analyzed using JMP 8.0  and SPSS 18.0 . P<0.05 was considered to indicate a statistically significant difference.The current study comprised 521 patients with acute onset CHF from a wide range of age groups [72  years]. The median (IQR) values of RDW and mean level of Hgb overall were 14.5 % and 11.7±2.5 g/dl, respectively. Based on the WHO criteria, 324 (62.2%) patients were diagnosed with anemia. Among the patients, 192 (36.9%), 200 (38.4%) and 129 (24.8%) were classified as NYHA functional classes II, III and IV, respectively. Univariate analysis showed that age, history of CRF, hemodialysis at presentation, history of diabetes mellitus, Hgb, anemia, NYHA classification, LVEF, BNP, TC, LDL-C, HDL-C, TG, BUN, eGFR and loop diuretics at presentation were significantly correlated with RDW . However, further multivariate analysis revealed Hgb, BNP, eGFR and HDL-C as independent predictors of RDW .Thirty-three (6.3%) patients succumbed in hospital. After a median follow-up of 24 months , 315 (64.5%) patients reached the endpoint of mortality or re-hospitalization.The RDW values were significantly higher in the group that succumbed while in hospital (DIH) compared with the group that remained alive while in hospital (AIH) . However, Hgb did not significantly differ between the two groups (11.0±1.8 vs. 11.8±2.6 g/dl, P>0.05; Throughout the median 24 months of follow-up, both Hgb and RDW significantly differed between the two groups . The meaKaplan-Meier survival curves for mortality from all causes and readmission to hospital demonstrated that rates of endpoints were significantly higher among patients with a higher RDW  and variThe results of the present study revealed that RDW may act as a powerful independent predictive factor for short- and long-term outcomes in patients with acute exacerbation of CHF and that this prognostic value remains significant even after adjustment for other known prognostic factors. The correlation between RDW and the long-term outcomes of patients with acute CHF provides prognostic data upon which to base risk factors and persists regardless of the levels of Hgb or BNP. Other prognostic markers identified in the current study were age, LVEF and NYHA class, all of which were consistent with the findings of published models on heart failure.The RDW is a measurement of the size variation among circulating red cells and is calculated as part of the routine complete blood count . The RDWAnemia has convincingly served as a powerful predictor of re-hospitalization rates and survival in CHF ,26,27. SThe RDW values become elevated under conditions of increased red cell destruction or ineffective red cell production . IncreasThe most notable finding of the present study was that after multivariate adjustment of all the patient data, RDW, but not Hgb, was predictive of both in-hospital and long-term outcomes. This indicates that the pathophysiology leading to increased RDW may affect outcomes in chronically ill patients, irrespective of anemia status. The finding may be explained as follows. As noted above, many variables are associated with anemia, such as inflammatory factors, nutritional deficiencies, renal dysfunction and inadequate erythropoietin production. The relationships among these variables and outcomes may be more directly reflected through their impact on RDW, than on Hgb. This was demonstrated in the present study as RDW predicted mortality in patients with and without anemia.Secondly, RDW may be an earlier marker of prognosis than Hgb as it reflects the early steps in the complex processes that lead to anemia. At this point red blood cell production is ineffective and red blood cell destruction increases, but Hgb remains within the normal range. In addition, all the patients in the current study had the onset of acute CHF. Hemodynamic changes during this acute phase, such as fluid retention, interfere with the accurate measurement of Hgb, which may generate misinformation about the status of anemia. Under these circumstances, RDW is likely to be a more appropriate marker of baseline anemia status.Another notable finding of the present study was that after stratifying levels of BNP, RDW remained associated with long-term outcomes. Although BNP is considered to be a powerful predictor of CHF outcomes , a singlThe RDW is a readily available and inexpensive test for patients with CHF. Results are reported together with a complete differential blood count and no extra cost is incurred. The RDW has a better prognostic value than Hgb for both short- and long-term outcomes in patients with decompensated CHF and the prognostic value in long-term outcomes remains significant regardless of anemia or BNP levels. Thus, RDW appears to carry prognostic information concerning states other than anemia. In the future, the inclusion of RDW in a combined model for the risk stratification of patients with acute exacerbation of CHF is recommended. Further study is required to clarify the detailed mechanisms of the effect of elevated RDW in CHF.


