The exact patho physiological mechanizm of optic nerve damage in glaucoma is not fully understood.To assess the vascular risk factors in open angle glaucoma in African eyes.Prospective multicenter hospital-based study in Edo State, Nigeria.Three hundred and twenty-two glaucoma patients and 184 control subjects were included in the study comprising 200 male glaucoma patients (62.11%) and 122 females (37.89%). A cohort of consecutive patients with a diagnosis of primary open angle glaucoma and age and sex matched control subjects were included in this prospective, cross-sectional, and multicenter hospital-based study conducted during the period January-June 2008. Blood pressure (BP), pulse and intraocular pressure findings were recorded and mean BP, pulse and perfusion pressure for each eye calculated.Mean, standard deviations, 95% confidence intervals, Welch's t test, and Fisher's exact test were calculated.P < 0.0001), diastolic blood pressure (P < 0.0001), mean arterial blood pressure (P < 0.0001), pulse pressure (P < 0.01), systolic perfusion pressure (P < 0.01) were all significantly higher in glaucoma patients than in control.The mean IOP in the 644 eyes of the 322 glaucoma patients was 22.65 mmHg (SD plus/minus 11.06). The systolic blood pressure (Higher systolic, diastolic, mean arterial BP and pulse pressure was found in Black African patients with open angle glaucoma. The exact patho physiological mechanizm of optic nerve damage in glaucoma is not fully understood. Several vascular factors have been investigated, with particular attention to blood pressure (BP) and perfusion pressure (PP).489Elucidating this relationship is important to understand the factors affecting OAG development as well as having clinical implications given the high prevalence of hypertension and use of BP-lowering treatment among older adults. The aim of this study was to examine the systolic, diastolic, mean and pulse pressure in Black African patients with OAG and compare them with the findings in control. It is not designed to determine the risk factors associated with the development or progression of the disease.This is a prospective, cross-sectional, multicenter hospital-based study of some vascular risk factors in Black African patients with OAG. All patients with a diagnosis of juvenile or adult onset primary open angle glaucoma attending two tertiary hospitals, University of Benin Teaching Hospital, Benin and the Irrua Specialist Teaching Hospital, Irrua, both in Edo State, Nigeria between January and June 2008 were interviewed and examined. The diagnosis of OAG required the presence of both visual field defects and optic disc damage after ophthalmologic exclusion of other possible causes. Intraocular pressure was not considered in this definition. Visual field defects were determined by specific criteria based on automated peri metric data using the Kowa automatic visual field plotter. . All the patients had at least two positive visual field tests. Optic disc damage was ascertained by the study of the optic discs of the patients using the Keeler specialist direct ophthalmoscope and the Volk lens with the Haag Streit slit lamp. Gonioscopy was done with the Goldmann goniolens while the intraocular pressure was measured using the Goldmann applanation tonometer. Patients were included in the study if they had:Pathologically cupped optic discs- cup-to-disc ratio of 0.6 or more in association with generalized or localized thinning of the neuroretinal rim, notching of the neuro retinal rim, optic nerve head hemorrhages, nerve fiber layer loss, cup-disc asymmetry greater than 0.2, and/or deep cup with prominent lamina cribrosa and bayoneting sign.Visual field defect suggestive of nerve fiber bundle defect such as arcuate scotoma in the central visual fields, nasal step, altitudinal scotoma, paracentral scotoma, and generalized field defects.Open angle on gonioscopy.Absence of secondary causes of glaucoma.Patients were excluded from this study if they were on antihypertensive medication or on any drugs that may affect blood pressure or intraocular pressure. Blood pressure was assessed using the mean of two measurements in a sitting position with a mercury sphygmomanometer during one session. The patients had at least two hours rest time after arriving at the hospital before the first BP was taken and at least, another one hour before the second BP reading was taken. Systemic hypertension was defined as a systolic BP of 160 mm Hg or higher or a diastolic BP of 95 mm Hg or higher or both or the use of systemic antihypertensive medication.The mean BP, pulse pressure and perfusion pressures for each eye were calculated.tm version 2.05a software. . The mean and standard deviations (SD) for the systolic, diastolic, mean blood pressure, pulse pressure and perfusion pressures were determined in glaucoma patients and compared with the values in control using the alternate t test (Welsh). The 95% confidence intervals (CI) and the standard error of the mean (SEM) were also determined. Tests for statistical significance were done using the Welch's t test. A P value of less than 0.05 was considered significant. The number of glaucoma patients with hypertension, diabetes mellitus and migraine were compared to the number of control subjects with the same conditions using the Fisher's exact test and the odds ratio calculated.Data analysis was done with the aid of computer using the Instat GraphPadEthical approval was obtained from the ethical committee of the University of Benin Teaching Hospital, Benin City, Nigeria.A total of 3472 patients in the two hospitals were screened; 322 consecutive glaucoma patients who met the inclusion criteria and 184 control subjects were included in the study. There were 200 male glaucoma patients (62.11%) and 122 females (37.89%). The mean age was 55.91 years (SD plus/minus 18.31). The SEM was 1.443 and the 95% CI was 53.08-58.74. The median age was 61 years. The age and sex distribution of the glaucoma patients is shown in t is equal to 19.648, df is equal to 817 and the two-tailed P value was less than 0.0001 which was statistically significant.The mean IOP in the 644 eyes of the 322 glaucoma patients was 22.65 mmHg (SD plus/minus 11.06) and the SEM was 0.80. The range was 9-68mmHg and the 95% CI was 20.92-24.37. All the glaucoma patients had features of glaucoma in both eyes. The patients were not classified according to severity of glaucoma, The mean IOP in the 368 eyes of 184 control subjects was 13.47 mmHg (SD plus/minus 3.23) and the SEM was 0.17. The range was 7-23mmHg and the 95% CI was 13.14-13.80. The Welch's approximate t is equal to 7.363, df is equal to 461, P less than 0.0001), diastolic blood pressure , mean arterial blood pressure , pulse pressure , systolic perfusion pressure  were all significantly higher in glaucoma patients than in control. There was no significant difference in diastolic perfusion pressure, mean perfusion pressure and pulse rate between glaucoma patients and control (P greater than 0.05). A total of 118 patients (36.65%) with glaucoma were found to have hypertension while six subjects (3.26%) out of the control were found to have hypertension . The odds ratio was 17.160 . Twenty-six patients (8.01%) with glaucoma had diabetes mellitus while two subjects (1.01%) out of the control had diabetes . The odds ratio was 7.993 . There was no glaucoma patient or control subject that had a past medical history of an event resulting in vascular collapse. Six glaucoma patients (1.86%) had migraine while four control subjects (2.17%) had migraine . The odds ratio was 0.8544 . This was not statistically significant.The vascular factors are shown in This study was designed simply to compare the vascular risk factors in POAG with control. It was not designed to discover new risk factors or determine the risk of developing glaucoma. A vascular role in the patho physiologic mechanism of optic nerve damage in OAG has been studied extensively.112The Barbados Eye Study23Considerable attention has been paid to hemodynamic crises and related dramatic drops in blood pressure, particularly as a potential causative factor in normal tension glaucoma.12Diabetes was also found to be significantly higher in patients with OAG in this study. This is in agreement with previous studies which also report this association.16In conclusion, hypertension and diabetes were more common among patients with OAG than in control in Black Africans. The systolic, diastolic, mean arterial and pulse pressures were significantly higher in glaucoma patients. A lower perfusion pressure could not be demonstrated in this study. A long term follow-up study of healthy subjects who later develop OAG may be able to associate lower perfusion pressure with glaucoma and other vascular risk factors not readily apparent in this study.


