P < 0.05). Characteristic biomarkers, including Ureaplasma, Bacteroides, Anaerococcus, Finegoldia, Lactobacillus and Acinetobacter lwoffii, were identified based on LEfSe analysis. Inferred functional analysis based on seminal microbiome data further indicated the presence of potential pathogenic biomarkers in patients with asthenospermia and oligoasthenospermia. These results provided profiles of seminal microbiota exhibited in different types of dysspermatism, thus providing new insights into their pathogenesis.Human microbiota play an important role in the health of their human hosts. Recent studies have demonstrated that microbiota exist in seminal plasma. The current study aims to elucidate whether seminal microbiota exist in patients with different types of dysspermatism and whether bacterial biomarkers can be identified for them. A total of 159 study participants were recruited, including 22 patients with oligoasthenospermia, 58 patients with asthenospermia, 8 patients with azoospermia, 13 patients with oligospermia, and 58 matched healthy controls. Seminal microbiota composition was analyzed using 16S rRNA gene-based sequencing. The results showed that the composition of seminal microbiota of patients with dysspermatism differed from those of healthy controls. Comparison of the microbiota composition in semen samples from patients with different types of dysspermatism showed that microbiota in patients with asthenospermia and oligoasthenospermia were distinct from healthy controls in beta diversity ( Advances in technology and new research have demonstrated that microbiota are found in seminal plasma, and play an important role in host homeostasis5. It has been demonstrated that the presence of bacteria in sperm is associated with male infertility6. Some bacteria in the urogenital tract may affect spermatogenesis and decrease sperm quality through various means, including decrease in sperm motility, deficiency in DNA integrity, and destruction of mitochondrial function7. Escherichia coli, Mycoplasma genitalium, Ureaplasma urealyticum, Mycoplasma hominis, Staphylococcus aureus, and Chlamydia trachomatis are pathogens associated with male infertility12. Several studies using high-throughput sequencing have demonstrated that seminal plasma has a bacterial community, which includes Lactobacillus, Pseudomonas, Prevotella, and Gardnerella, among others19.Human microbiota, with its diverse relationships—commensal, parasitic, mutualistic, and pathogenic—play an important role in human health. Recent studies have reported that microbiota exist in almost every part of human body—even in the endocrine niche, such as in tumors, blood, and synovial fluid21. There are several causative factors for male infertility, including genetic and environmental factors24. Abnormal semen (dysspermatism) is a reason for infertility, which occurs in about 50% of the cases of male infertity26. The changes in semen microenvironment could affect the spermatogenesis and motility. Many substances have recently been found in the seminal plasma that affect fertility, such as proteins, metabolites, environmental metals, etc. Compared to healthy controls, caspase-3 and cytochrome C levels were higher, and the total antioxidant capacity (TAC) was lower in seminal plasma of infertile patients28. Testosterone and androstenedione vectors correlate with steroids, which may function as biomarkers in patients with endocrine disorders, thus indicating that they may play an important role in sexual maturity29. A study also found that follicle-stimulating hormone deficiency could affect male fertility30. Several studies focused on environmental chemical substances, including perfluoroalkyl compounds, Pb, Cd, Ba, and U, have demonstrated that these substances may adversely affect seminal quality33. To summarize, seminal plasma functions not only as a medium to carry, protect, and nourish sperm after ejaculation up to fertilization, but also modulates sperm functions34.Approximately 15% of couples worldwide are unable to conceive due to infertility and males contribute to 50% of the infertility cases13. Another study showed that human testes have microbiota associated with idiopathic non-obstructive azoospermia15. Javurek et al. demonstrated that there is a difference in the composition of seminal microbiota in estrogen receptor-alpha knockout male mice and mice with high-fat diet, which indicates that seminal microbiota could be affected by genetic and environmental factors, thus increasing the risk of disease to the offspring17. These studies focused on the microbiota in seminal plasma, but did not find differences between patients with dysspermatism and healthy controls, hence, they remain inconclusive35.It is critical to identify the bacterial species composition of the microbiota in seminal plasma to better understand the etiology and pathogenesis of urogenital tract infections and their association with infertility. A study that recruited 58 patients with infertility and 19 healthy controls observed bacteria in seminal plasma by gram staining and explored the composition of microbiota. However, the authors did not discover any differences in the microbiota in seminal plasma of patients with infertility and healthy controlsAlthough previous studies have found microbiota in the seminal plasma of males with infertility, it remains unknown whether characteristic seminal microbiota exist in patients with different types of dysspermatism. This study aspires to improve the understanding of seminal microbiota and explore the potential role of microorganisms, by analyzing the seminal plasma from 159 study participants and characterizing the microbiota profile. KEGG analysis was adopted to predict potential pathways associated with dysspermatism.Proteobacteria, Firmicutes, Actinobacteria, Bacteroidetes and Fusobacteria, as shown in Fig. To characterize the features of seminal microbiota, 16S rRNA gene sequencing was done to measure 159 seminal samples, from 22 patients with oligoasthenospermia, 58 patients with asthenospermia, 8 patients with azoospermia, 13 patients with oligospermia, and 58 healthy controls. The clinical characteristics of the study participants are summarized in Table P > 0.05) and Shannon index (P > 0.05) showed no significant difference in patients with dysspermatism and the healthy control group  or azoospermia  showed no significant difference when compared to that of healthy controls; whereas seminal microbiota in patients with asthenospermia  or oligoasthenospermia  had significant composition variations compared to that of healthy controls  among the five groups  and Saccharopolyspora hirsute, Acinetobacter lwoffii, and Lactobacillus iners (at the species level) was observed, and a significant reduction in Pelomonas, Propionibacterium, Bosea, Sphingomonas, Phyllobacterium, Pedomicrobium, Xylanimicrobium, Mycobacterium, and Zoogloea (at the genus level) and Propionibacterium acnes and Bosea genosp (at the species level) was observed in the asthenospermia group, compared to the healthy control group  was used to explore the bacterial biomarkers in the semen of patients with asthenospermia. Eighty different taxa in the two groups were chosen based on LDA > 2. Significant increase in the relative abundance of up Figs.  and S1B.Propionibacterium , Pelomonas , Lactobacillus , and Propionibacterium acnes  were filtered. Additionally, we evaluated the effects of age and pH of seminal plasma on the four candidate biomarkers, in patients with asthenospermia and those in healthy controls , Acinetobacter , Propionibacterium , Pelomonas , Prevotella copri , and Propionibacterium acnes   Fig. . We also9%) Fig. .Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) was used to predict the different KEGG pathways in the two groups, and to discuss potential mechanisms of seminal microbiota in asthenospermia and oligoasthenospermia groups. Forty different KEGG pathways were displayed in patients with asthenospermia; these exhibited increased activities in some disease pathways such as cell growth and death, lipid metabolism, enzyme families, infectious diseases, cell division, cell motility, etc. There are 32 different KEGG pathways in patients with oligoasthenospermia and healthy controls, which showed increased pathways in cell growth and death, lipid metabolism, and metabolic diseases in patients with oligoasthenospermia Fig. .Figure 7In this study, high-throughput sequencing technology was used to analyze and measure the microbiota found in seminal plasma. Our study demonstrated that patients with different types of dysspermatism (oligoasthenospermia or asthenospermia) had significantly different composition of microbiota when compared to healthy controls. This pilot study also explored the opportunistic pathogens in the seminal plasma, which could be potential pathogens that increase the risk of dysspermatism.36. Recent studies have shown that bacteria also exist in the synovial fluid of patients with arthritis and play an important role in the occurrence of arthritis3. More interestingly, there are microorganisms in the blood4. This evidence indicates that different niches of the human body environment harbor distinct and potentially functional microbiota. In recent years, high throughput sequencing has been used to measure bacteria in seminal plasma, by which Lactobacillus, Pseudomonas, Prevotella Streptococcus, and Gardnerella were revealed to exist in seminal samples of patients and healthy controls35. These studies also found potentially pathogenic bacteria, such as Finegoldia and Anaerococcus14. We analyzed the composition of microbiota in the seminal plasma at the phylum level and found five dominant phyla: Proteobacteria, Firmicutes, Actinobacteria, Bacteroidetes, and Fusobacteria, which is consistent with the findings of a previous study15. We also analyzed major genera in the seminal plasma. The top 10 relatively abundant genera found commonly in the male seminal plasma were: Lactobacillus, Corynebacterium, Acinetobacter, Prevotella, Enterococcus, Veillonella, Streptococcus, Porphyromonas, Sneathia, and Pelomonas37. Based on all current studies, microbiota exist in the seminal plasma and share similar microbial community composition35.Technological advances in recent years have led to several studies on the relationship between microbiota and human health. A large number of studies have shown that disorders of human microbial groups can lead to diseases, such as type II diabetes38. A previous study indicated that inflammatory mediators can directly cause DNA fragmentation in ejaculated spermatozoa, which ultimately limits the fertilization abilities of the germ cells39.Variation in the composition of microbiota could affect patients with asthenospermia or oligoasthenospermia. We found most of the taxa that were found in increased concentration in the seminal fluid of patients with asthenospermia and oligoasthenospermia were gram-negative bacteria containing lipopolysaccharide (LPS) in their cell walls. LPS can upregulate cytokines causing inflammationUreaplasma, Bacteroides, Anaerococcus, Finegoldia, Lactobacillus, and Acinetobacter lwoffii was significantly higher in asthenospermia, and Lactobacillus was notably abundant in oligoasthenospermia. Ureaplasma is the smallest prokaryote between bacteria and viruses, mainly found in the genitourinary tract of the human body. Bacteroides ureolyticus is a species of Bacteroides that could impair sperm structure and function by diminishing motility and causing sperm membrane injury, especially to the lipid bilayers as shown in in vitro tests41. Another study using 16S rRNA sequencing demonstrated that genus Anaerococcus could be a biomarker for predicting male infertility13. We also found this bacterium