Obstructed nephropathy is a common complication of several disease processes. Accurate evaluation of the functional status of the obstructed kidney is important to achieve a good outcome. The purpose of this study was to investigate renal cortical and medullary perfusion changes associated with unilateral ureteral obstruction (UUO) using whole-organ perfusion imaging with 320-detector row computed tomography (CT).Sixty-four patients with UUO underwent whole-organ CT perfusion imaging. Patients were divided into 3 groups, mild, moderate, and severe, based on hydronephrosis severity. Twenty sex- and age-matched patients without renal disease, who referred to abdominal CT, were chosen as control subjects. Mean cortical and medullary perfusion parameters of obstructed and contralateral kidneys were compared, and mean perfusion ratios between obstructed and contralateral kidneys were calculated and compared. Mean cortical or medullary blood flow (BF) and blood volume (BV) of the obstructed kidneys in the moderate UUO and BF, BV, and clearance (CL) in the severe UUO were significantly lower than those of the contralateral kidneys (p < 0.05). The mean cortical or medullary BF of the obstructed kidney in the moderate UUO, and BF, BV, and CL in the severe UUO were significantly lower than those of the kidneys in control subjects (p < 0.05). Mean cortical or medullary BF of the non-obstructed kidneys in the severe UUO were statistically greater than that of normal kidneys in control subjects (p < 0.05). An inverse correlation was observed between cortical and medullary perfusion ratios and grades of hydronephosis (p < 0.01).Perfusion measurements of the whole kidney can be obtained with 320-detector row CT, and estimated perfusion ratios have potential for quantitatively evaluating UUO renal injury grades. Obstructed nephropathy is a common complication of several disease processes. It usually causes progressive renal damage, and ultimately leads to renal failure. An accurate evaluation of the anatomical and functional status of the obstructed kidney is important to determine optimal management and assess the effectiveness of therapy, especially when the disease involves only one kidney.Computed tomography (CT) perfusion imaging is a new, non-invasive technology that allows the quantification of renal blood flow abnormalities of a single kidney, as well as renal morphological changes –4. AlthoAn innovative 320-detector row CT allows for 160 mm coverage in the z-direction without table movement, which makes it possible to perform volumetric perfusion. As such, perfusion information of the whole organ, such as bilateral kidneys, can be obtained. This CT system has been successfully used to evaluate the hemodynamics of liver, pancreas and spleen perfusions ,6. As toThus, the purpose of this study was to determine the feasibility and effectiveness of whole-organ perfusion imaging based on 320-detector row dynamic volume CT for assessing renal hemodynamics and function in patients with unilateral ureteral obstruction (UUO).This study was approved by the Committee for Medical Ethics, the First Affiliated Hospital of Jinan University, China, and was performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients.Sixty-four consecutive patients with UUO as determined by ultrasound were enrolled in this study between January 2013 and September 2013. The patients included 25 females and 39 males with a mean age of 48.0 ± 4.5 years . Thirty-one of the obstructed kidneys were on the right side, and 33 were on the left. The causes of UUO were ureteral stones in 61 patients, and ureteropelvic junction stricture in 3 patients. Patient symptoms included flank pain, hematuria, pyuria, and dysuria. Patients with renal failure (serum creatinine >1.5 mg/dl [114 mol/l]), bilateral obstruction, or unilateral obstruction with an abnormal or absent contralateral kidney, and underage patients (less than 18 years) were excluded. In order to assess the effect of the severity of obstruction on renal function, patients were classified into 3 groups according to their CT findings [A group of 20 sex- and age-matched individuals  who had received upper abdominal perfusion imaging using 320-detector dynamic volume CT at our hospital were retrospectively chosen as control subjects. The subjects had no renal or renal vascular diseases or hypertension. All control subjects had normal serum creatinine levels, and they showed no morphologic abnormalities in both kidneys on CT examination.A low-dose perfusion protocol was used with a 320-detector row CT