The use of Intra-aortic counterpulsation is a well established supportive therapy for patients in cardiac failure or after cardiac surgery. Blood pressure variations induced by counterpulsation are transmitted to the cerebral arteries, challenging cerebral autoregulatory mechanisms in order to maintain a stable cerebral blood flow. This study aims to assess the effects on cerebral autoregulation and variability of cerebral blood flow due to intra-aortic balloon pump and inflation ratio weaning.augmentation of all cardiac beats) and during progressive reductions of the inflation-ratio to 1:3 (augmentation of one every third cardiac beat). Real time comparisons of peak cerebral blood flow velocities with systolic blood pressure were performed using cross-correlation analysis. The primary endpoint was assessment of cerebral autoregulation using the time delay between the peak signals for cerebral blood flow velocity and systolic blood pressure, according to established criteria. The variability of cerebral blood flow was also assessed using non-linear statistics.Cerebral blood flow was measured using transcranial Doppler, in a convenience sample of twenty patients requiring balloon counterpulsation for refractory cardiogenic shock (N = 7) or a single inotrope to maintain mean arterial pressure following an elective placement of an intra-aortic balloon pump for cardiac surgery (N = 13). Simultaneous blood pressure at the aortic root was recorded via the intra-aortic balloon pump. Cerebral blood flow velocities were recorded for six minute intervals at a 1:1 balloon inflation-ratio ; during 1:3 inflation-ratio mean time delay was significantly longer at -0.010 seconds . Finally, upon return to a 1:1 inflation-ratio, time delays recovered to those measured at baseline. During inflation-ratio reduction, cerebral blood flow irregularities reduced over time, whilst cerebral blood flow variability at end-diastole decreased in patients with cardiogenic shock.1:1 to 1:3 inflation ratio leads to a progressive reduction in time delays between systolic blood pressure and peak cerebral blood flow velocities suggesting that although preserved, there is a significant delay in the establishment of cerebral autoregulatory mechanisms. In addition, cerebral blood flow irregularities (i.e. surrogate of flow adaptability) decrease and a loss of cerebral blood flow chaotic pattern occurs during the end-diastolic phase of each beat in patients with cardiogenic shock.Weaning counterpulsation from  Aortic counterpulsation reduces myocardial ischemia by decreasing left ventricular afterload and increasing coronary blood flow. Pulse pressure variation is modified by the increase of diastolic-pressure time index and tension time index ratio (DPTI/TTI ratio). These principles are the physiological basis upon which the intra-aortic balloon pump (IABP) is used in states of cardiogenic shock and placed peri-cardiac surgery ,2. AlthoCerebral autoregulation is the mechanism by which constant CBF is maintained despite changes in cerebral perfusion pressure (CPP). Cerebral autoregulation mediates states of hyperemia or ischemia to avoid vasogenic edema or infarction respectively . ImpaireWhilst the use of IABP has represented a significant advantage in cardiovascular support and is often a necessary adjuvant for myocardial recovery, it is yet not clear what repercussions in CBF may imply, specifically during the weaning phase. This is the first study to assess cerebral autoregulation in a population at high risk of postoperative neurological damage during weaning of counterpulsation therapy.As an exploration of concept, a sample of 20 patients was recruited from two intensive care units. Group one comprised 13 patients requiring an elective insertion of an IABP following angioplasty or cardiac surgery and only one vasopressor to maintain mean arterial pressure (MAP). Group two consisted of seven patients with cardiogenic shock requiring an IABP as well as two or more vasopressors for MAP support, a persistent lactic acidosis and evidence of multiple-organ failure. Vasopressors were chosen at the clinician's discretion. The heterogeneous group size was not a limitation as intergroup comparisons were not the aim of the study. All patients recruited in this study gave informed consent.A total of ten patients had undergone coronary artery bypass surgery (CABG); ten had been treated with pharmacological measures and coronary angioplasty. The proportion of CAGB patients was balanced between the two groups. All patients were in the acute phase of their illness Table .Maintenance of a stable mean arterial pressure during inflation ratio reduction was ensured to allow a stable cerebral perfusion pressure and minimize interference with cerebral autoregulation. Patients were used as their own controls. Two patients were removed from the study due to significant hypotension (pre-defined as a reduction in BP systolic of more than 20% of baseline) during reduction of counterpulsation ratio. Data for 1:3 counterpulsation ratio was only collected in 11 patients, as the permission to wean counterpulsation was based on clinician judgment.® Sipplingen, Germany) used 2-MHz probes. Intra-patient variability was minimized using recordings only collected by one investigator formally trained in TCD [CBFV of middle cerebral arteries (MCAs) were measured using TCD following referenced criteria at the temporal acoustic window ,24. Bothd in TCD .Blood pressure signals from the IABP output channel and CBFV signals from the TCD device were simultaneously recorded using Powerlab  to minimise errors and bias which would be present if peripheral arterial pressure had been transduced. Stability of the insonated vessel diameter was assumed by maintaining a stable partial pressure of arterial carbon dioxide (PaCO2) during measurements. This assumption has been used previously in situations where transcranial color coded technology , is not available . PatientAn initial three minute steady-state CBFV was recorded. With the IABP at a ratio of 1:1 a total of six minutes was recorded. Subsequently, the IABP timing was reduced to 1:2 and a further six minute recording of CBFV was taken to ensure the establishment of autoregulatory changes. This data collection was then repeated using a counterpulsation ratio of 1:3. After completion of the 1:3 ratio recordings  patterns. It is also able to detect non-stationary or chaotic signals .For the non-linear analysis we used a third-order moment test as previously described . The croxcorr function in Matlab signal processing toolbox). The time delay was estimated for every subject and IABP ratio combination.For the cross-correlation analysis, BP and MCA velocity signals were bandpass filtered using a fifth-order Butterworth filter, into three frequency ranges: very low (0.015-0.07 Hz), low-frequency (0.07-0.15 Hz) and high-frequency (0.15-0.40 Hz) before applying cross-correlation . The timsampling by seconds) to further filter data; however, in this study signals were at risk of being dampened (or even lost) using windowing. Therefore, to minimize the risk of missing important signals, data was kept in a raw form at the expense of some increased noise.Time delays were virtually identical for all three frequency ranges. As such, subsequent analysis was performed on the very low frequency range only. No other data pre-processing was applied . Other rProc Mixed in SAS. To give a graphical picture of the overall delay, the average cross-correlation for each balloon and cohort combination was plotted . Each subject's beat length was initially estimated and the mean IABP and MCA velocity subtracted within each beat "window". The first 100 beats were then averaged from the start to the end of the beat in 0.001 second gaps. Mean beats for two subjects (each subject belonging to each study group) were plotted. This was a graphical analysis with no formal statistical testing.Phase delays between peak CBFV and systolic IABP at the very low frequency range, decreased with a reduction in counterpulsation ratio with mean delays for 1:1, 1:2 and 1:3 counterpulsation ratios of -0.016 seconds , -0.013 seconds  and -0.010 seconds  respectively; 1:1 counterpulsation ratio compared to 1:2, P < 0.0001; 1:1 counterpulsation ratio compared to 1:3, P < 0.0001. Following return to a 1:1 counterpulsation ratio, the phase delay increased between peak CBFV and systolic BP  being unchanged from initial 1:1 measures  of cerebral autoregulation. Cheung and colleagues found that CBFV-to-pressure ratio at end-diastole was dependent on the magnitude of augmentation rather than the timing of inflation for both augmented and non-augmented beats [Phase delays returned to baseline levels when the counterpulsation ratio returned to a 1:1 ratio, suggesting that there is an immediate recovery of the efficiency of autoregulation. Although the exact reason for this behavior is unclear, two explanations are plausible: Firstly, although not apparent in our study, non-significant reductions in MAP could have accompanied the change of IABP from 1:2 to 1:3, leading to small reductions in CBF which could have then diminished the efficiency of the autoregulatory response. Secondly, the reduction in the frequency of the counterpulsation balloon and therefore the lesser homogenous and more disturbed blood flow pattern exhausts the efficacy  and chaotic in the normal population while demonstrating monofractal behavior when cerebral autoregulation is impaired [Non-linear analysis shows that as IABP is weaned to 1:3 ratio, CBFV irregularities spread apart in time, shifting from left to right on the x axis Figures . An incrimpaired .and CBFV assessing their time delay using the cross-correlation approach [This study focuses on the relationship between IABP pressures at the tip of the descending aorta approach ,27,38. Tapproach .CBFV was initially recorded in both MCAs, but only the side with better acoustic properties was recorded and analyzed. Although spatial heterogeneity of cerebral autoregulation as well as interhemispheric differences are well described , an endpinflation-ratio reduction and pressure reduction) on cerebral autoregulation may be needed to define the implications of pulse pressure variation on cerebral autoregulation.Many authors have found time delays within two seconds in healthy populations when compared with patient cohorts . It coulAlthough this study clinically defines two groups with presumed differences in left ventricular function, such separations may have been arbitrary as there were no autoregulation differences between patients in refractory cardiogenic shock and those receiving supportive counterpulsation.Time domain cross-correlation functions are often applied to a series of signals in a different range of frequencies. Cerebral autoregulation is known to show high pass filter properties that enable low-frequency oscillations to be efficiently dampened by autoregulatory mechanisms while fluctuations in high-frequency ranges remain unfiltered . Slow spThis study shows that the use of fully augmented IABP does not adversely affect cerebral autoregulation. Reductions in inflation ratio during counterpulsation weaning progressively worsens cerebral autoregulation efficiency with the potential risk of cerebral hypoperfusion. Reduction in chaotic activity seen at end-diastole in patients with cardiogenic shock and inflation ratio reduction may also indicate impairment of CBF dynamics. Further studies must investigate optimal IABP weaning strategies to minimize the risk of reversed CBF at end-diastole, particularly amongst patients with poor residual left ventricular function.IABP: Intra aortic balloon pump; CBFV: cerebral blood flow velocity; TCD: transcranial Doppler; BP: blood pressure; CBF: cerebral blood flow; DPTI/TTI: diastolic pressure time index and tension time index ratio; CPP: cerebral perfusion pressure; CCF: cross-correlation function; MAP: mean arterial pressure; CABG: coronary artery bypass graft; MCA: mean cerebral artery; PaC02: partial pressure of carbon dioxide.The authors declare that they have no competing interests.JB and JF conceived and designed the study; JB and SG undertook patient screen and data acquisition. JB drafted the manuscript which was then reviewed and amended by JF and RB. RB was involved in extensive editing. AB performed all data analysis and supervised the data interpretation. DT facilitated and advised about the use of the powerlab technology. KD resolved all technical problems related to data acquisition. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/10/3/prepub