in patients with asthenospermia. Lactobacillus is a gram-positive bacterium, which produces SCFA (short-chain fatty acids). Recent studies have shown that SCFA are beneficial to human health. However, seminal pH is generally 7.242. Significant increase of Lactobacillus in asthenospermia may change the pH of semen and result in male infertility. Although our results found Lactobacillus in human semen, the mechanism remains to be determined, however, it provides new insights into male infertility.The relative abundance of Lactobacillus and decrease in Propionibacterium, Pelomonas, and Propionibacterium acnes in the seminal plasma of patients with asthenospermia, which indicated that these bacteria may affect sperm activity. Oligoasthenospermia features both lesser and weaker sperm activity. Our results indicated an increase in Lactobacillus and Prevotella copri and decrease in Propionibacterium, Pelomonas, Acinetobacter, and Propionibacterium acnes, which may correlate with sperm formation and activity.Bacteria that were filtered out by factors such as age may be potentially pathogenic. The characteristic of asthenospermia is that the activity of spermatozoa is weakened. We found an increase in 45. This finding also exhibits strong correlation with the change in microbiota.PICRUSt was used to predict potential metabolic pathways. We found that the lipid metabolism was significantly different in the three experimental groups. The essence of sex hormones is steroids. Previous studies have demonstrated that disorders of sex hormones result in male infertility. For instance, changes in FSH, LH, and T levels are associated with damage to the testes, impeding of spermatogenesis and maturation, and result in decreased sperm motility and activity, leading to infertilityTo summarize, our results suggest that dysspermatism is associated with seminal microbiota, and also show that seminal microbiota in patients with asthenospermia and oligoasthenospermia are different from those in healthy controls. Biomarkers were screened and the KEGG metabolic pathways predicted. These results are beneficial for clinical diagnosis and could be further used to develop new treatment for patients with dysspermatism. Although we performed a bacterial culture experiment on semen samples, the pathogens were not cultured because of their low content. To better understand the mechanism of dysspermatism, future studies are needed in combination with metabolomics and culturomics.6/ml), 8 patients with azoospermia (the absence of sperm or very low sperm content in semen), 13 patients with oligospermia (the proportion of progressive motility is less than 32%), and 58 healthy controls42. The study participants were about 31.65 ± 6.01 years old, and there was no significant difference among these groups. The diagnostic criteria of dysspermatism followed the 5th WHO laboratory manual for examination and processing of human semen42. Signed informed consent was taken and clinical indexes were also collected. All study participants met the following criteria: (1) study participants hadn’t taken antibiotics for three months prior to study enrollment, (2) study participants and their family members have no known genetic disease, (3) no history of sexually transmitted diseases, and (4) no history of corticosteroid use. All study procedures were approved by the Medical Ethical Committee of Maternal and Child Health Care Hospital of Shandong Province (#IRB: 2017-03). All methods and experimental protocols in this study were performed in accordance with relevant guidelines and standard operating procedures.A total of 159 study participants from Shandong Health Center for Women & Children were recruited, including 22 patients with oligoasthenospermia (having both characteristics of asthenospermia and oligospermia), 58 patients with asthenospermia  spectrophotometer was used to determine the concentration of extracted DNA. The V1–V2 regions of 16S rRNA gene were amplified and sequenced on an Illumina HiSeq. 2500 system. PCR was conducted using bacterial universal primers 27F (5′ -(6FAM) AGA GTT TGA TCC TGG CTC AG 3′) and 355R (5′ GCT GCC TCC CGT AGG AGT 3′). Each PCR reaction contained 12.5 ul Q5 Hot Start High-Fidelity 2X Master Mix (BioLabs), 1.25 μl 10 μM Forward Primer, 1.25 ul 10 μM Reverse Primer, and 10 μl DNA template in a total volume of 25 μl. The following experiments were carried out as per the sequencing manual.About 400 μl of seminal specimens were used for genomic DNA extraction, which was extracted using the CTAB (Cetyl trimethylammonium bromide) method47. All sequences were analyzed using the Quantitative Insights into Microbial Ecology  software suite48, according to the QIIME tutorial (http://qiime.org/) with a few modified methods. Chimeric sequences, where a single organism has distinct genotypes, were removed using Metagenomics tool—usearch61 with denovo models49. Sequences were clustered against the 2013 Greengenes (13_5 release) ribosomal database’s 97% reference data set (http://greengenes.secondgenome.com/downloads). Sequences that remained unmatched with any of the entries in this reference were subsequently clustered into de novo OTUs at 97% similarity, using UCLUST algorithm. Taxonomy was assigned to all OTUs using the RDP classifier50 within QIIME and the Greengenes reference data set. Rarefaction and rank abundance curves were calculated from OTU tables using alpha diversity and rank abundance scripts within the QIIME pipeline. The hierarchical clustering based on population profiles of most common and abundant taxa was performed using UPGMA clustering  on the distance matrix of OTU abundance. This resulted in a Newick-formatted tree, obtained utilizing the QIIME package. Furthermore, QIIME was used to analyze alpha diversity , beta diversity ), Linear discriminant analysis (LDA) and Effect Size (LEfSe). SPSS (version 23) was used to calculate the receiver operating characteristic (ROC) curve and the area under the curve (AUC) values.The 16S sequence paired-end data set was joined and qualitatively filtered using the Laser FLASH method described by Magoč and SalzbergAll sequencing data were submitted to the NCBI SRA database (accession number: PRJNA534354).P values <0.05 were considered statistically significant.The clinical characteristics of the study participants are represented as the mean ± SD, which were determined using Mann-Whitney U test. The diversity categorization of alpha and beta diversity is defined in the OTU table to a sequencing depth of 1,000 per sample. Moreover, alpha diversity was determined using Mann-Whitney U test and beta diversity was acquired using ANOSIM . LEfSe combines Kruskal-Wallis test or pair wise Wilcoxon rank sum test with linear discriminant analysis (LDA), whose threshold value on the logarithmic LDA score equals to 2.0. Analyses were performed using the SPSS statistical package (version 23). All study procedures were approved by the Medical Ethical Committee of Maternal and Child Health Care Hospital of Shandong Province (#IRB: 2017-03). All study participants signed informed consent forms and were from the same geographical area. Data was collected using a standardized questionnaire that included basic information, medical history, and examination results.Supplementary information


The differentiation of CD4+ lymphocytes Th17/regulatory T cells (Treg) and indoleamine 2,3-dioxygenase (IDO) is associated with the pathogenesis of allergic asthma. Basic research has shown that IDO is likely a “switch” of the transition from Th17 cells to Tregs under certain conditions. However, no relevant clinical studies have been reported on the association between IDO activity and Th17/Treg imbalance in children with allergic asthma. The goal of this study was to test whether indoleamine 2,3 dioxygenase (IDO) participates in the pathogenesis of pediatric allergic asthma by influencing Th17/regulatory T cell (Treg) differentiation and related cytokines.Thirty-three children with allergic asthma and 33 healthy children were selected. The subjects were evaluated via a pulmonary function test, a skin prick test, and an eosinophil count. Peripheral blood was collected to measure Th17/Treg percentages and related cytokine levels. Blood and induced sputum were obtained to measure the IDO level.Compared with the control group, the patient group had an obvious Th17/Treg imbalance; their IDO levels were significantly lower, their IL-17 and IL-6 levels were markedly higher, and their IL-10 and TGF-β levels were markedly lower than those of the control group. The IDO levels in both blood and induced sputum were negatively correlated with the Th17/Treg ratio.A significant correlation was observed between IDO activity and Th17/Treg imbalance in children with allergic asthma. IDO may upregulate Treg numbers by stimulating IL-10 production and inhibiting IL-6 expression. Therefore, IDO may be a molecular switch that leads to the conversion of Th17 cells to Tregs, thus playing a potentially protective role in the pathogenesis of asthma.Trial registration This study was approved by the Chinese Clinical Trial Registry with registration number ChiCTR-COC-15006080 and was reviewed and approved by the Ethics Committee of Southwest Hospital. The name of registration: The effect of indoleamine 2,3 dioxygenase (IDO) on Regulation of Th17/Treg Differentiation in Childhood Asthma. Date of registration: 14/03/2015. URL of trial registry record: http://www.chictr.org.cn Allergic asthma (asthma) is an allergic inflammatory disease characterized by airway hyperresponsiveness. The Th1/Th2 imbalance is key in the pathogenesis of asthma. In recent years, Th17 cells and regulatory T cells (Tregs) have also been found to play an important role in the pathogenesis of asthma. Studies in animal models have demonstrated that the ability of Tregs to inhibit the inflammatory response of Th2 cells is key to the development of tolerance to asthma. Th17 cells, a subpopulation of CD4+ T cells first discovered in 2005, are characterized by the secretion of IL-17. In addition to having a strong relationship with eosinophilic airway inflammation in asthma, IL-17 mediates airway neutrophilic inflammation in asthma and is correlated with the severity of asthma  demonstrDendritic cells (DCs) are the most effective antigen-presenting cells (APCs) in the airway. In addition to presenting antigens and inducing immune responses and asthma, airway DCs also induce CD4+ T cells to differentiate into Tregs and thus induce immune tolerance, preventing the onset of an asthma episode. Plasmacytoid DCs (pDCs) in the airway can induce immune tolerance. Therefore, the shift of airway CD4+ T cells to effector T cells or Tregs depends on the different DC subpopulations that present the antigen. Some researchers have even suggested that respiratory immune tolerance may be a function of the subtype of pDCs  found thIDO is the rate-limiting enzyme for the catabolism of tryptophan and plays an important role in peripheral tolerance. In addition to its roles in immune tolerance in pregnancy, organ transplantation and cancer, IDO was recently found to have key functions in allergic diseases , 7. RaitThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.This study was approved by the Chinese Clinical Trial Registry with registration number ChiCTR-COC-15006080 and was reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Army Medical University. The methods were carried out in accordance with the approved guidelines. The study was conducted in compliance with the principles of the Declaration of Helsinki. Written informed consent was obtained from the parents of all enrolled subjects. The authors have access to information that could identify individual participants during or after data