system . In order to minimize the radiation dose, we chose 100 kV as tube voltage, 100 mA as the mask tube current, and 60 mA as the following tube current. Other scan parameters were 0.5 mm × 320 collimator, 512 × 512 matrices, 320–350 mm field of view (FOV), and 0.5 s rotation time. Bilateral whole kidneys of each patient were covered by a single scan as a result of z-direction coverage of 160 mm.th second after the injection to obtain a mask, and acquisition was continued every 2 seconds intervals from the 12th second to the 30th second. Then, after a 3-second pause, 3-second intervals were used from the 33th second to the 48th second. Again, after a 7-second pause, 7-second intervals were used from the 55th second to 90th second. The patient was allowed to breathe gently throughout the examination.A total of 56 ml anon-ionic contrast material  was injected with a flow rate of 7 ml/s using a dual-shot injector  through an 18-gauge intravenous injection catheter inserted into an antecubital vein. A 100 ml 0.9% saline chaser was administered with the same flow rate after the injection of CM. The dynamic volume CT scan was started at the 7The volumetric CT dose index (CTDIvol) and dose-length product (DLP) of each examination was automatically archived by the system when the scan was finished. The effective dose (ED) was calculated using an appropriate k-factor of 0.015 mSv/mGy·cm . In ordePerfusion post-processing and measurement were performed by two experienced radiologists in consensus. The acquired perfusion volume data was loaded into the body perfusion software in the display console  for post-processing. First, volume registration was performed to eliminate the effect of breathing movement, and a new registered volume dataset was generated. Time–density curve (TDC) was obtained when regions-of-interest (ROIs) were placed on the abdominal aorta at the level of the renal hilum and renal cortex or medulla. A single input maximum slope algorithm was used to obtain a blood flow map  based on TDC, and Patlak plot method was used to acquire a blood volume map  and clearance map  based on Patlak graph ,11–13 F. BF was obstructed or left / perfusioncontralateral.ROIs for perfusion measurements were placed on the bilateral renal cortex and medulla on the perfusion maps and made as large as possible. ROIs of renal cortex and medulla were defined manually in axial and coronal planes for each area to minimize the influence of potential measurement errors . MoreoveThe mean and standard deviation (mean ± SD) of measurements were calculated for all perfusion parameters. A paired sample t-test was used to compare data in the obstructed kidneys with those in the contralateral non-obstructed kidneys for UUO patients. A paired sample t-test was also used to compare data in the left kidneys with those in the right kidneys for control subjects. Analysis of variance (ANOVA) was used to assess the differences of the cortical or medullary perfusion values between UUO patients and control subjects. A Pearson correlation analysis was performed to examine the relationship between the perfusion values and the hydronephosis severity. A p value less than 0.05 was considered to indicate a significant difference. Statistical analysis was performed using SPSS version 16.0A .Examinations were performed successfully in all 64 patients without any technical problems or adverse reactions to the CM. The estimated mean ED was 11.29 ± 0.36 mSv .Dilatation of the collecting system in UUO patients was mild in 26 patients, moderate in 22 patients, and severe in 16 patients.The mean cortical and medullary perfusion parameters of bilateral kidneys in control subjects and UUO patients are shown in Also, the mean cortical and medullary perfusion values of obstructed kidneys in UUO patients decreased as compared with kidneys of control subjects. In the cortex and medulla, the mean BF of obstructed kidneys in the moderate UUO, and BF, BV, and CL of obstructed kidneys in the severe UUO were significantly lower than those of the kidneys of control subjects (p <0.05). However, no significant differences in any perfusion values between them were observed in the cortex and medulla of the mild UUO (p >0.05). Mean cortical or medullary BF of non-obstructed kidneys in the severe UUO was statistically greater than that of normal kidneys in control subjects (p <0.05). However, no significant difference was found in the perfusion values between non-obstructed kidneys of the mild or moderate UUO patients and normal kidneys of control subjects (p >0.05).Mean