We are presenting a review of Isolated Systolic Hypertension (ISH) as a cardiovascular risk factor with emphasis on the perioperative period.Isolated systolic hypertension is associated with aging and is the most frequent subtype (65%) among patients with uncontrolled hypertension. ISH is strongly associated with increased risks of cardiac and cerebrovascular events exceeding those in comparably aged individuals with diastolic hypertension. Patients with ISH show an increase in left ventricular (LV) mass and an increase in the prevalence of left ventricular hypertrophy (LVH). These LV changes increase cardiovascular events and frequently lead to diastolic dysfunction (DD). Treatment to reduce elevated systolic blood pressure has been shown to reduce the risk of cardiovascular events.In the perioperative setting, essential hypertension has not been found to be a significant risk factor for cardiac complications. Most of the studies were based on the definition of essential hypertension and underpowered in sample size. The significance of perioperative ISH, however, is not well studied, partly due to its recognition only fairly recently as a cardiovascular risk factor in the non-surgical setting, and partly due to the evolving definition of ISH.Perioperative cardiac complications remain a significant problem to the healthcare system and to the patient. Although the incidence of perioperative cardiac complications is prominent in high-risk patients as defined by the Revised Cardiac Risk Index (RCRI), the bulk of the cardiac complications actually occur in low-risk group. Currently, little understanding exists on the occurrence of perioperative cardiac complications in low- risk patients. A factor such as ISH, with its known pathophysiological changes, is a potential perioperative risk factor.We believe ISH is an under-recognized perioperative risk factor and deserves further studying. Our research group has recently been funded by the Heart Stroke Foundation (HSF) to examine ISH as a perioperative risk factor (PROMISE Study). I)1)). It also found that SBP was a stronger predictor of outcome than diastolic blood pressure (DBP). The JNC-VII report confirms the close association between ISH and cardiovascular events [Isolated Systolic Hypertension (ISH) is increasingly recognized as a cardiovascular risk ,2. Severr events . It also2 & 3)). Masley et al. [The continuous graded influence of high blood pressure on cardiovascular disease (CVD) risk was also found in the meta-analysis of Prospective Studies Collaboration . It invoy et al. , in a rey et al. -12.1).The definition and classification of ISH have undergone several iterations. ISH is currently defined as SBP > 140 mmHg with DBP < 90 mmHg, and not secondary to another disorder in individuals aged 18 and older. This is based on the average of 2 or more seated BP readings on each of 2 or more office visits. The definition is adopted by the Seventh Report of the Joint National Committee (JNC-VII) on Prevention, Detection, Evaluation, and Treatment of High Blood pressure . The maiPre-hypertension (SBP of 120 – 130 mmHg) is not a disease category. Rather it is defined in order to identify individuals at risk of developing hypertension. They are not candidates for treatment but will require health-promoting lifestyle modifications to prevent cardiovascular disease. Classification of the JNC VII does not stratify hypertensive patients by the presence or absence of risk factors. Also, it does not stratify them by the presence or absence of target organ damage. Therefore, the JNC VII treatment recommendation does not take into consideration if either or both are present. However, it recommends that all individuals with stage 1 or 2 hypertension be treated.4)). The prevalence of ISH increases with age, and it accounts for substantial proportion of hypertensive patients. It is the most frequent subtype of hypertension in the US . The risIn the National Health and Nutrition Examination survey (NHANES III), 42.7 million adult Americans were identified as hypertensive, which represented 24% of the adjusted adult US population . Over 65The Canadian Heart Health Survey (CHHS) showed that the overall prevalence of ISH was 8.1% and the prevalence of untreated ISH was 6.4% . FiguresIn the WHO report, sub optimal BP (> 115 mm Hg SBP) is responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease . HoweverData from clinical studies indicate that ISH is a distinct syndrome with pathophysiological changes different from those in essential hypertension . The maiThe heart adapts to the ensuing increase in wall tension by hypertrophy and increased myocardial contraction time. Although these adaptations seem to preserve systolic function, diastolic impairment becomes apparent as LV compliance and early diastolic filling decline  ,34. As aThe presence of LVH in ISH patients frequently leads to diastolic dysfunction (DD) ,46. ThouFor decades, despite the focus on DBP, many investigators know that ISH is a cardiovascular risk factor, frequently seen in the elderly ,52-55. RIn a cardiovascular health study on hypertensive predictors of cardiovascular events , SBP was the single best predictor of cardiovascular events . After aFurther supporting data comes from the analysis of the Framingham 30-year study. It demonstrated that SBP is a strong and a consistent predictor of coronary artery disease over several age strata . The MRFStudies from Europe have also demonstrated a positive continuous, graded, and independent association for both total (P<. 001) and cardiovascular (P< .001) mortality with SBP but not DBP. Blood pressure was linearly related to the risk of stroke in untreated patients  but, in A study from China examined ISH, isolated diastolic hypertension and systolic-diastolic hypertension as predictors of stroke . The relBeside its cardiovascular risk, high blood pressure is regarded as a major risk factor for the development of renal insufficiency . When boTreatment to reduce elevated systolic blood pressure to less than 140 mmHg has been shown to reduce significantly the risk of cardiovascular events -70. The Encouraging results were also obtained from the Systolic Hypertension in Europe (Syst-Euro) trial ,71,72. IA reduction in the incidence of stroke and other cardiovascular complications was also achieved in the Systolic hypertension in China (Syst-China)  and the 1) has also recommended the use of a single antihypertensive therapy or a combination of two or more for stage 1 and stage 2 hypertension. The choice of the antihypertensive usually takes into consideration the type and subtype of hypertension, the severity, and the co-morbidities. In addition, when prescribing an antihypertensive medication, clinicians should also be aware of the patient’s compliance to treatment.Different drug therapies have been suggested to treat systolic blood pressure. These included the use of diuretics, beta-blockers, calcium channel blockers and angiotensin converting enzyme inhibitors (ACEI). The JNC-VII (Table A recent study suggested that caution should be exercised on lowering blood pressure less than 140/90 in patients over 80 years old . In anotII)Sprague, in 1929, was the first to examine the relationship between hypertension and perioperative cardiac risks. In his report, he described a series of 75 hypertensive patients of whom 1/3 died in the perioperative period . Prys-Roet al. [et al. [In a multicenter prospective study of 17,201 patients undergoing elective surgery, Forrest et al.  found 17et al. . Hyperte [et al.  evaluateAlthough well conducted at the time, we believe that these early studies failed to recognize ISH as a perioperative risk factor for the following reasons. First, ISH was recognized as a cardiovascular risk factor only in recent years. For decades, ISH was not deemed to be strongly associated with the same sequelae as in diastolic or combined hypertension ,91,92. Het al. examined the role of a number of risk factors in the development of silent ischemia after general anesthesia for general and vascular surgery in 183 patients [Howell patients . PatientAlso, Howell and co-workers examined the association between perioperative hypertension and cardiovascular complications including clinical trials, systematic reviews and meta-analysis -98. TherThe only study looking at the association between ISH and postoperative cardiovascular events was carried out in the open-heart surgery patients . It was Although the ACC/AHA guidelines do not identify hypertension as an independent risk factor for perioperative cardiovascular complications , it reflThe prevalence of perioperative ISH in non-cardiac surgery remains unclear. While it is unknown if the same percentage of ISH in the community presents for surgery, the proportion of untreated perioperative ISH is also unknown. In patients undergoing coronary artery bypass grafting (CABG), the prevalence of perioperative ISH was found to be 29.6% . ISH is A study on 118 patients with uncomplicated mild hypertension using echocardiography found that concentric LV geometry was found mainly in untreated patients. This resulted in the identification of a high-risk subgroup with concentric remodeling, which had not been recognized or treated . AlthougThe development of LVH and DD are common in ISH patients ,45. DiasDuring the perioperative period, stress hormones and catecholamine surges are well reported -121. SymPerioperative cardiac complications frequently complicate non-cardiac surgery patients. In 1990, perioperative cardiac complications affected up to 1 million patients and incurred an estimated cost of US$20 billion . When a A recent database study of over 700,000 patients showed that β-blockers in Revised Cardiac Risk Index (RCRI) Score 0 or 1 may increase all-cause mortality . Of the The aim of preoperative assessment is to evaluate and optimize the patient’s condition perioperatively thus minimizing adverse events or last-minute surgery cancellation. Evaluation of ISH patients presenting for surgery should follow the standard preoperative steps in obtaining medical history, physical examination and investigations. Acute onset of sever hypertension raises the suspicion of a secondary form of ISH. Patients with a history of cardiac, vascular or renal disease should be ensured about the level of their hypertension control. Individuals may have undiagnosed ISH for years without having had their blood pressure checked. Therefore, a careful history of end organ damage should be obtained. History of other cardiac risk factors including hypercholesterolemia, diabetes mellitus, tobacco, and family history of coronary artery disease should be obtained. If a secondary form of ISH is suspected, details of possible causes should be explored including renal diseases, pheochromocytoma, hyperthyroidism, and coarctation of aorta. An accurate measurement of blood pressure with a proper cuff size is crucial. The patient should rest quietly in the pre-assessment unit for at least five minutes before the blood pressure measurement. Cardiovascular examination should focus on listening for S3, S4 and murmurs of coexisting valvular disease. Peripheral pulses should also be palpated to assess for vascular disease. Also, ausculatation for renal artery bruit over the upper abdomen: the presence of a unilateral bruit with both a systolic and diastolic component suggests renal artery stenosis. A funduscopic evaluation of the eyes should be performed to detect any evidence of hypertensive retinopathy. Investigations in relation to ISH should be directed toward assessing the extent of the end organ damage.Currently, there is no evidence to identify stage 1 diastolic hypertension (DBP >90 - < 110 mmHg) as a predictor of adverse perioperative outcomes ,89. Whenet al. [In patients with ISH undergoing CABG, there is evidence that the incidence of perioperative cardiovascular complications is increased . Also, tet al. , noted net al. , congestet al. , renal, et al. . Any of et al. . In the In the community, ISH is the most prevalent subtype of hypertension and is a significant predictor for cardiovascular complications. Nevertheless, it is not recognized as a significant cardiac risk factor in the surgical setting. A number of reasons may explain why ISH is an unrecognized cardiovascular risk factor in the perioperative period. In addition, pathophysiological changes such as LVH and diastolic dysfunction as a result of ISH, in conjunction with the sympathetic and stress hormonal surges at the time of anesthesia emergence as well as during the postoperative period, provide the rationale that perioperative ISH deserves further studies.Information emerging from a large database suggested that majority of the perioperative mortalities occurred in low-risk groups. This attracted and will attract the attentions of clinical investigators to look at possible under diagnosed risk factors. We believe that ISH is under diagnosed risk factors. Because of the lack of perioperative ISH clinical trials, we were not able to conduct a systematic review or a meta-analysis of perioperative ISH at this stage.Until we have the complete necessary data, we will continue using best practice based on the available data. The current work of the PROMISE study will be the stepping-stone toward answering the question; is the perioperative ISH a cardiac risk factor?