collection.The subjects were recruited at the Pediatric Outpatient Department of Southwest Hospital. A total of 30 (the number of cases was estimated based on the significance of the expected difference) pediatric patients with allergic asthma (according to retrospective grading of disease severity) older than 5 years were enrolled, along with 30 age- and sex-matched healthy children who underwent a physical examination during the same period (control group). The average age and sex distributions of the patients were considered in the selection of subjects for each group to reduce deviations and ensure a normal distribution as much as possible. The clinical data of the 2 groups are comparable.The sample size was calculated using the superiority test formula for a two-sample mean comparison based on a two-group parallel controlled randomized block design:μ1 = 12.8, μ2 = 7, The observation indicator was IDO activity. According to relevant studies in China and other countries, the characteristic value of IDO activity, which is the ratio of kynurenine to tryptophan content (unit: %), was 12.8 in the experimental group and 7 ± 1 in the control group. Thus, α = 0.025 , 1 – β = 0.90, The inclusion criteria for the observation group were as follows: (1) patients aged 5 years or older; (2) patients who were diagnosed with asthma for the first time or were previously diagnosed with asthma but had not been treated with standard asthma therapies; and (3) patients who had not received treatment with an inhaled glucocorticoid or leukotriene receptor antagonist within 2 weeks prior to the study.Recurrent wheezing, coughing, shortness of breath and chest tightness that frequently occurs or is aggravated at night and (or) in the early morning and is mostly caused by exposure to allergens, cold air, physical and chemical stimuli, respiratory infection and physical activity;Audible scattered or diffuse wheezes mainly during the expiratory phase in both lungs during an attack, with a prolonged expiratory phase;The ability for the above symptoms and signs to be effectively relieved by asthma treatment or to be self-resolved;Exclusion of other diseases as the cause of wheezing, coughing, shortness of breath or chest tightness;Patients with atypical clinical manifestations (such as no obvious panting or wheezing) should have at least one of the following: (1) positive results on a bronchial provocation test or exercise challenge test; (2) confirmed existence of reversible air flow restriction, with positive results on a bronchial diastolic test, namely, a greater than 12% increase in forced expiratory volume during the first second (FEV1) 15 min after inhaling the fast-acting β2 receptor agonist salbutamol sulfate; and (3) daily variability in peak expiratory flow (PEF) (continuous monitoring for 1–2 weeks) of 20%.Patients who met items (1) to (4) (12 subjects) or items (4) and (5) (18 subjects) were diagnosed with asthma.A total of 30 healthy children  who underwent a physical examination at the outpatient office of the Department of Pediatrics were recruited during the same time period and had the desired age and sex distribution.Patients who were given oral or intravenous glucocorticoids or immunomodulators within 2 weeks prior to the study;Patients who had complications of other immune disorders, such as tuberculosis, systemic lupus erythematosus and juvenile idiopathic arthritis;Patients who had infectious diseases, such as an upper respiratory tract infection and pneumonia, within 4 weeks of the onset of the asthma episode;Patients who had cardiopulmonary failure.Part I: Collection of complete medical history, physical examination, pulmonary function tests, skin prick test for allergens and eosinophil count (EC).Pulmonary function tests:Quality control standard of children’s lung function: Exhale rapidly to PEF, no hesitation, smooth breath descending branch, no cough and glottis closing; Platform to achieve end expiratory flow; If flow at the end > 10%, It can be considered as early termination; deally, at least two acceptable tests should be completed, and the difference between two FVC and FEVT should be less than 0.1 L or 10%.Alternaria and Aspergillus.2. Skin prick test for allergens: allergenicity was defined as a positive skin reaction to more than one of the 12 common inhalant allergens, such as 2 types of dust mites, pollen, cat hair, dog hair, Implementation steps: Drop a drop of allergen test solution onto the sterilized skin on the palmar side of the forearm of the subject, and then prick it vertically with a point prick. The negative and positive control groups were set with normal saline and histamine diphosphate solution. According to the papule area ratio caused by pricking solution and positive control, the reaction level was judged: > 25% was positive, < 25% was negative.Part II: Peripheral blood tests.Specimen collection: Four milliliters of venous blood (with heparin as an anticoagulant) was collected from the subjects. Whole blood was centrifuged, and plasma was collected and stored at − 80 °C. Peripheral blood mononuclear cells (PBMCs) were isolated via density gradient centrifugation in Ficoll.Tested parametersAfter enrollment, blood samples were immediately collected from the subjects in the observation group and the control group, and the samples were processed as follows:1) Flow cytometry was used to detect Th17 (CD4+ IL17+) cells and Tregs (CD4+CD25+Foxp3+).Human IL–17/IL–17A PE–conjugated Antibody (IC317P); Mouse IgG2B PE-conjugatedIsotype control (IC0041P).Human/Mouse FoxP3 PE– conjugated Antibody (IC8214P-100); Normal Rabbit IgG.PE-conjugated control (IC105P)Human CD25/IL-2 R alpha APC– conjugated Antibody (FAB1020A-100); Mouse IgG2A APC-conjugated Antibody (IC003A)Human CD4 Fluorescein –conjugated Antibody (FAB3791F-100); Mouse IgG2A Fluorescein-conjugated Antibody(IC003F) gating procedures: Th17, the gate was set with CD4, and the proportion of CD4+ IL17+ in the gate was analyzed. Treg set the gate with CD4 and SSc. CD4 cells were selected to analyze the expression of CD25+ and Foxp3+, and the proportion of Foxp3 cells was analyzed.Antibodies used and isotype controls:FlowX FoxP3/Transcription Factor Fixation & Perm Buffer Kit (FC012-100)Flow Cytometry Staining Buffer (1×)(FC001).Cell fixation and or freezing employed:Machine and software involved:BD Accuri™ C6 software is Flowjo 7.6.1 Min2) Enzyme-linked immunosorbent assay (ELISA) was utilized to examine the levels of cytokines, including IL-10, IL-17, IL-6 and TGF-β, in plasma.Human TGF-beta 1 Quantikine ELISA Kit (DB100B),Human IL-17Quantikine ELISA Kit (D1700), Human IL-6 Quantikine ELISA Kit (D6050)Human IL-10 Quantikine ELISA Kit (D1000B) were used. 3) High-performance liquid chromatography (HPLC) was employed to determine tryptophan and kynurenine concentration. IDO activity was calculated as kynurenine concentration (μmol/L)/tryptophan concentration (μmol/L).It employed a Symmetry Shield RP-C18 column  and a mobile phase of 15 mmol/L sodium acetate-acetic acid solution containing 2.7% (v/v) acetonitrile (pH 3.6) at a flow rate of 1.0 mL/min. The ultraviolet detector was Operated at 225 nm. Serum samples were first precipitated with a 5.0% perchloric acid solution, then centrifuged to remove protein residue and finally analyzed by HPLC.Specimen collection: After enrollment, induced sputum samples were immediately collected from the subjects in the observation and control groups. Sputum was aspirated after subjects were given aerosolized 3% hypertonic saline (1.5 mL of 10% NaCl + 2.5 mL of 0.9% NaCl), and the induced sputum supernatant was stored at − 70 °C.Tested parameters: HPLC was employed to determine tryptophan and kynurenine concentration. IDO activity was calculated as kynurenine concentration (μmol/L)/tryptophan concentration (μmol/L).Part III: Induced sputum testAll data were statistically analyzed using the software SPSS18.0. Normality tests (Kolmogorov–Smirnov and Shapiro–Wilk tests) and a test for the homogeneity of variance (Levene test) were performed before multigroup comparisons. An independent samples t test was used for intergroup comparisons of data with a normal distribution and homogeneity of variance, and the experimental results are presented as the mean . The Mann–Whitney U test for nonparametric statistical analysis was used for data that did not have a normal distribution, and the experimental results are presented as the median (quartile). Multivariate linear regression analysis was used to analyze correlations among multiple groups, and differences of P < 0.05 were considered statistically significant.Alternaria and Aspergillus). Additionally, the eosinophil count was significantly higher (P < 0.001), and the pulmonary function indicator FEV1.0/FVC% was markedly lower (P < 0.001) in the children with allergic asthma.A total of 30 patients  were included in the observation group of this study, with 30 age- and sex-matched healthy children in the control group. The clinical characteristics of the subjects are summarized in Table The IDO activity was significantly lower in the pediatric patients with allergic asthma than in the control patients in both induced sputum  and Tregs CD4+ CD25+ Foxp3+) among peripheral PBMCs were examined using flow cytometry for both the allergic asthma and healthy control groups (Fig. 5+ Foxp3+The plasma levels of cytokines related to Th17 cells and Tregs, including IL-17, IL-6, IL-10 and TGF-β, were examined Table , Fig. 3.In children with allergic asthma, the IDO concentration in the induced sputum was positively correlated with the peripheral concentration of Tregs, was not significantly correlated with the Th17 cell concentration and was negatively correlated with the Th17/Treg ratio Table , Fig. 4.Th1/Th2 imbalance is key in the pathogenesis of allergic asthma, with Th2 cells playing a particularly important role. However, in recent years, Th17 and Tregs have been found to have a critical function in asthma pathogenesis. Tregs are different from Th1 and Th2 cells; they have immunosuppressive activities and are primarily regulated by FOXP3. CD4+ CD25+ Tregs are currently considered to play a pivotal role in peripheral tolerance, and therefore, Treg generation is important in the airway immune tolerance of allergens . AllergeThe immune regulation and induction by IDO in infections, pregnancy, and autoimmune and tumor-like lesions have been widely recognized. IDO has been detected in eosinophils, endothelial cells and pulmonary epithelial cells, indicating its role in allergic reactions , 20. At As mentioned in the introduction, plasma IDO activity and IL-10 levels were shown to be higher in allergy patients without clinical symptoms than in symptomatic allergy patients and healthy individuals . ManeechThere were a few limitations of this study. For instance, the number of subjects enrolled in the study was relatively small due to difficulties in clinical specimen collection. The study aimed to evaluate children with asthma who were over 5 years old, and it did not adequately examine the characteristics of preschool children with symptoms of wheezing or panting. As a clinical investigation, this study did not conduct an in-depth investigation of the mechanism of action underlying the promotion of Th17 cell conversion to Tregs by IDO, and further validation with in vitro studies is needed.IDO activity exhibited a clear correlation with Th17/Treg differentiation in children with allergic asthma. We speculate that IDO upregulates Treg levels, possibly by stimulating IL-10 production and inhibiting IL-6 expression. Tt needs to be confirmed by further experiments IDO is likely a molecular switch for the conversion of Th17 cells to Tregs and potentially plays a protective role in the occurrence of asthma.