cortical or medullary BF ratio, BV ratio, and CL ratio between the obstructed and contralateral kidneys in UUO patients and between the left and right kidneys in control subjects are shown in In the cortex and medulla, the mean BF ratio, BV ratio, and CL ratio decreased with increasing the severity of hydronephrosis. Variations of the perfusion ratios across the mild, moderate, and severe groups were larger in the cortex than in the medulla. However, the same relationships were not observed with mean BF, BV, and CL values.Statistically significant correlations were detected between cortical or medullary BF ratio, BV ratio, and CL ratio and severity of hydronephrosis .Electron-beam CT (EBCT) was first used to complete the perfusion imaging because of its high temporal resolution, which has been shown to provide reliable measurements of renal flow –16. MultIn the current study, 320-detector row dynamic volume CT successfully assessed the bilateral function through the volumetric perfusion imaging, reflecting the intra-renal hemodynamic changes of both the obstructed and contralateral kidneys in UUO patients. Preoperative perfusion information of obstructed kidney is one of the independent factors affecting renal function recovery in patients with UUO. Quantitative assessment of relative individual renal function can help the urologists track the effectiveness of treatment and influence the clinical judgment. Compared with other imaging modalities, CT perfusion is relatively low-cost, fast and safe, especially on an advanced 320-dectector row CT with a well-refined protocol. The ED in this study was 11.29 mSv, which was lower than that reported in some previous studies with the same CT system ,6,8.Our study results demonstrated a decrease in the perfusion parameters of the obstructed kidneys, suggesting the abnormal low perfusion in the cortex and medulla in patients with a moderate and severe unilateral ureteral obstruction. This finding is supported histological changes seen after the ureteral obstruction. The early histological patterns include increasing edema in Bowman’s space, tubular dilatation, flattening and atrophy, and peritubular inflammation. Long existence of obstruction can lead to high risks of glomerular sclerosis, reduction of renal glomeruli, and interstitial fibrosis –27. FurtIn the cortex and medulla, mean BF value of non-obstructed kidneys in the severe UUO was statistically greater than that of normal kidneys in control subjects. However, no significant difference was found in all of hemodynamic parameters between non-obstructed kidneys of the mild or moderate UUO patients and normal kidneys of control subjects. Similarly, Lerman et al.  reportedIn our study, average BF values of left and right renal cortex in healthy control group were 266.15 and 268.68 ml/100ml/min, which were different from those reported in previous studies with the same CT system ,8. ZhongIn the current study, there were no significant differences in mean cortical or medullary perfusion values between the left and right kidneys in control subjects. This indicates that BF between the left and right kidneys in the healthy subjects is uniform. Therefore, it might be more reasonable to evaluate renal damage of one side using perfusion values of the other side as the reference. We also found that mean cortical and medullary perfusion ratios between obstructed and contralateral kidneys decreased with increasing severity of hydronephrosis. Also, inverse correlations were observed between perfusion ratios and hydronephrosis grades. These results are consistent with those reported by Pelaez et al.  and SheeThe present study has several limitations. First, the overall number of patients was small. A larger number of patients may provide more precise values. Second, although the low-dose perfusion protocol used in the current study allows lowering the tube current-time product to 30 mAs, the radiation dosage for CT perfusion imaging is still of great concern. Liu et al.  achievedThis study showed that 320-detector row dynamic volume CT is capable of detecting the hypoperfusion of an obstructed kidney as compared to a healthy kidney. CT perfusion imaging is a simple, accurate, and non-invasive technique that allows quantified assessment of the function of a single kidney affected by UUO as determined by significantly different perfusion values from that of a healthy kidney. Estimated perfusion ratio values between the obstructed kidney and the healthy kidney have the potential for quantitatively evaluating UUO renal injury grades.