Asthma is a complicated network of inflammatory reactions. It is classified into mild, moderate, and severe persistent asthma. The success of asthma therapy relies much on understanding the underlying mechanisms of inflammation at each stage of asthma severity. The aim of this study was to explore the differences in apoptotic potential, CD4/CD8 ratio, memory compartment, and T- helper (Th) 1 and 2 profile of peripheral blood lymphocytes (PBL) in patients with mild intermittent asthma and severe persistent asthma during exacerbation periods.+/CD8+ ratio, CD45RO+, CD45RA+ markers with memory/naïve ratio (CD45RO+/CD45RA+). Th2/Th1 cytokines balance represented by IL-4/IFN-γ ratio was measured by enzyme-linked immunosorbent assay (ELISA) for in vitro PBL cytokine synthesis. It was found that Bcl-2/Bax ratio was higher in severe than in mild asthmatics which in turn was higher than in healthy group. And memory/naïve ratio of PBL was higher in severe than in mild asthmatics. Moreover, memory cells, CD45RO+ and CD45RO+/CD45RA+ ratio were correlated directly with Bcl-2/Bax, in severe and mild asthma patients. In contrast, CD4+/CD8+ ratio was not changed significantly among healthy group, mild and severe asthmatics. However, CD8+ cells were correlated directly with memory cells, CD45RO+, in severe asthmatics only. Interestingly, the dominant profile of cytokines appeared to change from T helper 2 (Th2) in mild asthmatics to T helper 1 (Th1) in severe asthmatics where the lowest in vitro IL-4/IFN-γ ratio and highest IFN-γ were found.Four research lines were investigated and compared among mild asthmatics, severe asthmatics, and healthy groups by applying immunocytochemical staining of PBL. Antiapoptotic and proapoptotic proteins with Bcl-2/Bax ratio, CD4, CD8 markers with CD4+, leading to persistent baseline inflammation.It was concluded that the underlying mechanisms of inflammation might vary greatly with asthma stage of severity. Mild intermittent asthma is mainly Th2 allergen-oriented reaction during exacerbations with good level of apoptosis making the inflammation as self-limiting, while in severe persistent asthma, the inflammatory reaction mediated mainly by Th1 cytokines with progressive loss of apoptosis leading to longer exacerbations, largely expanded memory cells, CD45RO Inflammation is the central feature of asthma pathogenesis and the core of its clinical manifestations that plays the main role in airway obstruction and hyperresponsiveness . Asthma The 'Th2 hypothesis for asthma' was first suggested by Mosmann in 1989 , who had+ T cells in the immunopathogenesis of asthma is well documented, though little is known about the role of CD8+ T cells. A study [+ T cells might play a role in the pathogenesis of asthma. Regarding the effector memory cells of PBL, it has been shown that CD45RO+, may provide pro-inflammatory signals that contribute to the persistent airway inflammation of asthma [+ cells, vary with the progression of asthma disease or not [Regarding CD4 and CD8 markers, the role of CD4 A study  demonstrf asthma . And it e or not .+/CD8+ ratio in peripheral blood lymphocytes (PBL) between mild intermittent and severe persistent asthmatic adult patients during exacerbations. The previous studies either were conducted on asthmatic children or involved only part of the research lines implemented in this study. Hence, this study was designed to explore the correlations and changes in Th1/Th2 balance, represented by PBL in vitro synthesis of IL-4 and IFN-γ and their ratio, PBL CD4+/CD8+ ratio, PBL Bcl-2/Bax ratio, and PBL memory/naïve CD45RO+/CD45RA+ ratio in healthy volunteers, mild intermittent, and severe persistent asthmatic patients. This exploration is believed to be essential for acquiring a better understanding for the dynamic nature of immune reaction and inflammatory process that take place in different types and stages of asthma. This could help physicians employ more adjustable treatments on asthma targeting the real causative factors specifically.There is to date no or very few published studies demonstrating the relationship of changed Th1/Th2 balance with changes of apoptosis, changes of memory cell compartment, and changes of CD4Fifty two asthmatic patients were involved in this study during the period from February 2007 to March 2008 in Selangor, Malaysia. The age of the studied patients ranged from 17 to 53 years, none of them was regular smoker or has other major illnesses. Thirty six patients were selected with mild intermittent asthma and 16 with severe persistent asthma. All patients were diagnosed by a specialist of respiratory diseases and diagnosis was confirmed by pulmonary function tests in the central Kuala Lumpur hospital. Twenty age- and sex-matched healthy volunteers (HV) were involved in this study, aged 23 to 55 years. HV had no history of smoking or any medical disease, and their chest radiograms and pulmonary function tests showed no evidence of respiratory diseases. Five mL of blood were withdrawn from asthmatic patients and HV for PBL isolation. Blood was sampled from asthmatic patients within the first 12 hours of asthma exacerbation. Moreover, all involved patients were subjected to similar modes of therapy to avoid discrepancies in therapy protocols and to equalize the interfering effects of the oral or inhaled therapy with the study findings. Written consents were granted by all patients and HV for interviewing and blood sampling. Dealing with human subjects was carried out within the scope of Helsinki declaration of ethical principles of medical research and permission was granted from the ethics committee of biomedical research of University Putra Malaysia.Mouse monoclonal antibodies for immunocytochemistry (ICC) assay were derived from  and as follows; anti-human CD4 antibody (B379), anti-human CD8 (BL-Ts 8/2), anti-human CD45RO (2Q1392), anti-human CD45RA (MEM-56), anti-human Bax (ID3), and anti-human Bcl-2 (4D7). For ELISA, mouse monoclonal antibodies were used as follows; anti-human IL-4 (NYRhIL4) from  and anti-human IFN-γ (25718) from . Abcam Biotinylated goat secondary antibodies (ab6785) were used against mouse immunoglobulins in both ELISA and ICC assays.6 cells/mL [PBL were isolated from heparinized whole blood of asthmatic patients in order to prepare a pure population of lymphocytes. PBL separation was done in ultraviolet hood by implementing the gradient density sedimentation technique using Ficoll hypaque (Sigma). Diluted blood 1:2 in RPMI 1640 media (Sigma) was added slowly onto below Ficoll layer to create two interfacing layers. By the effect of the centrifugal force, lymphocytes were grouped into one web-like layer which then was withdrawn and washed three times with phosphate buffered saline (PBS) (Sigma). Final concentration of lymphocytes suspension was adjusted to 1 × 10cells/mL .6 cells/mL of lymphocytes suspension were aliquoted into wells of the cytospin. Cytospins were performed, 650 rpm for 6 minutes on silane-coated slides. Slides were dried in a desiccation chamber for overnight. Slides then were fixed in 2% paraformaldehyde (BDH) for 20 minutes at room temperature and washed 3 times in PBS. Slides were incubated in 95°C preheated antigen retrieval buffer, 100 mM Tris (Sigma), 5% (w/v) urea (Merck), pH 9.5 for 10 minutes in a water bath. After 3 times PBS washing, cells were permeabilized for 15 minutes at room temperature in blocking buffer, 3% BSA (Merck) in PBS, plus 0.1% Triton X-100 (Sigma) followed by blocking of nonspecific binding in blocking buffer for 1 hour at room temperature.ICC procedure was carried out according to the instructions of the manufacturer of primary and secondary antibodies (Abcam) with modifications. 200 μl of 1 × 10One hundred μl of mouse monoclonal antibodies diluted 1:50 in blocking buffer at final concentration 0.005 mg/mL were added on ICC slides against human Bax, Bcl-2, CD4, CD8, CD45RO, and CD45RA. Slides were incubated overnight in a humid chamber at 4°C. Next day, slides were rinsed gently with PBS-0.05% Tween20 (Merck) and placed in fresh PBS-Tween bath for 1 minute. 100 μl of the biotinylated goat anti-mouse secondary antibodies 1:400 diluted in PBS at final concentration 0.00125 mg/mL were added and incubated in humid chamber for 1 hour at 37°C. After washing with PBS-Tween20 solution, two drops of streptaviden-Horseradish peroxidase reagent (Dako) was applied, slides were placed in humid chamber and incubated for 30 minutes at 37°C. The prepared DAB-substrate chromogen (Dako) solution was then applied and slides were incubated in dark for 20 minutes at room temperature. Mayer's hematoxylin stain was used as counterstain, and slides were then dehydrated and mounted with DPX mounting fluid. The immunostained cells at moderate to intense dark brown color were considered positive and other cells were considered negative as seen in  (Merck). 50 μl/well of the supernatant-coating buffer mixture were added in duplicates to a sterile 96 wells microtiter plate which was incubated overnight at 4°C. Next day, the remaining fluid was aspirated and wells were washed twice with washing buffer . Blocking buffer  was then added for 1 hour. After a washing step, 50 μl of mouse monoclonal antibodies diluted 1:50 in blocking buffer at final concentration 0.002 mg/mL were added and incubated for 2 hours at 37°C. After a washing step, 50 ul of the biotinylated goat anti-mouse antibodies at final concentration 0.003 mg/mL were added and incubated for 1 hour at 37°C. After washing, 50 ul of streptaviden-horseradish peroxidase reagent (Dako) were added and incubated for 30 minutes at 37°C. After washing, 50 ul of OPD-H2O2 chromogen solution (Sigma) were added and microtiter plate was kept in dark for 15 minutes at room temperature. ELISA readings for optical density (OD) were measured immediately by microtiter reader A-1764A (Beckman) at wavelength of 492 nm [PBL cells were incubated for 3 days at 37°C in 1.5 mL microcentrifuge tubes containing complete RPMI-1640 medium (Sigma) with 200 U/mL penicillin G, 200 μg/mL streptomycin, and 10% human AB serum at a concentration of 1 × 10The statistical analysis was preformed using software SPSS version 10 and MS Excel 2000. After confirming the normal distribution pattern of both ICC and ELISA values by using normal distribution tests, mean ± 2 standard error and parametric multivariate student t-tests were used to evaluate the significance of differences. Pearson's correlation coefficient was used for correlating the level of expression of the studied targets in the involved groups of asthmatic patients.The isolated PBL from mild asthmatics, severe asthmatics, and HV groups were examined by immunocytochemistry. It was found that the mean percentage of the positive PBL for Bax was lower in severe asthmatics, 11.48 ± 9.6, than the close figures found in both mild, 29.41 ± 7.4, and HV, 35.23 ± 7.5 (P < 0.05). In contrast, the mean percentage of positive PBL for Bcl-2 was higher in severe asthmatics, 33.57 ± 8.4, than the close figures in both mild asthmatics, 16.38 ± 5.4, and HV, 8.34 ± 4.8 (P < 0.05). Accordingly, the mean Bcl-2/Bax ratio was calculated and was at highest level in the severe asthmatic patients, 2.9 ± 1.6, and significantly higher than in mild asthmatics, 0.55 ± 0.1, (P < 0.05) and in mild asthmatics was in turn higher than in HV, 0.23 ± 0.11, (P < 0.05) . Similarly, the mean percentage of CD8+ PBL was not significantly different in severe asthmatics, 26.62 ± 8.5, mild asthmatics, 23.92 ± 6.5, and HV, 24.57 ± 5.6 (P > 0.05). Accordingly, the mean CD4+/CD8+ ratio was not significantly different too in severe asthmatics, 1.41 ± 0.31, mild asthmatics, 1.89 ± 0.46, and 1.6 ± 0.35 (P > 0.05) , while no significant difference was found for the mean percentage of naïve CD45RA+ PBL in severe asthmatics, 67.35 ± 8.5, mild asthmatics, 70.4 ± 11.8, and HV, 71.5 ± 9.1 (P > 0.05). Accordingly, the memory/naïve CD45RO+/CD45RA+ ratio in severe asthmatics, 0.58 ± 0.11, was higher than that in mild asthmatics, 0.33 ± 0.12, and in HV group, 0.34 ± 0.11 (P < 0.05)  values. It was found that the in vitro synthesis of IFN-γ was increasing in parallel with disease severity. It was found that OD level of IFN-γ in severe asthmatics, 0.65 ± 0.1, was significantly higher than in mild asthmatics, 0.44 ± 0.08 (P < 0.05) which in turn was higher than in HV, 0.23 ± 0.07 (P < 0.05)  was used as a tool to shed light on the correlating behavior of the expressed markers and the synthesized cytokines of PBL with each other. It was found that the PBL expression of Bax was inversely correlated with Bcl-2, in mild asthmatics, r = -0.65, severe asthmatics, r = -0.43 and in HV, r = -0.47 groups (P < 0.05). CD45RO+/CD45RA+ ratio was correlated directly with Bcl-2/Bax ratio, r = +0.53, in severe asthmatics only (P < 0.05). The level of CD45RO expression was positively correlated with Bcl-2 in PBL of severe asthmatics, r = +0.74, and mild asthmatics, r = +0.63 (P < 0.05). The level of CD8 expression was positively correlated with that of CD45RO, r = +0.62 in severe asthmatics only (P < 0.05).The Pearson's correlation coefficient (In this study, ICC was used to visualize the expression of the studied markers. Although ICC is not a sophisticated procedure, it is considered by some reports as more sensitive and specific than flow cytometry . MoreoveIt was found that the survival of PBL in asthmatic patients was higher than in HV and increases with asthma severity, represented by increasing Bcl-2/Bax ratio. The results of this study are in agreement with other recent studies revealed that Bcl-2 or Bcl-2/Bax ratio increase in asthmatic lungs in comparison with normal lungs ,19. In a+ PBL as well as memory/naïve, CD45RO+/CD45RA+, ratio were much higher in severe asthmatics than in mild asthmatics or in HV group. This indicated that the memory compartment in PBL of severe asthmatic patients was expanded significantly and this might lead to persistent inflammatory reactions in lung with or without the presence of the specific allergen. Few studies have reported imbalance in memory CD45RO+ cells in the peripheral blood of patients with asthma and allergy but the results were inconsistent [+, in lung or peripheral blood may be an evidence of chronic inflammation in asthmatic children [+ PBL and CD45RO+/CD45RA+ ratio with apoptosis markers was investigated. It was found that percentages of CD45RO+ PBL and CD45RO+/CD45RA+ ratio were positively correlated with Bcl-2 and Bcl-2/Bax ratio respectively in mild and severe asthmatic patients. This is in agreement with another study [Decreased apoptosis in PBL may explain the extensive exacerbations but not the persistent inflammatory reactions seen exclusively in severe persistent asthma. Persistent inflammation needs abundant presence of readily primed memory lymphocytes in lung and peripheral blood . Therefonsistent -24. Othechildren . Howeverer study  that sta+/CD8+ ratio in the studied groups of asthma and HV. This provided evidence that asthmatic inflammation, even though severe, is not solely triggered by CD4+ cells, as previously was believed. This study suggests that asthmatic inflammation originates from both CD4+ and CD8+ cells. This finding is backed up by a previous report [+ T cells. As a remarkable finding, the percentage of CD8+ cells was positively correlated with the percentage of memory cells, CD45RO+ PBL, in severe asthmatics. This finding might indicate an increasing role of the memory cells, CD8+CD45RO+ in the pathogenesis of severe asthmatic inflammation.Surprisingly, there were no significant changes observed in the expression level of CD4 and CD8 markers, nor changes were found in CD4s report  which idSpontaneous in vitro synthesis of cytokines was pursued in this study to avoid any induced T helper polarization. Some reports demonstrated an increased PBL production of IFN-γ in subjects with asthma via induced in vitro synthesis ,27 which+ and CD8+ cells affect the disease without bias to each of them. On the other hand in severe persistent asthma, immune reactions seem to be mediated increasingly by Th1 cytokines, with longer life span of PBL due to progressive loss of apoptosis, with expanded compartment of memory cells in PBL leading to more persistent inflammatory reactions, and both CD4+ and CD8+ cells seem to act together in the disease with predilection to CD8+ type of memory cells, CD45RO+ cells. Collectively, this scenario provides the bases for persistent less allergen-dependent inflammation in severe asthmatic patients. In respect to the current findings, it might be necessary to adjust asthma therapy to the type and severity of asthma where different mechanisms of allergic inflammation and immune responses take place.Taken together, asthma is a disease of different pathogenetic backgrounds. The immune reactions in mild intermittent asthmatics seem to be mediated mainly by Th2 cytokines, with shorter life spans of PBL due to better functioning apoptotic pathways, with less memory cells of PBL, and both CD4The authors declare that they have no competing interests.ASA and RRH carried out patients sampling and interviewing, lymphocytes isolation, and did the immunostaining. FA carried out the ELISA for in vitro synthesis of cytokines. KAA and ASA carried out the paper drafting, statistical design, statistical analysis, and the proofreading of the article language and integrity. All authors read and approved the final manuscript.


This study is an attempt to develop a technique by which complete hemostasis can be achieved on table by giving traction to the Foley's catheter thereby compressing the venous plexus and the avulsed prostatic arteries at the bladder neck by the inflated balloon. A total of 170 cases of BPH were operated by Freyer's Suprapubic Trans-vesicle prostatectomy. In the technique, bladder mucosa is reposited below the balloon and the balloon is inflated to 60 ml of normal saline. The balloon is kept at the bladder neck and traction is applied to the catheter. Traction is maintained by strapping the catheter to the thigh of the patient with sticking plaster for 24–48 h. The average blood loss was 18.9 ml which proves that the Foley's balloon pressure traction method at the bladder neck is effective in achieving hemostasis in patients undergoing open prostatectomy. Benign prostatic hyperplasia (BPH) is the most common benign tumor in men and its incidence is age related. Surgery The present study was conducted from June 2005 to October 2007, in the patients of Benign prostatic hyperplasia (BPH) admitted in the surgery ward at AVBR hospital, Sawangi, after the approval from the Ethical Committee of the above institute and with legal consent of patients. The procedure was carried out under the supervision of senior Surgeon.Patient selection: A total of 170 cases of BPH were operated by Freyer's Suprapubic Trans-vesicle prostatectomy. All the patients presented with symptomatic BPH. They were all admitted and treated as in-patients.Preoperative workup: Detailed clinical history of each patient was recorded and AUA symptom score was calculated. All patients were subjected to thorough clinical examination. Renal function tests, serum electrolytes, Urine culture and antibiotic sensitivity was done for all the patients. X-ray KUB and USG KUB was done and prostate size and post void residual urine was calculated. Serum PSA was done only if Digital Rectal Examination was suspicious.Surgery: After making the bladder full with normal saline by per urethral catheter, a suprapubic midline incision was taken and abdomen opened in layers. Bladder was opened with a stab knife. Prostate was supported with a finger passed per rectally and enucleation of prostate was done. After enucleation of prostate in addition to the index finger, middle finger was inserted and the rectum was pulled caudally. This helps to exert minimal pressure over the venous plexus. A 22 – 24 No three way foley's catheter is placed in the bladder and the bladder mucosa is reposited below the balloon posteriorly, by the finger. The balloon is inflated to 60 ml of normal saline and is kept at the bladder neck and traction is applied to the catheter. Traction is maintained by strapping the catheter to the thigh of the patient with sticking plaster for 24 to 48 h. On table, clear urine is confirmed and bladder is closed primarily in two layers. No suprapubic and retropubic drain is kept. Irrigation is started as a precautionary measure and wound is closed in layers. Traction is removed after 24 to 48 h and balloon deflated gradually. Foley's is removed on fifth and seventh post operative day and the patient is discharged after suture removal on tenth day.Calculation of blood loss: Study of intraoperative blood loss was calculated by weight of sponges pre and post operatively soaked with blood. This gives the amount of loss in the sponge (1 gm = 1 ml) to whichPost operative blood loss =Hb % UrineHb% Patient× volume of urine (24 h)The blood loss was calculated by the above formula for all the patients. Mean amount of postoperative blood loss was 18.9 ml. All the patients had blood loss in the range of 0 to 50 ml . None ofMcGill and Belfield described Suprapubic transvesical partial enucleation of the prostate in the late 1800s. Fuller and Frayer popularized the technique of complete enucleation of the gland. However,Naninga and O'Coner in their study noted blood loss of more than 100ml in just 15% patients treated with balloon pressure traction technique which is little more in comparison with our study.[The average blood loss in our study was 18.9 ml. All the patients in the study group had blood loss ranging from 10 to 50 ml. In our study, two patients required blood transfusion as the hemoglobin was less than 9 gm% preoperatively. et al, reported 1% blood transfusion rate which is comparable with our study.[Sheen and Quinlan used early suture control at 3'o clock and 9'o clock for achieving hemostasis. They reported a mean blood loss of 841 ml in their study.[Moon reported a blood transfusion rate of 83.3% in patients undergoing Freyer's Prostatectomy when standard technique was used.[Condie ur study. Sheen anir study. This is was used. This is was used..Ceylan K reported a significant blood loss rate of only 3.2% in his study. He had used both sutures at 3'o clock and 9'o clock position as well as traction at the bladder neck to achieve hemostasis. As a corollary, it can thus be inferred that while suture technique alone is ineffective in achieving hemostasis, traction at the bladder neck achieves hemostasis.[mostasis.Goodyear and Beard have shown by means of serial postoperative urethrogram that the prostatic fossa, like the uterus, contracts to 50% of its size within few minutes, to 25% in 6 to 12 hours and gradually it contracts completely. This is an important mechanism for achieving hemostasis postoperatively.[Traction at the bladder neck also has the advantage of allowing normal involution of the prostatic fossa and thus aids in ensuring complete hemostasis which is a significant advantage over the technique of keeping inflated balloon in the prostatic fossa, wherein this normal involution is hampered and rebound hemorrhage is common. ratively.In contrast to packing of prostatic fossa which interferes with this normal involutory response, the Foley's balloon pressure traction technique not only allows the normal contraction of prostatic fossa but rather aids it.The balloon pressure traction technique is an effective method of achieving haemostasis and avoids blood transfusion in almost all of the patients thus treated. Hence, open prostatectomy with Foley's balloon pressure traction technique for BPH is an acceptable option with a high degree of safety and efficacy in areas where the TUR-P equipment or the surgical expertise is lacking and out of reach of rural population.


Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). Cardiovascular risk assessment in this population is hampered by the failure of traditional risk factors to fully account for the elevated CVD risk (reverse epidemiology effect) and the presence of emerging risk factors specifically related to kidney failure. Therefore, diagnostic tools capable of improving cardiovascular risk assessment beyond traditional risk factors are currently warranted. We present the protocol of a 4-year prospective study aimed to assess the predictive value of non-invasive imaging techniques and biomarkers for CVD events and mortality in patients with CKD.From November 2009 to October 2010, 4137 asymptomatic adult patients with stages 2 to 5 CKD will be recruited from nephrology services and dialysis units throughout Spain. During the same period, 843 participants without CKD (control group) will be recruited from lists of primary care physicians, only at baseline. During the follow-up, CVD events and mortality will be recorded from all CKD patients. Clinical and laboratory characteristics will be collected in a medical documentation sheet. Three trained itinerant teams will carry out a carotid ultrasound to assess intima-media thickness and presence of plaques. A composite atherosclerosis score will be constructed based on carotid ultrasound data and measurement of ankle-brachial index. In CKD patients, presence and type of calcifications will be assessed in the wall of carotid, femoral and brachial arteries, and in cardiac valves, by ultrasound. From all participants, blood samples will be collected and stored in a biobank to study novel biomarkers.The NEFRONA study is the first large, prospective study to examine the predictive value of several non-invasive imaging techniques and novel biomarkers in CKD patients throughout Spain. Hereby, we present the protocol of this study aimed to explore the most effective way in which these tests can be integrated with traditional risk factors to maximize CVD detection in this population. Cardiovascular disease (CVD) is the leading cause of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) ,2. This per se  - 13.6, where PWT is the posterior wall thickness, IVST is the interventricular septal thickness and LVEDD is the LV end-diastolic diameter. LV mass will be normalized to body height as an index in g/m2. LV hypertrophy will be defined according to Framingham's criteria  [A standard two-dimensional M-mode color Doppler echocardiography will be performed on CKD patients using a 3 MHz transducer . LV mass will be calculated as follows: 0.8 × [1.04 × (PWT + IVST + LVEDD)n males) . LV ejecSamples will be collected of whole blood into 10 ml EDTA vacutainers, maintained at ambient temperature and transported overnight to a centralized biobank named REDinREN . These samples will be processed immediately after their reception by a laboratory technique according to the biobank protocol . Plasma,The sample size needed to address the objectives of this study has been estimated with the following assumptions: alpha 5%, beta 10% (power 90%), loss to follow-up 25%, and revised incidence of CV outcomes at each CKD stage [P values <0.05 will be considered statistically significant.SPSS software (version 17.0) will be used for statistical analyses. Data will be presented as means ± SE for continuous variables and as frequencies or percentages for categorical variables. Differences in mean values will be assessed by analysis of variance and unpaired t-tests, or the Mann Whitney U-test when the variables have a skewed distribution. Categorical variables will be compared by using the Pearson chi-square or the Fisher's exact tests. The relationship between measured primary and secondary end-points will be analyzed by multivariate Cox regression. Survival curves will be constructed using the Kaplan-Meier method, and long-rank test will be used for exploratory univariate analysis of survival differences between groups. We will use ROC curves analysis to calculate the additional predictive value for CV outcomes of imaging parameters and biomarkers beyond and above that provided by traditional risk factors. Two-sided The present study is the first large, prospective, observational study to examine the usefulness of different non-invasive imaging techniques and biomarkers to predict CVD events and mortality in CKD patients throughout Spain. Given the paradoxical associations between traditional risk factors and CVD risk in patients with CKD, additional diagnostic tools are currently warranted to identify the real cardiovascular culprits. Hereby, we present the protocol of the NEFRONA study aimed to explore the most effective way in which these tests can be integrated with current clinical laboratory markers to maximize their synergism for CVD detection.CIMT is a well-documented surrogate marker of preclinical atherosclerosis, by which higher CIMT measurements have been associated with an increased risk of CVD . Severalvs. medial) in 202 HD patients using radiographs of the pelvis and the thigh. London et al [Vascular calcification is a common complication in CKD, and several investigators have demonstrated that presence and extent of vascular calcifications is an independent predictor of CV mortality -23. Inteon et al  found thCalcifications of cardiac valves have also been associated with an increased risk for mortality and CVD events in healthy populations . In CKD On the other hand, the collection of plasma, DNA and RNA samples in this study will contribute to a better assessment of CVD in renal patients. Although recent studies  suggest Overall, the NEFRONA study may provide new insights into the natural course, genotype-phenotype interactions and pathophysiology of CKD, providing new targets for early diagnosis and therapy for CVD in these patients. The present study has several strengths, including the large sample size nationally representative, the complete nature of the dataset, the existence of a central biobank, the use of clinically important primary end-points , the performance of all imaging techniques by three trained itinerant teams using a common protocol, and the large follow-up period of this study (4 years). Importantly, the longitudinal nature of the present study will allow us to determine the temporal and causal relationships among CVD risk factors, CKD, imaging parameters, and biomarkers. However, there are some limitations to our study. First, estimation of kidney function by determination of serum creatinine may be responsible for misclassification of some participants in the analyses by stage of kidney function; however, its determination will be made using the Jaffe kinetic method by all participating centers. Second, we will use estimated GFR rather than more precise measures of kidney function, like iothalamate clearance. Finally, prevalent dialysis patients will be included, which may introduce survival bias because of early mortality.In conclusion, the NEFRONA study will examine whether non-invasive imaging techniques and biomarkers may increase the predictive power to detect CV morbidity and mortality in asymptomatic CKD patients, beyond traditional risk factors. Moreover, the present study may enable us to understand the molecular mechanisms leading to atherosclerosis in these patients, contributing to the reduction of their morbimortality risk due to CVD.(CVD): Cardiovascular disease; (CKD): chronic kidney disease; (AHA): American Heart Association; (SHAPE): Screening for Heart Attack Prevention and Education; (ABI): ankle-brachial index; (PAD): peripheral arterial disease; (CIMT): carotid intima-media thickness; (GFR): glomerular filtration rate; (HD): hemodialysis; (PD): peritoneal dialysis; (MDRD): Modification of Diet in Renal Disease Study; (CKD-EPI): Chronic Kidney disease Epidemiology Collaboration; (BP): blood pressure; (ICD9-CM): International Classification of Diseases, Ninth Revision, Clinical Modification; (LV): left ventricular; (AS): atherosclerosis score.The authors declare that they have no competing interests.EF: Principal Investigator; the conception and design of the study; MJ and EF: the writing of the manuscript draft; MJ, TV, MM, BC, JV, MB, EF: participated in design and co-ordination; helped to draft manuscript; read and approved the final manuscript; MJ, TV, MM, BC, JV, JR, FS, MB, EF: critical review of the manuscript; MJ, MM: statistical expertise; EF, MJ, BC, JV: obtained funding.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2369/11/14/prepub


Patients with type-2 diabetes mellitus have greater carotid intima media thickness and they are at risk for generalized atherosclerosis. This study aimed to compare the thickness of carotid artery intima media in type-2 diabetes mellitus patients with and without nonblood pressure component metabolic syndrome.This was a comparative observational study conducted in the Departments of Pharmacology and Physiology in the College of Medicine, Al-Mustansiriyia University in cooperation with Baghdad Teaching Hospital.Forty-six diabetic patients of both sexes with systolic blood pressure < 130 mm Hg and diastolic blood pressure < 85 mm Hg were subjected to high resolution B-mode ultrasonography of the common and internal carotid arteries. Patients were grouped into those without metabolic syndrome (Group I) and with nonblood pressure component metabolic syndrome (Group II).The two-tailed unpaired Student's t-test was used in this study.Significantly high mean thickness was observed in the common carotid intima media (0.824 ± 0.155 mm) but not in the internal carotid arteries in group II patients compared to group I patients (0.708 ± 0.113 mm). Group II also had a significant number of patients with increased lesion intima media thickness (≥ 1.1 mm).The greater carotid intima media thickness observed in type 2 diabetes mellitus patients is related to the metabolic syndrome even in the absence of the blood pressure component. Measurement of carotid intima media thickness (IMT) using high-resolution B-mode ultrasonography is a noninvasive, well validated method to assess early cardiovascular disease.2 In type3et al. later found that after adjustment of other risk factors, the increase in carotid IMT was greater in elderly women who developed metabolic syndrome than in those who did not.[et al. found that the nonglucose component of metabolic syndrome did not correlate to increased IMT.