Background and Objectives: The harmonization of recovery of consciousness and muscular function is important in emergence from anesthesia. Even if muscular function is recovered, tracheal extubation without adequate recovery of consciousness may increase the risk of respiratory complications. In particular, upper airway obstruction is one of the common respiratory complications and can sometimes be fatal. However, the association between the timing of sugammadex administration and the upper airway obstruction that can occur during awakening from anesthesia has rarely been studied. Materials and Methods: The medical records of 456 patients who had surgery under general endotracheal anesthesia (GETA) at the Haeundae Paik Hospital between October 2017 and July 2018 and who received intravenous sugammadex to reverse rocuronium-induced neuromuscular blockade were analyzed. The correlations between bispectral index (BIS) and minimum alveolar concentration (MAC) at the time of sugammadex administration, the incidence of complications, and the time to tracheal extubation were analyzed to investigate how different timings of sugammadex administration affected upper airway obstruction after tracheal extubation. Conclusions: The effect of BIS and the duration from anesthetic discontinuation to sugammadex administration on upper airway obstruction was not statistically significant. However, the odds ratio of complication rates with MAC < 0.3 compared with MAC ≥ 0.3 was 0.40 , showing a statistically significant increase in risk with MAC ≥ 0.3 for upper airway obstruction. The onset of action of any medication and its interaction with other drugs should be considered to maximize its therapeutic effects and minimize adverse effects . As suchSugammadex is a newly developed drug that reverses muscle relaxants. This is a modified γ-cyclodextrin and a selective relaxant–binding agent used to inactivate specific nondepolarizing neuromuscular blocking agents, such as a rocuronium. The required doses according to the degree of muscle relaxation of sugammadex are widely known, but the relationship between the residual inhalation anesthetic or the sedation level and the timing of sugammadex administration is not well known. In most patients, all different levels of neuromuscular blockade are reversed within 2 to 3 min after administration of sugammadex . Howeverhttps://cris.nih.go.kr (protocol number KCT0003356) and the requirement for written informed consent was waived by the IRB. All patients who had surgery under GETA using inhalation anesthetics at the Haeundae Paik Hospital between October 2017 and July 2018 and who received intravenous sugammadex to reverse rocuronium-induced neuromuscular blockade were included in this study. We reviewed electronic medical records, including preoperative evaluations, anesthesia records, and postoperative care unit (PACU) records and nursing information surveys, in order to collect data on bispectral index (BIS)  and minimum alveolar concentration (MAC)  of volatile anesthetics at the time of sugammadex administration. The age, sex, height, weight, American Society of Anesthesiology Physical Status (ASA PS) score, diagnosis, type of surgery, underlying diseases, medical and medication history, type of inhalation anesthetics (sevoflurane or desflurane), total dose of rocuronium administered, total dose of sugammadex, operation duration, anesthesia duration, time when an inhalation anesthetic was discontinued (T1), time of sugammadex administration (T2), and time of tracheal extubation (T3) were also recorded. The dose of sugammadex was determined by the anesthesiologist taking into consideration the time of the last administration of rocuronium, the total amount of rocuronium, and the patient’s response. Using these data, we investigated the distribution in durations between anesthetic discontinuation and sugammadex administration  as well as whether these durations have any correlation with the incidence of respiratory complications after extubation. To investigate how the different timings of sugammadex administration affected the respiratory complications, we analyzed the correlations between BIS and MAC at the time of sugammadex administration, the incidence of complications, and the time to tracheal extubation . The primary outcome for our study was the incidence of upper airway obstruction according to the timing of administration of sugammadex. We defined upper airway obstruction as the necessity for an airway device or manual intervention to maintain the airway listed in the medical record, such as continuous positive pressure or manual positive pressure ventilation.This retrospective study was conducted at the Haeundae Paik Hospital of Inje University, and it was approved by the Institutional Review Board (IRB) and registered at The patients whose parameters were missing in the electronic medical records, those who had surgery under total intravenous anesthesia, those who received other reversal agents , and those who were administered sugammadex after tracheal extubation were excluded from this study.We presented the data as frequency and percentage for categorical variables and mean ± standard deviation (SD) for numeric variables. The differences in study participants’ characteristics were compared across subgroups using the Chi-square test or Fisher’s exact test for categorical variables and using the independent test or the Mann–Whitney U test for continuous variables as appropriate. To check normal distribution, we used the Shapiro–Wilk test.p-value were calculated with a multivariate logistic regression analysis method. Variables were selected using the backward elimination method using a 0.05 alpha level.The effect of independent variables on response variables was analyzed using the univariate and multivariate linear regression, and the statistically significant variables were selected by the backward elimination method using a 0.05 alpha level. To check the multicollinearity problem, the variance inflation factor (VIF) was also estimated. The VIF quantifies the severity of multicollinearity in regression analysis and a VIF < 10 indicated that there was no problematic multicollinearity among the independent variables (VIF < 10). We set complication as a dependent variable. The corresponding odds ratio of each independent variable with a 95% confidence interval and an equivalent p values < 0.05 were considered significant.All statistical analyses were carried out using the SPSS 24.0 software and n = 2712), those who had surgery under total intravenous anesthesia (n = 177), those who received other reversal agents concomitantly (n = 32), and those who were administered sugammadex after tracheal extubation (n = 14) were excluded from this study. The patients’ basic characteristics are shown in p = 0.03). Also, the total dose of rocuronium or sugammadex did not affect the occurrence of complications. However, the odds ratio of complication rates with MAC < 0.3 compared with MAC ≥ 0.3 was 0.40 , showing a statistically significant increased risk with MAC ≥ 0.3 for complications. All patients with complications recovered immediately after appropriate treatment in the early stage, and there were no other serious sequelae, and there were no patient complaints of recall of memory during awakening from anesthesia.A total of 3391 patients were administered sugammadex during the period. Based on our inclusion criteria, we included a total of 456 patients in our study. The patients whose parameters were missing in the electronic medical records (p < 0.05). T3–T1 significantly increased if sevoflurane was used for anesthesia  or the duration of surgery was prolonged (p < 0.05)  .We investigated the association between the timing of sugammadex administration and the emergence from anesthesia and found that upper airway obstruction after reversal of muscle paralysis was reduced with sugammadex administration at an MAC value <0.3. Recovery of neuromuscular function and consciousness are two important factors in the recovery from GETA, and their harmony is essential for a smooth awakening. If only the neuromuscular functions have been restored, a patient may not cooperate, leading to a high probability of respiratory complications ,6. ConveA BIS monitor analyzes patterns of electroencephalogram to assess the level of sedation. The BIS value is maintained between 40 and 60 under GETA, and the value > 60 may indicate a risk for anesthesia awareness . We set ® anesthesia machine were calculated based on the end-tidal inhalation anesthetic concentration and each patient’s age using the formula designed by Mapleson [In 1965, Eger et al. introduced the concept of MAC, relating the concentration or partial pressure of volatile anesthetics to a single clinically relevant end point of GETA . The defMapleson . The MACMapleson ,14,16,17Mapleson ,19,20. RThis study had some limitations. Because it was a retrospective study, we could not control several variables that affect the outcome, such as the concentration of inhalation anesthetics for maintenance, types of surgery, and the amounts of sugammadex and rocuronium administered. In addition, association with the Train of four (TOF) ratio could not be analyzed since TOF monitoring was not routinely performed in our hospital.In conclusion, we found that the incidence of upper airway obstruction after successful reversal of muscle paralysis could significantly be reduced when reversal with sugammadex and then extubation were performed with <0.3 MAC.