Epicardial fat tissue is known to have an unique endocrine function which affect the cardiac autonomic system. Heart rate recovery (HRR) is a simple non-invasive measurement that assesses autonomic nervous system dysfunction. We aimed to investigate the association among epicardial fat thickness (EFT), HRR and circadian blood pressure (BP) variation in patients with hypertension.A total of 358 consecutive patients who underwent both 24-hour ambulatory BP monitoring (ABPM) and a treadmill test were enrolled. Echocardiographic EFT and HRR, defined as peak heart rate minus heart rate after a 1-min recovery time, were measured. Patients were classified according to the ABPM; 147 patients with hypertension with a dipping pattern at night (dippers), 140 patients with hypertension with a non-dipping pattern at night (non-dippers) and 71 normotensive controls.p < 0.001). HRR was significantly lower in both hypertensive groups as compared to the control group and was the lowest in the non-dipper group . EFT was significantly correlated with age, body mass index, 24-hour mean systolic BP and 24 h mean BP variability, whereas exercise duration, metabolic equivalents (METs) and HRR were inversely correlated with EFT. Furthermore, EFT > 6.7 mm was associated with a blunted HRR with 76 % sensitivity and 61 % specificity . In a multivariate analysis, EFT  and 24-hour mean BP variability  were independent predictors of a blunted HRR defined as HRR ≤ 12 beats (n = 63) in patients with hypertension.EFT was significantly higher in hypertensive patients, especially in the non-dipper group, compared to the controls (non-dippers, 7.5 ± 2.9 mm; dippers, 6.6 ± 1.6 mm; controls, 5.5 ± 2.1 mm; EFT and HRR were significantly correlated with circadian BP variability in patients with hypertension. EFT and circadian BP variability were independent predictors of blunted HRR, which suggests a link between epicardial fat and autonomic dysregulation in hypertension. Blood pressure (BP) is subject to diurnal variation, and studies using ambulatory BP monitoring (ABPM) have demonstrated that a blunted reduction in nocturnal BP  is associated with severe end-organ damage and an increased risk of cardiovascular events, especially in hypertensive patients , 2. AlthEpicardial fat thickness (EFT) is a newly identified cardiovascular risk factor. A high amount of epicardial fat is dangerous because this fat tissue is known to have unique endocrine and paracrine functions which affect the cardiac autonomic system –13. BecaThis cross-sectional, observational single-center cohort study included 358 consecutive patients who simultaneously underwent 24-hour ABPM, an exercise treadmill test and echocardiography between January 2010 and March 2015. Inclusion criteria were: 18–80 years of age, normal renal function and for women to be on a regular menstrual cycle. Exclusion criteria were: any systemic disease such as significant liver disease, neurologic disorders or malignant disease; secondary hypertension; valvular heart disease; a positive treadmill test; a history of heart failure; a history of acute coronary syndrome; myocar dial infarction or any revascularization procedure. Demographic characteristics recorded at the first visit included age, gender, height, weight, current medications, smoking history and other comorbidities. Blood was drawn for measurement of total serum cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol, triglycerides, blood glucose, creatinine, uric acid, and high sensitivity C-reactive protein (hs-CRP). Body mass index (BMI) was calculated as the ratio of weight in kilograms to height in square meters. This study was approved by the Kosin University International Review Board. All patients were required to provide written informed consent to participate.Office BP measurements were measured twice at 5-min intervals using a mercury sphygmomanometer. Noninvasive 24-hour ABPM was performed on each patient’s non-dominant arm using an automatic oscillometric device  on a normal working day. Patients were generally asked to refrain from fast exercise or stop taking the antihypertensive medications before 48 h. All subjects were instructed to rest or sleep between 10:00 PM and 7:00 AM (nighttime) and to continue their usual activities between 7:00 AM and 10:00 PM (daytime). The accuracy of the device was checked against the standard auscultatory method to assure the difference in BP measurements between methods did not exceed 5 mmHg. The device was set to obtain BP readings at 20-min intervals during the daytime and at 40-min intervals during the nighttime. Only 24-hour recordings that included at least 80 % successful recordings were accepted as valid. Each ABPM dataset was first automatically scanned to remove artifactual readings according to preselected editing criteria. The following ABPM parameters were evaluated: 24-hour mean systolic and diastolic BP levels, daytime mean systolic and diastolic BP levels, nighttime mean systolic and diastolic BP levels and BP variability assessed by standard deviation (SD). Additionally, the magnitude of the nocturnal decline in BP  was calculated as follows: daytime average BP minus nighttime average; the percentage change in BP from day to night (% day – night BP) was calculated as: (daytime BP – nighttime BP) × 100/daytime BP.Following the recommendations of the European Society of Hypertension,  a normotStandard 2-dimensional echocardiography were performed on all subjects while lying in the left lateral decubitus position using a 3.5-MHz transducer  and the echocardiography examiners were blinded to patient information. Measurements of the thickness of the interventricular septum and posterior wall, the diameter of the left ventricle (LV) cavity, and the LV mass index (LVMI) were performed according to criteria outlined by the American Society of Echocardiography . EchocarOn the same day as the echocardiographic examination, patients underwent symptom-limited exercise stress testing  according to the protocol by Bruce et al. . During p < 0.05 was considered to be statistically significant.Statistical analyses were performed with the commercially available computer program SPSS 18.0 for Windows . Data are presented as mean ± standard deviation for continuous variables and their percentages (%) if the data are categorical. The Mann – Whitney U test was used for continuous variables and the chi-square test was used for categorical data. The normality of data was tested using the Kolmogorov–Smirnov test. Parameter differences among the three groups were evaluated using a one-way ANOVA for normally distributed variables or the Kruskal–Wallis test for non-normally distributed variables. Relationships between variables were examined with Pearson correlation coefficients. The cutoff value of EFT for predicting blunted HRR with corresponding sensitivity and specificity was estimated by receiving operator characteristic (ROC) curve analysis. Multivariate logistic regression models for blunted HRR were built to determine which variables were independently associated with this status. A two-tailed p < 0.05). Circadian BP profile and BP variability assessed by 24-hour mean BP SD were greater in hypertensive patients, and especially in non-dippers .A total of 287 hypertensive patients  and 71 normotensive patients  were analyzed, and their clinical features and ambulatory blood pressure parameters according to diurnal variation are given in Tables p < 0.001; Fig. p < 0.05). HRR was significantly lower in both hypertensive groups as compared to the control group and was the lowest in the non-dipper group ; there was no significant difference between dipper and non-dipper groups.Although there was no significant difference in systolic function, hypertensive patients showed significantly greater wall thickness, greater LVMI and a larger left atrial diameter, all of which were more prominent among the non-dippers Table . EFT wasp < 0.001, Fig. p < 0.001, Fig. p < 0.001, Fig. p < 0.001, Fig. p < 0.05, Table p < 0.001)  and 24-hour mean BP SD  were independent predictors of blunted HRR in patients with hypertension  Fig. . In multThis is the first study investigating the association between EFT and HRR from symptom-limited exercise testing in hypertensive patients according to the diurnal variation within our knowledge. The most relevant findings obtained from this study are as follows: 1) epicardial fat was thickest in the non-dipper group, 2) HRR was lower in hypertensive patients, 3) there was a significant correlation between EFT and HRR, and HRR was also significantly correlated with 24-hour mean systolic/diastolic BP variability and 4) EFT and circadian BP variability were independent predictors of blunted HRR in patients with hypertension. Our findings suggest a possible link between epicardial fat and autonomic dysregulation in hypertension.Abnormalities of the autonomic nervous system play a fundamental role in BP regulation, and the majority of hypertensive patients have increased sympathetic activity along with diminished parasympathetic tone. Furthermore, the lack of a decrease in nocturnal BP is associated with severe end-organ damage and an increased risk of cardiovascular events, especially in hypertensive patients , 2. AlthRecently, epicardial adipose tissue has been found to reflect visceral adiposity and has been proposed as a new cardiometabolic risk factor, carrying more risk than general fat accumulation –13. SeveGenerally, an increase in HR during exercise occurs as a result of the combination of sympathetic activation and parasympathetic withdrawal. In contrast, parasympathetic reactivation is the principal determinant of the decrease in HR during early recovery, and this mechanism is independent of age and the intensity of exercise . Given tOur study has several limitations. First, to decrease the effect of ischemic symptoms after the termination of exercise test, we excluded patients with a history of heart failure, revascularization, or a positive result of an exercise test. However, the presence of coronary artery disease was excluded using only exercise testing, and further stress imaging modalities were not used. Second, because this study was performed at a single tertiary care center, there might be biases in patient referral and population sampling. Moreover, previous hypertensive medications might have an important impact on the BP variability and HRR. In order to account for these possible confounding effects, we performed sensitivity analysis for the binary regression analysis according to the use or nonuse of medications; the results were not different. Finally, EFT can be affected by metabolic syndrome, however, we do not check the waist circumference from the enrolled patients, so the metabolic syndrome cannot be defined from this result. However, regarding the significant correlation between EFT and obesity represented by BMI or EFT and 24-hour mean SBP, we can imagine the possible association between metabolic syndrome and EFT.In conclusion, EFT, an indicator of cardiac autonomic activity, was greatest in hypertensive patients with a non-dipping pattern, and impaired HRR, an indicator of abnormal parasympathetic reactivation, was observed in hypertensive patients regardless of nocturnal BP patterns. There was a significant correlation between EFT and HRR, and EFT and circadian BP variability were independent predictors of blunted HRR in patients with hypertension. Our data suggest that there is a cross link between epicardial fat and autonomic dysregulation in hypertension. The association between EFT and adverse cardiovascular outcomes in patients with blunted HRR needs to be investigated in further detail in future research.