[Hypertension, duration of diabetes, hyperglycemia, and dyslipidemia are associated with IMT and have been identified as significant risk factors for stroke.6 Increas3 did not. Bertoni ased IMT. Moreoverased IMT.This study aimed to demonstrate the association of increased carotid artery IMT with nonblood pressure component metabolic syndrome in T2DM patients.Subjects in this investigation were recruited from the vascular Doppler unit in Baghdad Teaching Hospital during the year 2005. An independent scientific committee revised and approved the study protocol and the information to be provided to the patients. Subjects' written consent was obtained prior to their enrollment in the study. The criterion of inclusion was T2DM. Patients were excluded if they had any previous history of ischemic stroke, hypertension, familial hyperlipidmia, history of angina, myocardial infarction, angioplasty, congestive heart failure, atrial fibrillation coronary bypass, carotid or peripheral vascular surgery, or renal insufficiency. Patients receiving oral hypoglycemic agents, antihypertensive (angiotensin-converting enzyme inhibitors or angiotensin receptor II antagonists) and antiplatelet were not excluded from the study.A total number of 46 subjects  aged 45 to 77 years were able to comply with the study protocol.Each patient was clinically examined at the time of initiation of the study. Three blood pressure measurements were taken on the right arm using an appropriately sized cuff with the subject in the seated position. Mean values were taken of the second and third blood pressure readings. Patients with systolic blood pressure ≤ 135 mm Hg and / or diastolic blood pressure ≤ 80 mm Hg were included in the study. Anthropometric measurements of body weight (kg) and height (m) were done. Body mass index (BMI) was calculated using Quetlet's index. Biochemical analysis included fasting plasma glucose, triglycerides, and high density lipoproteins.Subjects were categorized as having nonhypertensive components of metabolic syndrome when they had at least three of the following criteria:152Body mass index (BMI) ≥ 30 kg/mFasting plasma glucose ≥ 110 mg/dLFasting plasma triglycerides (TG) ≥ 150 mg/dLHigh density lipoprotein (HDL) ≤ 40 mg/dL (men) and ≤ 50 mg/dL (women)Accordingly, the subjects were assigned to two groups:Group I : diabetic patients without metabolic syndromeGroup II : diabetic patients with nonblood pressure component metabolic syndromeUltrasonography was performed with B-mode images of a high-resolution ultrasound scanner equipped with a 7 MHz linear array transducer. Anterior, antero-lateral, and postero-lateral projections were used to obtain images of the left and right common and internal carotid arteries.Arterial diameter and IMT measurements were done three times for each artery at each site. The average of three measurements of each cartotid artery diameter or IMT was taken; the coefficients of variation of these measurements ranged from 1.5 to 2.3%.P ≤ 0.05 as the lowest limit of significance.The results are presented as absolute number, percent, median, range, and mean ± SD. The data have been analyzed by using unpaired, two-tailed Student's t-test taking P < 0.001) high BMI , nonsignificant (P > 0.05) increases in fasting serum triglycerides , and significant (P < 0.05) decreases in high density lipoprotein  than group I patients [n = 17 vs 143.8 ± 15.3, n = 29 respectively) [P < 0.02) longer duration of T2DM . The number of smokers was higher in group II than in group I. Common and internal carotid arteries diameters were not significantly different in the two groups [Group II have significantly (patients . No signctively) . Howevero groups . Mean coo groups . Group Io groups .et al. who reported that blood pressure is the most important factor for significantly high IMT values in metabolic syndrome.[Type 2 diabetes mellitus patients with nonblood pressure component metabolic syndrome have significant greater mean common carotid IMTs than those who are free from metabolic syndrome. Significantly greater IMT is observed in the common carotid but not in the internal carotid artery of either side. Many cross studies have shown an association of metabolic syndrome with the thickness of the carotid intima media.17 Our stsyndrome.et al.[7et al. reported a higher IMT value (0.95 ± 0.31 mm) in diabetic patients than found in the present study.[et al. found that metabolic syndrome plays a crucial role in the development of recurrent stroke in diabetes patients with an odds ratio of 1.57.[As carotid IMT  is conset al.7 as well et al.7 Carotid et al.7 Accordinnt study. Possible of 1.57. The smok


Piezoresistive pressure measurement technique (PRM) has previously been applied for direct IAP measurement in a porcine model using two different devices. Aim of this clinical study was to assess both devices regarding complications, reliability and agreement with IVP in patients undergoing elective abdominal surgery.®-probe or an Accurate++®-probe . Probes were placed on the greater omentum and passed through the abdominal wall paralleling routine drainages. PRM was compared with IVP measurement by t-testing and by calculating mean difference as well as limits of agreement (LA).A prospective cohort study was performed in 20 patients randomly scheduled to receive PRM either by a Coach® and in 7/10 patients with Accurate++®. Analysis was carried out only for Accurate++®. Mean values did not differ to mean IVP values. Mean difference to IVP was 0.1 ± 2.8 mmHg (LA: -5.5 to 5.6 mmHg).There were no probe related complications. Due to technical limitations, data could be collected in 3/10 patients with Coach® were comparable to IVP, the device might be too fragile for IAP measurements in the clinical setting. Local ethical committee trial registration: EK2024Direct IAP measurement was clinically uneventful. Although results of Accurate++ Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been observed to occur in any patient population needing intensive care with an incidence rate of 37% and 7% respectively ,2.Intra-abdominal pressure (IAP) measurement has been recommended in patients at risk to develop IAH and ACS . The golIn a previously described porcine model two different devices capable of automatic continuous piezoresistive pressure reading measurement (PRM) were used for direct IAP measurement. Both, a probe to be connected to a handheld reading device and the other with the ability to perform a reset to the atmospheric pressure showed a high precision and a good agreement with bladder pressure measurement,10. AlthAim of the underlying study was to evaluate PRM for direct measurement with regard to feasibility, complications and agreement with bladder pressure measurement in patients undergoing elective abdominal surgery.With approval of the local ethical committee (document-nr. EK-2024) a prospective cohort study was performed between January and August 2003 at the surgical intensive care unit (ICU) of the Department of Surgery, University Hospital of the RWTH Aachen, Germany. The study was conducted in accordance with the study protocol, the Declaration of Helsinki and applicable regulatory requirements.Study participants were recruited from patients scheduled for elective abdominal surgery after informed and written consent was obtained on the day before surgery was performed. Study participants received colonic resection (n = 7), oesophageal resection (n = 4), pancreaticoduodenectomy (n = 2), gastrectomy (n = 4), liver resection (n = 2) and incisional hernia repair (n = 1). Patients were included if an abdominal drainage was placed and if postoperative ICU surveillance as well as placement of a Foley-catheter was deemed necessary due to the standard surgical procedure (not for study reasons).Excluded were patients with an age < 18 years, coagulation dysfunction, intraabdominal inflammation, liver insufficiency (Child-Pugh-stage B or C), renal failure with necessity for dialysis and inclusion in other studies.Measurement of IAP via piezoresistive pressure measurement was done with two different probes implanted in 20 patients in randomised order.®-system  was used. This system has been used for measurement of the pressure within the intramuscular compartment [In 10 patients the Coachpartment . It cons®-probe  was used. This probe has been designed to measure the intracerebral pressure. The pressure sensor of this probe is covered by a membrane and the outer diameter is 5 mm. The probe can be exposed to the atmospheric pressure allowing a reset to zero in-situ. APRM can be connected to every standard ICU-monitor without a special reading device. Pressure readings are displayed in mmHg. The probe is reusable after resterilization (120°C steaming for 20 minutes). After use in patients, both types of probes were mechanically cleansed and the function tested. If functioning correctly, they were sent to sterilization. Otherwise, they were sent to the manufacturer for repair.In another group of 10 patients the Accurate++2O were converted into mmHg by multiplication with 0.74.For hydrostatic intravesicular pressure (IVP) measurement in both groups, the tubing system, Foley catheter, and bladder were firstly flushed with 50 ml sterile saline. This fluid was completely drained leaving no air in situ before another 50 ml saline was injected serving as measurement volume. Using a standpipe, pressure readings were obtained at the end of the expiration. The level of the symphysis always served as reference and readings in cmH®) and were fixed to the skin with a suture. The probes were connected to the reading device (CPRM) or to the hemodynamic monitor (APRM) and the surgeon was asked to gently squeeze the probe with his fingers in order to test overall function of catheter and monitor. Afterwards, the abdomen was closed.For direct IAP measurement, CRPM or APRM probes were placed on the greater omentum in midline position cranial of the umbilicus at the end of the operation. Catheters were then passed through the abdominal wall paralleling the routinely used drainages  were calculated according to the method of Bland and Altman .Patients had a mean age of 57.1 years. The mean body weight was 75.4 kg with a mean body-mass-index (BMI) of 24.4.In one patient scheduled to receive CPRM, no signal could be retrieved intra-operatively due to a break in the conductive path. In six from the remaining 9 patients measurements had to be aborted ahead of schedule because of disconnection (2 patients) or offset-failure due to a fibrin-encrustration (4 patients). Thus, only 3 of 10 patients were examined according to protocol leading to an overall measurement rate of 0.3.In two patients scheduled for APRM readings did not change with application of manual pressure. In both cases, probes were not inserted. However, probes turned out to function properly afterwards as confirmed by the manufacturer. In one of the 8 remaining patients an offset-failure was observed. Accordingly, the overall measurement rate was 0.7.Postoperative course of all patients was uneventful. There were no signs of probe related organ lesion or surgical site infection. Withdrawal of the measurement probe at the end of the measurement period could be done uneventfully in all patients.®-probe was 0.1 ± 2.8 mmHg. Limits of agreement were -5.5 mmHg to 5.6 mmHg . The mean difference between IVP and AccurateDirect measurement of the intraabdominal pressure has been regarded to be invasive . In contIn the underlying study, placement of an intraabdominal measurement probe in patients undergoing elective abdominal surgery did not lead to adverse effects. This is in accordance to Brooks and co-workers, who recently evaluated a device for a direct and continuous assessment of IAP and reported no complications .The use of CPRM was associated with frequent technical difficulties during the study. Disconnection of this measurement system occurred in two patients. As a reset to the atmospheric pressure (zeroing) cannot be performed reliably in vitro, readings were not credible. Consequently, probes were withdrawn. Furthermore, malfunction was found in five patients.APRM in contrast was applicable in 7 of 10 patients and an offset-failure could be noticed in one case only. The other two malfunctions remain unclarified but could result from faulty operating of these sensitive devices. Exploring the occurrence of technical difficulties we could not assess a learning curve contamination bias.While pair wise measurements in CPRM were too sparse for a reliable analysis, only APRM could be used for altogether 21 recordings. Mean difference to IVP was 0.05 mmHg with limits of agreement ranging from -5.5 mmHg to 5.6. To our knowledge, this kind of piezoresistive pressure measurement probe has not been used for assessment of IAP yet.The consensus conference definitions and recommendations on IAH and ACS stated that a new IAP measurement technique should have a mean difference from -1 to 1 mmHg and limits of agreement within 4 mmHg . In thisRegarding the limited amount of measurements and a measurement rate of 0.7, it appears that APRM is basically capable to measure the IAP reliably but is probably too fragile for the setting of the underlying study. To improve the setting the probes may be put into the rectus abdominis muscle space in order to avoid fibrin-encrustration like Meier et al. explored in an experimental model . FurtherThe measurement volume has been described to falsely induce intrinsic pressure when exceeding 25 ml . MalbraiThe facility of continous IAP measurement using piezoresistive pressure monitoring may lead to a more frequent execution in the ICU. In this context we have to complement that there are several indirect techniques  of continous IAP monitoring .Intraperitoneal measurement of IAP was performed in 17 patients after elective abdominal without adverse effects. Regarding piezoresistive measurement probe with the possibility for in-vitro reset to zero, agreement with standard IVP was acceptable. However, the device might be too fragile for routine IAP measurements in the clinical setting.A.S. is Scientific Manager for B. Braun Melsungen, Germany which does not manufacture a commercially available kit for intra-abdominal pressure monitoring. The remaining authors have no financial involvement with any organization or entity with a financial interest in or in financial competition with the subject matter or materials discussed in the manuscript.J.O. and A.S. have made substantial contributions to conception and design. D.K. and M.J. have been involved in revising the manuscript critically for important intellectual content. M.B. and R.D. have made substantial contributions to acquisation of data. V.S. has been involved in analysis and interpretation of data and has given final approval of the version to be published.The pre-publication history for this paper can be accessed here:


The severity of associated soft tissue trauma in complex injuries of the extremities guides fracture treatment and decisively determines patient's prognosis. Trauma-induced microvascular dysfunction and increased tissue pressure is known to trigger secondary soft tissue damage and seems to adversely affect skeletal muscle function.20 patients with isolated tibial fractures were included. Blood pressure and compartment pressure (anterior and deep posterior compartment) were measured continuously up to 24 hours. Corresponding perfusion pressure was calculated. After 4 and 12 weeks isokinetic muscle peak torque and mean power of the ankle joint in dorsal and plantar flexion were measured using a Biodex dynamometer.A significant inverse correlation between the anterior perfusion pressure at 24 hours and deficit in dorsiflexion at 4 weeks was found for both, the peak torque  and the mean power . The posterior perfusion pressure at 24 h and the plantar flexion after 4 weeks in both, peak torque  and mean power  displayed a significant correlation.The functional relationship between the decrease in intramuscular perfusion pressures and muscle performance in the early rehabilitation period indicate a causative and prognostic role of early posttraumatic microcirculatory derangements and skeletal muscle function. Therapeutic concepts aimed at effective muscle recovery, early rehabilitation, and decreased secondary tissue damage, should consider the maintenance of an adequate intramuscular perfusion pressure. The severity of soft tissue trauma and the degree of secondary tissue damage, has a fundamental impact on the mid- and longterm prognosis of complex injuries to the extremities -3. The eAmong other factors, complete restitution of skeletal muscle contraction force, and the restoration of intramuscular energy resources are major determinants for the outcome. These influence the return of muscle function and determine the speed and success of rehabilitation. In particular, the direct impact of secondary fracture-associated soft tissue damage on long-term isokinetic skeletal muscle performance is only partly understood. Therefore, this study was aimed to quantitatively analyze the effect of soft tissue injury after isolated tibial fracture on the skeletal muscular outcome. This was assessed by measuring of the intramuscular perfusion pressure and the post-traumatic isokinetic muscle performance and recovery.Between June 2004 and May 2005, 20 patients with isolated unilateral, solitary closed and open fractures of the tibia diaphysis, were prospectively studied . The average age was 42 years (range: 25 to 65). All the in- and exclusion criteria were preset in a prospective study design prior to enrolment of patients. Due to the temporal profile of posttraumatic increase in tissue pressure, patients were only included if surgical treatment , started within the first 24 hours after trauma. Previous studies have demonstrated that the temporal profile of increase in intramuscular pressure in response to soft tissue trauma and/or fracture peaks within the first 24–48 hours ,14. In oPatients with closed Tscherne G3- and open Gustilo typ IIIB/C soft tissue damage, i.e. with impending/manifest compartment syndrome or traumatic ischemia were not entered into the study, as the often subsequently performed emergency fasciotomy and compartment decompression does not allow a valid intramuscular pressure measurement. Patients with an age of less than 18 years, or patients with multiple life-threatening injuries (polytrauma), or traumatic brain injury (no written consent available), additional fractures of the ipsi- and/or contralateral extremity, or patients who developed manifest compartment syndrome requiring fasciotomy within the first 24 hours, were also excluded. Due to the increased risk of progressive hematoma and bleeding by percutaneous insertion of the microsensor probe, patients with blood coagulation disorders and/or anticoagulative medication were not enrolled into the study. Exclusion and inclusion criteria are summarized in Table The criteria to plan surgical treatment followed the guidelines of the AO foundation . DecisioFractures were classified according to the AO classification of long bones . Soft tiant) and deep posterior compartment (IMPpost). Therefore, a CODMAN® microsensor  was used, placed at the level of the fracture line.Intramuscular compartment pressure (IMP) recordings were assessed prior to surgery, directly postoperatively, 2, 4, 6, 8, 10, 12, 16, and 24 hours after surgery in the anterior (IMPant/post = MAP - IMPant/post).  were monitored over 24 hours after trauma. The intramuscular perfusion pressure (PP) was calculated from the difference of mean arterial blood pressures, and the compartment pressure Throughout the entire study period and postoperative course, clinical signs of a compartment syndrome were monitored continuously. The diagnosis of acute compartment syndrome of the thigh, was based on the diagnostic criteria previously described for acute compartment syndrome ,20. DiagSerum levels of creatine kinase (CK), myoglobin, C-reactive protein (CRP), white blood cell count (WBC), haemoglobin (Hb) and haematocrit (Hct), were determined pre-operatively, one and four days after surgery.Muscle function was assessed using a Biodex dynamometer . Isokinetic peak torque and the mean power (considered as the endurance parameter) of the ankle joint in dorsiflexion and plantar flexion, were determined after 4 and after 12 weeks following injury. Peak torque was measured by five repetitions at a slow speed, (60°/s) while the mean power was assessed using 10 repetitions at an increased speed (120°/s). These tests were performed for both the uninjured, and the injured limb. Determined functional parameters for the uninjured limb were considered to be the patients individual muscle strength. Muscle function of the injured limb was expressed as a percentage of the uninjured one. All kinematical tests, were carried out by a research physiotherapist, who was blinded to the underlying compartment and perfusion pressure valuesThe Kruskal-Wallis, Wilcoxon rank-sum, and Spearman's rank correlation coefficient, were used for statistical analysis. A significance was specified for a p value lower than 0.05 for all statistical test methods.The patient characteristics and results of the AO fracture classification are shown in table None of the 20 investigated patients developed a clinically manifest compartment syndrome during the study period. Neither clinical suspicion, nor relevant persistent elevations of compartment pressures exceeding generally accepted limits , were foA positive correlation was shown, between the increase of serum levels of creatine kinase, and the perfusion pressure in the posterior compartment, 24 hours postoperatively . When studied, no further significant correlations were found, between perfusion pressure values, and serum levels of evaluated blood parameters.Figure ant was significantly increased (P < 0.05) when compared to the IMPpost, while the corresponding perfusion pressure was decreased (P < 0.05) (i.e. the perfusion pressure in the anterior compartment was significant decreased compared to perfusion pressure in the posterior compartment). In 6 patients, compartment pressures were temporary elevated over 40 mmHg, with an anterior pressure maximum of 63 mmHg after 2 hrs in one patient, which was measured in an anterior compartment. During the first 24 hours, all 20 Patients showed perfusion pressures higher than 40 mmHg.The IMPMean deficit (%) in dynamometric Biodex measurements for peak torque, and mean power in dorsiflexion and plantar flexion after 4 and 12 weeks, respectively, are given in table ant), 24 hours postoperatively, and the dorsiflexion after four weeks was shown for both the peak torque  and the mean power   in plantar flexion after four weeks  correlates significantly with the post traumatic muscle performance while absolute intracompartimental pressures alone did not. Perfusion pressure is, by taking into account the arterial blood pressure, i.e. the macrohemodynamic situation, a more valid parameter to reflect posttraumatic muscle tissue damage. As a result, an increased compartment pressure in combination with an adequate blood pressure appears to not be unavoidably related with a greater extent of muscle cell damage, risk of compartment syndrome, or an impaired post traumatic muscle performance. In our study, 6 patients had a temporary compartment pressure higher than 40 mmHg. In all of these patients, a sufficient perfusion pressure was calculated and existed. The later performed Biodex measurements in these patients corresponded to the perfusion pressure, while a relationship to compartment pressures was not shown. Despite an elevation in the compartment pressure, the evaluated peak torque and mean power results were in the range of the other patients. This notion is confirmed by an evaluation of skeletal muscle metabolism with nuclear magnetic resonance spectroscopy . The autIn a recent study, White et al. demonstrated, that a decrease of perfusion pressure to a lower limit of 30 mm Hg, and an elevated intramuscular pressure to an upper level of 70 mm Hg, is tolerated without significant adverse consequences . ObviousWe were able to show a significant correlation between the perfusion pressure after 24 hours and the functional outcome in muscle performance after 4 weeks. There was no correlation between muscle function and the intracompartimental pressure itself. Alterations in muscle perfusion, caused by primary and secondary soft-tissue damage were responsible for the substantial muscle dysfunction seen for up to 4 weeks following trauma. Obviously, monitoring perfusion pressure is far more superior and sensitive, in the assessment of post-traumatic effects on muscle performance and recovery. Therefore, effective treatment strategies must be made to ensure the restitution of nutritive perfusion and sufficient perfusion pressure. This is in order to prevent future deficits in muscle performance, and a delayed rehabilitation.