Half of our KTRs cohort after successful HCV eradication noted clinically important improvement of both OBP control and central aortic pressure parameters, including AIx. The concomitant decrease of liver steatosis was observed only in the subgroup of patients with improvement of blood pressure control. Hepatitis C virus (HCV) infection in kidney transplant recipients (KTRs) can be successfully treated with direct antiviral agents (DAA). The aim of our study was to analyze different measures of vascular function during and after the DAA treatment. As we have observed the improvement of blood pressure (BP) control in some individuals, we have conducted an analysis of potential explanatory mechanisms behind this finding. Twenty-eight adult KTRs were prospectively evaluated before and 15 months after start of DAA therapy. Attended office BP (OBP), augmentation index (AIx), pulse wave velocity (PWV), flow-mediated dilation (FMD), liver stiffness measurement (LSM), and liver steatosis assessment (controlled attenuation parameter (CAP)) were measured. In half of the patients, improvement of OBP control (decline of systolic BP by at least 20 mmHg or reduction of the number of antihypertensive drugs used) and parallel central aortic pressure parameters, including AIx, was observed. There was a significant decrease in CAP mean values (241 ± 54 vs. 209 ± 30 dB/m,  Arterial hypertension is highly prevalent in kidney transplant recipients (KTRs) as a consequence of common pretransplant hypertension and as an additional effect of immunosuppressive medications ,2. It haChronic hepatitis C virus (HCV) infection has been shown to independently worsen posttransplant survival . HCV infA few years ago a breakthrough in the treatment of chronic hepatitis C occurred. The previous interferon-based therapy, which was contraindicated for kidney transplanted patients due to increased risk of organ rejection, was replaced by new, direct acting antiviral (DAA) drug regimens. In our observation, the effectiveness of this therapy, based on sofosbuvir, reached 100% . We hypoThe study protocol was accepted by the Bioethics Committee of the Medical University of Silesia in Katowice (KNW/0022/KB1/119/16) and all participants provided written informed consent. The study was conducted in accordance with the Declaration of Helsinki. We prospectively studied all eligible adult kidney transplant recipients (KTRs) who completed treatment with DAA therapy due to HCV infection and completed both baseline and follow-up examination at least 12 months after the start of DAA therapy. 2). Body surface area (BSA) was calculated according to the DuBois formula and was expressed in m2.Body weight and height were measured following standard procedures and body mass index (BMI) was then calculated (kg/mKidney graft function was measured by the estimated glomerular filtration rate (eGFR), which was calculated according to the abbreviated Modification of Diet in Renal Disease formula. HOMA-IR (Homeostatic model assessment of insulin resistance) was calculated to assess insulin resistance. ® AmpliScreen HCV v.1.0, with lower limit of detection of 15 IU/mL . HCV genotyping and viral load was performed with Linear Array Genotyping Test and COBAS®TaqMan® Quantitative test v.1.0, with lower limit of detection of 21 IU/mL .HCV RNA was measured with COBAS1C), serum creatinine, total cholesterol, triglycerides, and total bilirubin concentrations, as well as aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma glutamyl transpeptidase (GGT) activity were routinely measured during standard outpatient visits. Additional blood samples were withdrawn in a closed system into tubes containing citrate and ethylenediaminetetraacetic acid (EDTA) for nonroutine analyses. The tubes were allowed to stand for 2 h at room temperature, then centrifuged , and finally plasma aliquots were preserved at −70 °C. Concentrations of blood glycated hemoglobin (HbAThe plasma concentrations of high-sensitivity C-reactive protein (hsCRP) were assessed with the use of an enzyme-linked immunosorbent assay (ELISA) , with the limit of quantification (LoQ) of 0.09 mg/L, intra-assay variation <6%, and inter-assay variation <11.6%. Plasma concentrations of interleukin-6 (IL-6) were assessed with an ELISA  with a LoQ of 0.7 pg/mL, intra-assay variation <4.2%, and inter-assay variation <6.4%. Plasma concentrations of fibroblast growth factor 21 (FGF-21) were assessed with an ELISA  with a LoQ of 7 pg/mL, intra-assay variation <2.0%, and inter-assay variation <3.3%. Plasma concentrations of C-peptide and insulin were measured using a Cobas E411 analyzer with intermediate precision <5.0% and <2.8%, respectively. Each study examination consisted of the measurement of office BP and central arterial pressure parameters. Echocardiography, pulse wave velocity (PWV), FMD, liver stiffness measurement (LSM), and liver steatosis assessment (controlled attenuation parameter (CAP)) were also performed at the same time points. Attended office blood pressure measurements (OBP) were performed three times in the sitting position after more than a 5-min rest in the sitting position on the arm without arterio-venous fistula at the beginning of the study. Patients with systolic BP values ≥140 mmHg and/or diastolic BP values ≥90 mmHg or those who received antihypertensive medication were diagnosed as hypertensive. For the present post hoc analysis, the OBP control improvement was defined as the decline of attended office systolic pressure by at least 20 mmHg without pharmacotherapeutic changes or the reduction of antihypertensive treatment due to the BP decline during the follow-up period. The cut-off value (20 mmHg) was established based on doubled maximum measurement error of 10 mmHg ,17. PatiEchocardiographic measurements were performed using Toshiba Xario 100 Diagnostic Ultrasound System . M-mode and two-dimensional measurements were performed as recommended by the American Society of Echocardiography , includiFMD was measured in the morning, after 10 min of lying in a quiet dimmed room using the Toshiba Xario 100. During the examination, the patients rested in a seated position with their forearms and backs supported. A manual sphygmomanometer cuff was placed on the arm without arteriovenous fistula and the diameter (lumen) of the brachial artery was measured with a linear transducer. The cuff was then inflated at approximately 50 mmHg above the current systolic pressure for 5 min . After tNon-endothelial dependent vasodilation (NMD) was assessed after at least a 15-min rest from the FMD acquisition. Similarly to FMD measurements, vessel diameters were assessed before and after sublingual nitroglycerin (400 μg) application (Nitromint (glyceroli trinitras), Proterapia, Poland). Of importance, as we observed unexpected reduction of NMD values in some patients, we repeated all NMD measurements using a double dose of nitroglycerin, i.e., 800 μg, after approximately 6 months from the previous follow-up series. Pulse waveform analysis was performed with the commercially available SphygmoCor 2000 . Peripheral pressure waveforms were recorded from the radial artery using applanation tonometry. After the acquisition of at least 20 sequential waveforms, a validated generalized transfer function was used to generate the corresponding central aortic pressure waveform. Central blood pressure measurements, including central aortic systolic and diastolic blood pressure, central pulse pressure, and augmentation index were performed. Augmentation index was then normalized according to the heart rate (AIx@75). Only high-quality recordings, defined as an in-device quality index greater than 80% and visually acceptable curves by the investigator, were included in the analysis. The entire pulse wave analysis was performed in the sitting position under standardized conditions in the morning hours, after at least 15 min of rest in the supine position.Arterial stiffness was also assessed using SphygmoCor 2000 placed over the carotid and femoral arteries. Pressure signals were calibrated using brachial BP and PWV was calculated as the time of the pulse wave between the diagnosed points (distance (m)/time (s)). The controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were performed using transient elastography with a M-probe . The operator was a technician certified by Echosense and unaware of patient status. The measurements were performed using a 3.5-MHz standard probe on the right hepatic lobe through the intercostal spaces with the patient lying in a supine position. As recommended by the manufacturer, 10 successful measurements were performed for each patient and only those with a success rate of at least 60% and an interquartile range/median value of less than 0.3 were considered reliable. The final CAP and liver stiffness were expressed in dB/m and kPa, respectively ,22. 2 test for qualitative variables. Variables with not normal distribution were compared using the Mann–Whitney U test. The comparison of baseline and follow-up values was performed using the Student t-test, or the Wilcoxon test for variables with not normal distribution. Correlation coefficients were calculated using the Pearson test. Due to its not normal distribution, FGF-21 data were logarithmized before the correlation analyses. In all statistical tests, ‘p’ values below 0.05 were considered as statistically significant. Statistical analyses were performed using the STATISTICA 13.0 PL for Windows software package . The values were presented as mean values with 95% confidence interval (CI) , medians with Q25-Q75 quartile values , or frequencies. Comparisons between groups were done by using the Student t-test for quantitative variables or the χOut of all 73 KTRs with the presence of anti-HCV antibodies, HCV-RNA was detected in 40 patients. These patients were qualified to further HCV genotyping and viral load. Out of them, 8 patients had started DAA therapy without baseline examination planned for the present study and were not included in the final analysis. The other 32 patients were treated with the DAA anti-HCV protocol, including 8 with a 6-month regimen and 24 patients with a 3-month regimen based on sofosbuvir. The DAA regimen was shortened in the later enrolled patients as the treatment recommendations were updated during the study period. Out of this group, 4 KTRs were excluded: 2 of them were normotensive prior to HCV treatment and 2 others did not finalize the study protocol . Hence, p = 0.02), but similar diastolic BP (DBP) . Patients with OBP improvement had initially higher systolic BP (SBP) (BP (DBP) . In addiAt baseline, the antihypertensive treatment was used in all patients: Beta-blockers in 67.9%, calcium channel blockers in 