Background. We investigated the predictive value of morning blood pressure surge (MBPS) on the development of microalbuminuria in normotensive adults with a recent diagnosis of type 2 diabetes. Methods. Prospective assessments of 24-hour ambulatory blood pressure monitoring and urinary albumin excretion were performed in 377 adult patients. Multivariate-adjusted Cox regression models were used to assess hazard ratios (HRs) between baseline and changes over follow-up in MBPS and the risk of microalbuminuria. The MBPS was calculated as follows: mean systolic BP during the 2 hours after awakening minus mean systolic BP during the 1 hour that included the lowest sleep BP. Results. After a mean follow-up of 6.5 years, microalbuminuria developed in 102 patients. An increase in MBPB during follow-up was associated with an increased risk of microalbuminuria. Compared to individuals in the lowest tertile (−0.67 ± 1.10 mmHg), the HR and 95% CI for microalbuminuria in those in the highest tertile of change (24.86 ± 6.92 mmHg) during follow-up were 17.41 (95% CI 6.26–48.42); p for trend <0.001. Mean SD MBPS significantly increased in those who developed microalbuminuria from a mean [SD] of 10.6 [1.4] to 36.8 [7.1], p < 0.001. Conclusion. An increase in MBPS is associated with the risk of microalbuminuria in normotensive adult patients with type 2 diabetes.  Normoal102 patients that developed microalbuminuria had a significant increase in MBPS over time (from 10.9 ± 1.4 to 35.3 ± 9.2 mmHg), while the MBSP did not significantly change in those who remained normoalbuminuric over time  Figure .Lastly, proliferative retinopathy developed in 18 subjects , but none of the 18 subjects had clinical evidence of neuropathy.Hypertension is certainly a major determinant of microangiopathy in diabetes, but the relationship between hypertension and microalbuminuria in diabetes is complex. Hypertension and microalbuminuria often coexist in diabetic patients, and reducing blood pressure reduces microalbuminuria in type 1 diabetes . HoweverEarly documentation of an increase in morning pressure might warrant the use of agents such as angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers in a patient with type 2 diabetes. Documentation of normal morning blood pressure, on the other hand, might suggest that there is no need for early therapeutic interventions other than those designed to provide optimal glycemic control.What Is New? We for the first time evidenced that an increase in blood pressure during morning period, detected by ambulatory blood pressure monitoring, preceded the development of microalbuminuria in newly diagnosed type 2 diabetes. In contrast, in subjects in whom microalbuminuria did not develop during a follow-up period of more than five years, neither nighttime, daytime, nor morning blood pressure increased significantly.What Is Relevant? The evaluation of the blood pressure circadian rhythm at an early stage of type 2 diabetes would provide the best basis for choosing therapies designed to prevent the progression to microalbuminuria. Early documentation of an increase in morning pressure might warrant the use of agents such as angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers in a patient with type 2 diabetes. Summary. An increase in morning systolic blood pressure is associated with the risk of microalbuminuria in normotensive adult patients with type 2 diabetes.