25%, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in 32.1%, alpha-blocker in 25%, and diuretics in 32.1% of study participants. The structure of antihypertensive medication classes was similar in both study subgroups (data not shown).p = 0.13). Out of whole group, only 4 patients were previously treated with interferon-based anti-HCV regimens. There were no differences in regards to baseline values of serum lipid concentrations, fasting glucose and insulin concentrations, glycated hemoglobin, and HOMA-IR values between subgroups . The mean time between baseline and follow-up study examinations was also similar . Also, the HCV genotypes were similar in both subgroups, including 11 patients with genotype 1b in each group. The percentage of patients with advanced fibrosis, defined based on a METAVIR score >2, was comparable , whereas median tacrolimus (Tc) doses were significantly greater in subgroup 2 (4.0 (2.5–6.0) mg vs. 1.0 (1.0–2.0) mg in subgroup 1, p < 0.05). Notably, median CyA (97 (70–128) vs. 125 (100–146) ng/mL, respectively; p = 0.30) and Tc (7.1 (6.1–7.4) vs. 8.4 (6.7–8.7) ng/mL, respectively; p = 0.22) blood trough concentrations were similar. During and after DAA treatment, the improved liver function resulted in the reduction of calcineurin inhibitor (cyclosporine or tacrolimus) blood trough concentrations as compared with baseline values, which were similar in both study subgroups (−21.4 (−37.2 to −5.7) vs. −11.3 (−33.5 to 10.9)%, respectively; p = 0.42) and required individual dose adjustments in 61% of patients (n = 17) as soon as after one month of therapy. The consecutive CNI dose adjustments were made at physician discretion and were guided by the drug blood concentration, to prevent the CyA level decreasing below 70 ng/mL or Tc level decreasing below 5 ng/mL. Overall, the median CNI dose changes in both study subgroups were similar (13.4 (interquartile range (IQR) 0–25) vs. 25 (0–75)%, respectively; p = 0.26). Also, the absolute median dose changes of CyA (0 (0–75) vs. 25 (12.5–25) mg, respectively; p = 0.73) and Tc (0.5 (0.5–1.0) vs. 0 (−1.5–0.5) mg, respectively; p = 0.26) were similar. Both study subgroups were similar in respect to calcineurin inhibitor (CNI) structure . There wAt baseline, there was a numerical difference in HCV viremia between subgroups , but neir = 0.669, p < 0.001, follow-up r = 0.557, p < 0.01 for SBP; and baseline r = 0.730, p < 0.001, follow-up r = 0.502, p < 0.01 for pulse pressure, respectively). There were also significant correlations between baseline augmentation index values standardized to heart rate (AIx@75) and both baseline and follow-up values of office SBP and pulse pressure   . r = 0.438, p < 0.05) and the change in AIx@75 . Of note, both baseline  and follow-up  CAP results correlated with corresponding BMI values.Parallel to OBP, we observed a 15.4% decline in aortic systolic pressure, a 12.1% decline in aortic diastolic pressure, and a 21.7% decline in aortic pulse pressure in subgroup 1 after successful DAA treatment . Of noteAt baseline and in the follow-up period, PWV values were similar in both subgroups . FMD valp = 0.84)) and mean LVMI (113 (94–131) vs. 114 (95–133) g/m2, p = 0.98) were comparable in subgroups 1 and 2, respectively. Similarly, there were no differences in the follow-up LVM and LVMI values , and their absolute changes during the study period did not differ significantly (LVM 7.9 (−23.5 to 39.2) vs. −0.3 (−44.4 to 43.8), p = 0.57; LVMI 3.3 (−13.4 to 19.9) vs. −1.3 (−23.2 to 20.6) g/m2, p = 0.70).At baseline, both mean LVM (210 (169–250) vs. 211 (173–250) g, p = 0.07)). At follow-up assessment, there was a borderline increase of median hsCRP in subgroup 2 (3.6 (0.5–6.7), p = 0.06), whereas no difference was noted in subgroup 1 (1.8 (1.5–3.0), p = 0.33). There were no significant differences in IL-6 concentration median values, both at baseline (2.7 (2.2–3.2) vs. 2.2 (1.8–2.5) pg/mL, p = 0.23) and at the follow-up examination (2.7 (1.7–4.1) vs. 2.6 (1.7–5.7) pg/mL, p = 0.76). Levels did not change significantly during the study period.The baseline median of CRP concentration was slightly higher in subgroup 1 (1.7 (IQR 1.1–2.4) vs. 0.9 (0.4–1.4) mg/L in subgroup 2, with borderline significance (p < 0.01), while they remained unchanged in subgroup 2 (189 (147–481) vs. 226 (116–267) pg/mL at baseline, p = 0.22). The baseline number of antihypertensive drugs was borderline associated with log values of baseline FGF-21  and significantly associated with follow-up values of FGF-21 . However, the log values of both baseline and follow-up FGF-21 did not correlate with baseline SBP or DBP values, whereas they correlated significantly with baseline central systolic aortic pressure  and borderline with central diastolic aortic pressure . Moreover, the log values of follow-up FGF-21 negatively correlated with the change of central systolic and diastolic aortic pressures  with both p values = 0.06.Median values of FGF-21 measured at follow-up increased significantly in subgroup 1 (411 (204–706) vs. 215 (120–535) pg/mL at baseline, In the present study, we demonstrated the clinically important improvement of blood pressure control, defined as the decline of attended office systolic pressure by at least 20 mmHg without pharmacotherapeutic changes or the reduction of antihypertensive treatment due to the BP decline, in half of our cohort of HCV-infected stable kidney transplant recipients after successful HCV eradication with sofosbuvir-based DAA therapy. In this subgroup of patients, we observed the reduction of systolic BP values despite the de-escalation of antihypertensive treatment in 9 out of 14 subjects. Moreover, we also documented the parallel decline of central aortic pressure parameters, obtained with the Sphygmo-Cor device, including augmentation index, in patients with improved BP control. Finally, we noted the corresponding decrease of liver steatosis, measured by the controlled attenuation parameter, in this subgroup of patients, which may suggest the potential underlying mechanism of beneficial vascular changes. We are aware that nowadays a majority of dialysis patients with previously diagnosed HCV infection have already been successfully treated with DAA regimen even before they get a kidney transplant. Nevertheless, the confirmation of relatively moderate BP control improvement in patients being currently on dialysis would be much more difficult due to procedural-related fluctuations in volemia. Thus, the present study findings may help to elucidate or confirm some mechanisms linking the HCV infection with BP control in CKD patients. There are several possible pathomechanisms linking the chronic HCV infection with elevated blood pressure and increased cardiovascular risk, including increased arterial stiffness , endotheWhen considering the possible changes of endothelial function after successful HCV eradication with DAA, the reduction of endothelium-derived adhesion molecule levels at the SVR12 time point was confirmed by two small studies ,27, but It is important to notice that both analyzed subgroups did not differ at baseline in terms of demographics, co-morbidity, or kidney graft function. Also, arterial stiffness and endothelial function measures, as well as liver function tests and liver stiffness measurements, were comparable. There were significantly higher baseline office systolic blood pressure and pulse pressure values, but not central blood pressure parameters, in subgroup 1. The posttreatment follow-up evaluation, along with the substantial BP control improvement, revealed a significant decrease of CAP values in these patients. Notably, in patients without known cause of chronic liver disease, increased CAP was shown to be a good indicator of fatty liver disease with metabolic abnormalities that manifest even before a sonographic fatty change appears . In HCV-infected patients, an intrahepatic viral load directly enhances the liver steatosis , especiaIt is well known that in the population of KTRs, the measures of vascular damage are conditioned by many factors, including the duration of chronic kidney disease, pretransplant dialysis vintage, concomitant immunosuppressive regimen, and non-optimal kidney graft function. Thus, the possibility for marked improvement of vascular elasticity and distensibility after the successful HCV treatment is much lower than in the general population. Nonetheless, overall results of our investigation may indirectly confirm the notable role of decreasing liver steatosis in the BP control improvement in the study group.Finally, FGF-21 levels are reported to increase in acute liver injury, but decrease in chronic hepatitis B patients , especiaThe main limitation of our analyzed cohort was its small size, which limited multivariate analysis of factors independently associated with the BP control improvement. Therefore, our preliminary data should be investigated in a larger multicenter cohort. However, we included all eligible KTRs with the sustained elimination of chronic HCV infection. Of note, the structure of DAA regimen in our patients was uniform: All were treated with a sofosbuvir-based therapy. Another limitation was the method of OBP measurement used in this study, specifically the lack of unattended BP measurement, which eliminated the potential bias related to the ‘white coat’ effect. In addition, we did not perform the 24-h ambulatory blood pressure monitoring; however, we observed the central blood pressure values and found a strong association with OBP results. Lastly, we would like to acknowledge the lack of monitoring of the adherence to antihypertensive medication in our study.In conclusion, we observed the clinically important improvement of both office blood pressure control and central aortic pressure parameters, including augmentation index, in half of our cohort of HCV-infected stable kidney transplant recipients after successful HCV eradication with a sofosbuvir-based DAA therapy. The concomitant decrease of liver steatosis, measured by the controlled attenuation parameter, was only observed in this subgroup of patients, which may suggest the potential underlying mechanism of beneficial hemodynamic changes. Further investigation would elucidate the pathomechanism of the observed improvement of blood pressure control, however, the increased availability of DAA therapy already resulted in pretransplant eradication of HCV infection in a majority of currently dialysis patients. We believe that patients receiving DAA therapy in the pretransplant period will benefit even more. Nevertheless, the confirmation of relatively moderate BP improvement in dialysis patients would be much more difficult due to procedural-related fluctuations in volemia.


ObjectiveBlood pressure (BP) has been found to rise among populations due to the high body mass index (BMI). Overweight and persons who have high BP are prone to develop heart diseases. The objective of this study was to evaluate the correlation between BMI and BP among hypertensive patients in both males and females aged 18 years and above.MethodologyA cross-sectional study was carried out among patients with a self-reported history of hypertension and anti-hypertensive medication. After taking ethical approval, a total of 337 patients aged 18 or above were selected by using convenience sampling. The duration of the study was six months. A detailed history was taken from each patient about hypertension associated symptoms with the help of a self-designed questionnaire. The BMI of the patients was assessed. Statistical Package for Social Sciences (SPSS) Version 20.0  was used to analyze the collected data. Spearman correlation was used, and p-value <0.05 was considered significant.Results2, and the mean systolic blood pressure level was 141.78±13.00 mm Hg whereas the diastolic blood pressure was 85.21±10.03 mm Hg. The results also showed that among males the BMI had a significant negative correlation with both systolic blood pressure level  and diastolic blood pressure level , while in females the correlation was insignificant.In a total of 337 patients, the mean age of the patients was 45.87±13.38 years. In which 176 (52.2%) were males and 161 (47.8%) were females. Their mean BMI level was 26.83±5.83 kg/mConclusionOur study results concluded that the BMI of the patients had a significant weak negative correlation with both systolic blood pressure level and diastolic blood pressure level in males; however, no significant correlation was found in females. Presently, the occurrence of obesity in European countries ranges from 10% to 20% for men and 10% to 25% for women . The inc2), overweight (26-30 kg/m2), and obese (>30 kg/m2) [As stated by the World Health Organization (WHO), overweight and obesity have become so common that they are substituting the more traditional public health distresses, such as undernutrition and contagious diseases . Worldwi0 kg/m2) .Research in Pakistan has shown that around 30% of cases of hypertension may be due to obesity in men under the age of 45 years. However, in some cases, this figure may be as high as 60% . AnotherThe objective of this study was to evaluate the correlation between BMI and BP amongst hypertensive patients in both males and females aged 18 years and above.This cross-sectional study was carried out among patients with a self-reported history of hypertension and anti-hypertensive medication. After taking ethical approval, data were collected from the medical outpatient department of a secondary care hospital in Karachi. A total of 337 patients aged 18 or above were included in the study by using convenience sampling. The duration of the study was six months from January 2019 till July 2019.A detailed history was taken from each patient about hypertension-associated symptoms with the help of a questionnaire designed specifically for the study. Patients with a history of diabetes, cardiac events, neurological disorders, cluster headache, gastrointestinal disease, and morbid obesity were excluded from the study. Age and gender were recorded. Blood pressure was measured using a sphygmomanometer with a stethoscope, and BMI was classified according to WHO classification .Data were analyzed using Statistical Package for Social Sciences Version 20.0 . The descriptive analysis was performed by calculating means and standard deviations, whereas qualitative data were expressed as frequency and percentages. Spearman correlation was assessed. P-value <0.05 was set as statistical significance.2. The mean systolic blood pressure level was 141.78±13.00 mm Hg, whereas the mean diastolic blood pressure level was 85.21±10.03 mm Hg  of them were males while 161 (47.8%) of them were females. Their mean BMI level was 26.83±5.83 kg/mThe study results further revealed that the BMI of the patients had a significant weak negative correlation with both systolic blood pressure level  and diastolic blood pressure level  of the patients  and diastolic blood pressure level  of the patients, while among females, the BMI of the patients had no significant correlation with either systolic blood pressure level  or diastolic blood pressure level  of the patients , the overweight prevalence was 13.5% for males and 19.6% for females, whereas the underweight population was 25%, which is not comparable with our study. According to NHSP, the mean BMI was 21.3kg/m2 for males and females, while in our study, the mean BMI in males and females was 26.83kg/mhan NHSP . Anotherhan NHSP . ChangesAnother study reported that age is also a main factor that affects BMI. Throughout the age groups, the highest rate of obesity (4.0%) was documented by the 46-50 years’ age group in their research. The increased rate of obesity in people with an increase in age was due to the reduced physical activity in spite of retaining the same energy intake in their past years. Therefore, the surplus energy that is not used is stored as fat, thus increasing the risks of becoming obese . People We found a weak negative correlation between BMI and systolic  and diastolic blood pressures  in males  and diastolic blood pressure level  of the patients (Table The correlation analysis of our study showed a significant weak negative correlation of BMI with both systolic and diastolic blood pressure levels for male patients. On the other hand, no significant correlation was noted in females. Therefore, it can be concluded that, due to the weak negative correlation, the BMI does not affect blood pressure.


The association among psychological, neuropsychological dysfunctions and functional/clinical variables in Chronic Heart Failure (CHF) has been extensively addressed in literature. However, only a few studies investigated those associations in the older population.To evaluate the psychological/neuropsychological profile of older CHF patients, to explore the interrelation with clinical/functional variables and to identify potential independent predictors of patients’ functional status.This study was conducted with a multi-center observational design. The following assessments were performed: anxiety , depression , cognitive impairment , executive functions , constructive abilities , psychomotor speed and alternated attention , functional status  and clinical variables .100 CHF patients  were included in the study. Anxious and depressive symptoms were observed in 16% and 24,5% of patients, respectively. Age was related to TMT-A and CDT , Log-BNP was related to ACE-R-Fluency subtest, , and 6MWT was related to ACE-R-Memory subtest and TMT-A . Both anxiety and depression symptoms were related to ACE-R-Total score  and depressive symptoms were related to CDT . At multiple regression analysis, Log-BNP and TMT-A were significant and independent predictors of functional status: worse findings on Log-BNP and TMT-A were associated with shorter distance walked at the 6MWT.Psychological and neuropsychological screening, along with the assessment of psychomotor speed (TMT-A), may provide useful information for older CHF patients undergoing cardiac rehabilitation. Chronic heart failure (CHF) affects more than 37 million people in the world and represents one of the diseases with the highest impact on health outcomes. It is a chronic condition associated with high rates of hospitalization, re-admissions, severe disability and high risk of mortality. In developed countries, 1–2% of the adult population suffers from this chronic condition and the rates are even higher, reaching 10%, in people aged 70 years or over  in the presence of reduced ejection fraction (LVEF <40%); or II) signs and symptoms of HF  with preserved (LVEF ≥50) or mid-range ejection fraction (LVEF 40–49%) .The exclusion criteria were: severe clinical conditions , no Italian education, severe visuo-perceptive deficits, low subjective motivation/interest or refusal to undergo the evaluation, severe psychiatric disorders  and severe cognitive deterioration, evaluated through the Mini-Mental State Examination (MMSE) (MMSE score ≤18.3)  that is Psychological assessment was performed with the Geriatric Depression Scale (GDS)  for deprNeuropsychological assessment consisted of cognitive screening and specific executive function tests. The MMSE  is a briFor the executive functions screening, the Frontal Assessment Battery (FAB) was administered . It is aThe scores of all the aforementioned neuropsychological tests were adjusted for age, sex, and educational level. All the tests have good psychometric properties, are validated in the Italian population, and normative data are available ,24–28.New York Heart Association (NYHA), Brain Natriuretic Peptide (BNP), left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), left ventricular end diastolic volume (LVEDV), tricuspid annular plane systolic excursion (TAPSE) are clinical variables considered to describe CHF sample. LVEF and Log-BNP were also considered in statistical analysis for their clinical predictive value .The 6-minute walking test (6MWT) is considered an adequate submaximal test and is commonly used to measure the functional exercise capacity in individuals with CHF. It is a self-paced exercise test that entails measurement of distance walked over a span of 6 minutes, that is better tolerated and more reflective of daily activities than other maximal exercise tests .All patients were admitted to an inpatient rehabilitation program comprehensive of medical history and physical examination, evaluation of laboratory parameters, ECG, chest X-ray, color-Doppler echocardiogram, medical therapy optimization, exercise testing , educational sessions, exercise training , psychological counselling, and metabolic evaluation with a personalized diet when needed.The patients signed an informed consent for all procedures and explanations concerning the study. The study was approved by the Institutional Review Board and Central Ethics Committee of the ICS Maugeri SpA SB (CEC) .During the first week of admission, all enrolled patients filled in a socio-demographic form and then underwent psychological and neuropsychological assessment. The psychological and neuropsychological research assessment was performed in a dedicated room of the Psychology Unit of each Institute and divided in two sessions: 1) ACE-R, HADS and GDS and 2) FAB, CDT, TMT-A/B, semantic and word fluency that were administered the subsequent day in order to avoid an interference effect. Trained psychologists evaluated the patients according to standardized administration and scoring procedures. The patients were supported throughout the testing period (30’ each session) to maintain motivation and to elicit the optimal level of performance; a break was always allowed if necessary. Furthermore, patients underwent a clinical psychological treatment: they received the results of their research assessment and they underwent a psychological interview according to the rehabilitation protocol and the specific needs of the patient.A sample size of 67 patients was deemed to be necessary to disclose, with a power equal to 80% and a Type I error of 0.05, a difference between an expected Pearson correlation coefficient equal to 0.3 and a correlation coefficient equal to 0 assessing the relationship between cognitive screening , psychological  and clinical/functional variables . We anticipated that during the study period (the year 2017) we would be able to enroll many more patients among all those hospitalized in the ICS Maugeri cardiac rehabilitative department.Descriptive statistics are reported as mean ± standard deviation (SD) for continuous variables and as number (percentage) for discrete variables.The association between pairs of variables  was assessed by Pearson correlation coefficient r. The associations between functional status as assessed by the 6MWT and clinical , demographic , neuropsychological  and psychosocial variables (HADS-A and GDS) was assessed by multiple regression analysis. Multicollinearity was checked computing the variance inflation factor (VIF). Variables showing VIF value greater than 10 were considered potentially problematic.All statistical tests were two-tailed and statistical significance was set at p<0.05. All analyses were carried out using the SAS/STAT statistical package, release 9.2 .In this multi-center cross-sectional observational study, 123 CHF patients aged ≥ 65 years, in NYHA class II-IV, consecutively admitted for inpatient rehabilitation, were screened for inclusion. Of these, 23 patients were excluded for the following reasons: clinical exacerbation during hospitalization (n = 3), no Italian education (n = 3), visuo-perceptive deficits (n = 3), low subjective motivation, or refusal, to undergo the evaluation (n = 7), severe psychiatric diseases (n = 1), and severe cognitive impairment (MMSE≤18.3) (n = 6). The final study population consisted of 100 patients.s the demographic, psychosocial, functional and clinical characteristics of the study sample. Moderate/severe anxiety symptoms were present in 16% of patients, and moderate/severe depressive symptoms in 24.5% of patients.As to the significant association between demographic/clinical/functional variables and neuropsychological adjusted scores, age was related to TMT-A and CDT , Log-BNP was related to ACE-R-Fluency, , and 6MWT was related to ACE-R-Memory and TMT-A . Both anxiety and depression symptoms were related to ACE-R-Total  and depressive symptoms were related to CDT  .At multiple regression analysis, among the set of variables considered potential predictors of functional status as assessed by the 6MWT , Log-BNP and TMT-A were identified as significant and independent predictors of functional status . MulticoOur study provides useful information concerning the psychological and cognitive screening in older and oldest-old CHF patients and an in-depth analysis of the cognitive impairments through a specific neuropsychological evaluation. In addition, it analyzed the relationship between cognitive performance and clinical, functional and psychological variables and it investigated which of the psychological, neuropsychological and clinical variables were independent predictors of the functional status.Our psychological screening highlighted the presence of moderate/severe anxiety (16%) and depressive (24.5%) symptoms, in accordance with the existing data in the literature . A briefFor our neuropsychological assessment, we chose the ACE-R as a screening tool, because it enables a deeper analysis of global and specific cognitive functioning . ParticuIt is important to highlight that the well-known relations within neuropsychological, psychological and clinical variables were not considered because they were not the focus of the present study.ACE-R total and CDT adjusted scores both have a negative relation with depression scores, meaning that patients with worse performance at neuropsychological tests presented a higher presence of depression symptoms. These data highlight that our sample’s results are in line with the existing literature about the prevalence of emotional distress in people with cognitive impairment ,34. In fAlso in our study we found significant relations between ACE-R Fluency and Log-BNP and other interesting associations between 6MWT and both ACE-R Memory subtest and psychomotor speed . This liIn a multidisciplinary and rehabilitative setting, this fact could be extremely challenging. Further research is needed to find a possible algorithm to predict patients’ functional status, starting from both clinical status and the result of psychomotor speed evaluation  in older CHF patients who cannot undergo a 6MWT evaluation. Moreover, this statement acquires greater importance considering the significant impact that psychomotor speed has on CHF patients’ self-care .An accurate psychological and neuropsychological screening is time saving and it requires a brief specific training. This kind of screening could play a pivotal role as it allows to implement an effective multicomponent and tailored rehabilitative intervention ,29,40,41Considering the strengths, it is a multi-center study, providing the first Italian ACE-R data on older and oldest old CHF patients. Moreover, it considers many different variables and their relationships by comparing psychological and neuropsychological aspects to clinical and functional ones and it provides interesting cues for future research on the results concerning psychomotor speed and functional status. As to limitations, the neuropsychological in-depth evaluation focused only on executive and attentional aspects, whereas a wide spectrum evaluation could be useful to identify the possible presence of other impaired cognitive domains in older CHF patients. Secondly, because of our small sample size, our conclusions may not be generalized to all CHF patients, in particular to CHF outpatients.Based on our findings, more attention should be paid to the link between cognitive and emotional variables, functional status and CHF clinical data. Concerning the psychosocial aspects, a more in-depth psychological interview is recommended to further investigate the evidence from the screening tests in a wider psychosocial perspective and to support patients who have emotional distress.Consistent with our findings, besides cognitive screening, an evaluation of psychomotor speed could be useful to further investigate and to predict CHF older patients’ functional status when they are unable to perform the dedicated functional test (6MWT).In conclusion, a psychological and neuropsychological screening can be useful means to obtain individualized information about the patient’s cognitive and emotional status and, where necessary, to guide the choice of subsequent in-depth investigations, in order to better tailor rehabilitative intervention.S1 Appendix(XLS)Click here for additional data file.