Evidence for pharmacogenetic risk stratification of angiotensin-converting enzyme inhibitor (ACEI) treatment is limited. Therefore, in a cohort of ACEI-treated patients with congestive heart failure (CHF), we investigated the predictive value of two pharmacogenetic scores that previously were found to predict ACEI efficacy in patients with ischemic heart disease and hypertension, respectively. Score A combined single nucleotide polymorphisms (SNPs) of the angiotensin II receptor type 1 gene (rs275651 and rs5182) and the bradykinin receptor B1 gene (rs12050217). Score B combined SNPs of the angiotensin-converting enzyme gene (rs4343) and ABO blood group genes (rs495828 and rs8176746).Danish patients with CHF enrolled in the previously reported Echocardiography and Heart Outcome Study were included. Subjects were genotyped and categorized according to pharmacogenetic scores A and B of ≤1, 2 and ≥3 each, and followed for up to 10 years. Difference in cumulative incidences of cardiovascular death and all-cause death were assessed by the cumulative incidence estimator. Survival was modeled by Cox proportional hazard analyses.We included 667 patients, of whom 80% were treated with ACEIs. Differences in cumulative incidences of cardiovascular death (P = 0.346 and P = 0.486) and all-cause death (P = 0.515 and P = 0.486) were not significant for score A and B, respectively. There was no difference in risk of cardiovascular death or all-cause death between subjects with score A ≤1 vs. 2 (HR 1.03 [95% CI 0.79–1.34] and HR 1.11 [95% CI 0.88–1.42]), score A ≤1 vs. ≥3 (HR 0.80 [95% CI 0.59–1.08] and HR 0.91 [95% CI 0.70–1.20]), score B ≤1 vs. 2 (HR 1.02 [95% CI 0.78–1.32] and HR 0.98 [95% CI 0.77–1.24]), and score B ≤1 vs. ≥3 (HR 1.03 [95% CI 0.75–1.41] and HR 1.05 [95% CI 0.79–1.40]), respectively.We found no association between either of the analyzed pharmacogenetic scores and fatal outcomes in ACEI-treated patients with CHF. AGTR1) and bradykinin receptor B1 gene (BDKRB1), as well as the ACE gene (ACE) and ABO blood group genes (ABO), respectively, were recently found to predict ACEI efficacy and ACE activity in European patients with stable ischemic heart disease (IHD) and in Asian patients with young-onset hypertension, respectively . Ac. AcABO i genes aptivities –11.Several large studies have shown that patients with ischemic CHF, independent of blood pressure reduction, benefit from ACEI treatment with a relative reduction in fatal outcomes of approximately 20% –21. HoweIn addition to the considerations mentioned above, other limitations apply to the interpretation of the present work. For example, although the current study was based on a cohort of patients with comparable baseline characteristics who were recruited for a randomized controlled trial, the risk of unmeasured confounding is inherent to retrospective cohort studies. Also, as opposed to score A, score B was originally associated with systemic ACE activity and blood pressure response to ACEIs, but not directly with clinical outcomes in patients receiving ACEIs , 11. In The current study of patients with CHF treated with ACEIs did not find any significant association between CV death and all-cause death and two genetic scores (score A and B) that have previously been associated with ACEI efficacy. However, the analyses suggested a trend for increased risk of CV death with increased score A in ACEI-treated patients with ischemic CHF relative to non-ischemic CHF. While this finding warrants further study, genome-wide association studies and analyses that incorporate multiple gene interactions may be necessary to provide more detailed insights into the potential role of pharmacogenetic risk stratification of patients with CHF.


The mechanism by which transmyocardial revascularization (TMR) offers clinical benefit is controversial. We hypothesized that TMR ameliorates vasoconstriction in patients with ENDCADThis study was undertaken to demonstrate that transmyocardial laser revascularization in patients with advanced CAD improves results of combined operations CABG+ TMR through reduction of vasoconstrictionWe investigated vessels of coronary microvascular network of patients with ENDCAD and analyzed the histological changes in two groups: in group of patients died after sole CABG (1-st group - 8 heart specimens) and group of patients died after combined operations CABG+TMR (2-nd group - 6 heart specimens).These data are compared with hospital results  in two large groups of patients with ENDCAD: with isolated CABG (1-st group -33 operations) and CABG+TMR (2-nd group - 87 operations), operated in 2011-2012.in all hearts after sole CABG was identified coronary arteriolar vasospasm that decreases coronary and bypass flow and thus increase the probability of thrombi formation. All cases after CABG+TMR revealed vasodilatation in lased areas. Reduction in the occurrence of vasospasm in cases with CABG+TMR can prevent graft and coronary occlusion. High indices of hospital mortality (12.1%) and morbidity(33.3%) in cases with sole CABG can be explained with coronary spasm in patients with advanced CAD. On the other hand, reduced hospital mortality (1.15%) and morbidity (2.3%) in the second group(CABG+TMR) can be explained by laser-influenced vasodilatation of distal coronary bed. Elevated resistance of the coronary bed hinders the effectiveness of the graft and myocardial blood flow(MBF). We suggest, that intraoperative effectiveness of TMR based of denervation, dilatation of microvascular network of the myocardium and intraoperative improvement of perfusion.elevated resistance of myocardial microcirculation(vasoconstriction) in patients with advanced CAD inhibit the effectiveness of the CABG. In cases with TMR effectiveness is most likely due to vasodilatation of vasoconstriction of myocardial microcirculation