There are no prior publications or submissions with any overlapping information, including studies and patients. The study data have not been presented as an abstract or poster before the submission.Objectives: The study was conducted to analyze the changes of baroreflex sensitivity and heart rate variability from supine to upright standing in children and adolescents with orthostatic hypertension to explore whether and how the autonomic nerve regulation was involved in the development of pediatric orthostatic hypertension.Methods: This case-control study included twenty-five children with orthostatic hypertension (the patient group) and twenty-six healthy controls (the control group). All subjects underwent a standing test, during which their hemodynamic parameters were continuously monitored by a Finapres Medical System, and baroreflex sensitivity and heart rate variability were calculated.Results: The demographic characteristics, supine baroreflex sensitivity, and supine heart rate variability including time domain and frequency domain indices did not differ between the patients with orthostatic hypertension and healthy subjects (P > 0.05). However, a more obvious drop of baroreflex sensitivity and a greater increase of low frequency/high frequency ratio from supine to upright were observed in subjects with orthostatic hypertension compared with those in the healthy children . Changes of baroreflex sensitivity were negatively related to mean arterial pressure changes from supine to upright in all subjects (P < 0.01), and the increases in low frequency/high frequency ratio from supine to standing were positively correlated with those in mean arterial pressure in the study subjects (P < 0.001).Conclusion: Upright sympathetic overactivation is associated with pediatric orthostatic hypertension. Orthostatic hypertension (OHT) refers to a significant blood pressure (BP) elevation in the upright position compared to supine or sitting position, which reflects abnormal regulation of BP during postural changes. Streeten et al.  first puWhile, in adolescents and children, OHT has been recognized recently and it is now considered as an important cause of orthostatic intolerance (OI) –13. Our OHT stands for the hypertension occurring from supine to upright, and the autonomic nervous system regulates and maintains BP and heart rate (HR) during postural changes via baroreceptors . Hence, Therefore, this study was aimed to examine the possible changes in BRS and HRV indices from supine to upright in children and adolescents with OHT, and reveal the role of autonomic regulation in the development of pediatric OHT.Standing test); and exclusion of other diseases that cause OI symptoms (This case-control study enrolled 25 children with OHT (the OHT group) and 26 healthy children (the control group). The OHT group included 11 girls and 14 boys, from age 8 to 17 (12.5 ± 0.5) years old. All patients with OHT were admitted to the Department of Pediatrics at Peking University First Hospital from October 2015 to June 2019 with OI symptoms as their chief complaints and were diagnosed with OHT according to the published guidelines ≥ 20 mmHg and/or increased diastolic BP (DBP) ≥ 25 mmHg (in children 6–12 years old) or ≥ 20 mmHg (in adolescents 13–18 years old) from supine to upright standing; or during upright standing, BP ≥ 130/90 mmHg (in children 6–12 years old) or ≥ 140/90 mmHg (in adolescents 13–18 years old) , 20.During the standing test, HR, BP, and standard three-lead electrocardiograph were taken and recorded with a Dash 2000 Multi-lead Physiological Monitor . The last BP measured in supine position and the BP measured at 3 min after standing served as supine BP and upright BP, respectively. R-R interval (RRI) data obtained from electrocardiograph were visually reviewed, and five-min segments free of ectopic beats and artifacts severally in supine and upright position were used for further analysis.Meanwhile, the Finapres Medical System  was applied to continuously and non-invasively record beat-to-beat BP data during the standing test and calculating hemodynamic parameters and BRS afterwards. Using a finger plethysmogram, beat-to-beat BP measures of SBP, DBP, and pulse intervals were collected. Then, stroke volume (SV) was computed with the model flow method. HR was calculated as the inverse of the pulse interval, and cardiac output (CO) was calculated as HR multiplying SV. Mean arterial pressure (MAP) was computed as the true integral of the arterial pressure wave over one beat, and total peripheral vascular resistance (TPVR) was calculated from MAP divided by CO. Average CO and TPVR taken from the last 1 min of the supine period was regarded as the supine values, and the upright CO and TPVR were computed as a 1-min average in the third minute after standing. The reliability of beat-to-beat BP measurements was validated using a Finapres system .P < 0.01, the slope between SBP and interbeat interval was documented as one BRS value  and root mean square of successive differences (RMSSD) of RRI were analyzed. Original RRI series was altered to equidistantly sampled sequence by a cubic spline interpolation method. Fast Fourier transformation was then used to obtain power spectral density (PSD) functions with Welch's periodogram method. Total power (TP) in the frequency range from 0.0 to 0.4 Hz was composed of very low frequency , low frequency  and high frequency  bands. Powers of each band were computed as integrals under the respective PSD functions. The ratio between normalized LF power and HF power was calculated as LF/HF ratio.P < 0.05 (2-tailed) indicated a statistically significant difference. The independent t test was applied for the comparisons between groups in the same position, and the paired t test was utilized to compare the corresponding parameters before and at standing for the same person. The Chi-squared test was used to compare categorical variables. Covariance analysis was adopted to compare all autonomic measures (BRS and HRV) after adjusting for gender, age and body mass index (BMI). Pearson correlation analysis was used for linear correlations and partial correlation analysis was adopted to correct the influence of gender, age, and BMI.Statistical analyses were carried out with SPSS 20.0 software . All data are expressed as means ± SE, and P > 0.05, The sex ratio, age, height, weight, or BMI between the subjects in OHT and in control groups did not significantly differ . However, at 3 min of standing, the patients with OHT exhibited significantly higher SBP, DBP, and MAP than the control subjects . In addition, from supine to standing, OHT patients experienced an obvious decrease in CO (P < 0.01) and a marked increase in TPVR (P < 0.01), while the CO and TPVR of the control group did not show any significant changes upon standing (P > 0.05).As seen in P < 0.001), and the upright BRS in the OHT group was significantly lower than that in the control group after controlling for gender, age and BMI (P < 0.001). As for HRV indices, SDNN, RMSSD, TP, and HF power markedly decreased upon standing in all subjects, but at standing, SDNN, RMSSD, TP, LF power, or HF power did not significantly differ between the two groups. While, the elevation in LF/HF ratio from supine to upright was significantly greater in the OHT subjects compared with the healthy children, after controlling for gender, age and BMI (P < 0.01). Specific values in BRS and HRV changes from supine to upright are shown in P < 0.01, P < 0.001, Pearson correlation analysis showed that changes in BRS were negatively correlated with changes in MAP from supine to upright in all subjects  that we used for assessing the autonomic nervous function, due to the difficulties in the implementation of invasive methods in children, are not the most direct. Muscle sympathetic nerve activity (MSNA) detected by microneurography is another reliable way of evaluating sympathetic activity, which is more direct, but it is hard to conduct and not included in the present study due to the invasiveness of testing . The cohIn conclusion, our study provided new insight into the vital role of sympathetic hyper-activation upon standing in pediatric OHT. The data would greatly further the understanding of the mechanisms for OHT in children and adolescents.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by The Ethics Committee of Peking University First Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JD, BH, and CTan contributed to the conception and design of the study, revise of the manuscript, and final approval of the version to be published. YH, YuW, YaW, YJ, ZH, CTao, CTan, and HL analyzed and interpretated the data, and drafted the article. YyW, BH, YaW, ZH, CTao, and HL undertook the test and acquired the data. JD, YJ, and CTan revised the manuscript critically for important intellectual content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.