Physostigmine (0.6 μg/kg/min) resulted in higher cerebral blood velocity during tilt (90.5 ± 1.5%) than the equivalent neostigmine (85.5 ± 2.6%) or saline (84.8 ± 1.7%) trials (P < 0.05). This increase occurred despite a greater postural hypocapnia, suggesting physostigmine had a direct vasodilatory effect on the cerebral vasculature. Cerebral hypoperfusion induced by repeated tilts was eliminated by infusion of physostigmine not neostigmine. In conclusion, this study provides the first evidence that enhancement of central, not peripheral, cholinergic activity attenuates the physiological decrease in CBF seen during upright tilt. These data support the need for further research to determine if enhancing central cholinergic activity may improve symptoms in patients with symptomatic orthostatic intolerance.Cerebral blood flow (CBF) and consequently orthostatic tolerance when upright depends on dilation of the cerebral vasculature in the face of reduced perfusion pressure associated with the hydrostatic gradient. However, it is still unclear if cholinergic activation plays a role in this dilation. To determine if enhancing central cholinergic activity with the centrally acting acetylcholinesterase inhibitor, physostigmine would increase CBF when upright compared to the peripherally acting acetylcholinesterase inhibitor, neostigmine, or saline. We performed a randomized double-blind dose-ranging study that took place over 3 days in a hospital-based research lab. Eight healthy controls  were given infusions of physostigmine, neostigmine, or saline on three different days. Five-minute tilts were repeated at baseline (no infusion), Dose 1  and Dose 2 (0.6 μg/kg/min physostigmine or 0.3 μg/kg/min neostigmine), and placebo (0.9% NaCl). Cerebral blood velocity, beat-to-beat blood pressure, and end-tidal CO Orthostatic intolerance, which includes symptoms of lightheadedness, weakness, dizziness and presyncope, is a consequence of the inability to maintain cerebral perfusion when upright . While tThe upright posture results in a reduction in cerebral perfusion pressure due to the hydrostatic gradient , and thuCerebral vessels are densely innervated by parasympathetic nerves , 8 that To examine the role of the cholinergic system in cerebral vasodilation in healthy control participants during orthostatic stress, we administered the centrally acting, tertiary amine, cholinesterase inhibitor, physostigmine to enhance central cholinergic activity during orthostatic stress to determine if the CBF response to upright tilt would be improved. To control for the effects of increased peripheral cholinergic activity, we administered the quaternary amine, cholinesterase inhibitor, neostigmine, which does not cross the blood brain barrier. We hypothesized that cholinergic cerebral vasodilation would increase CBF in the upright posture.All procedures were approved by Beth Israel Deaconess Medical Center Committee on Clinical Investigations. All participants were consented by Dr. Jorge Serrador prior to participation in the study. Participants were given the consent form and the opportunity to read it. Then procedures were verbally explained by Dr. Serrador, and they were asked if they had any questions or concerns. After verbal confirmation was received that they understand the procedures and risks, they signed the consent form, and it was witnessed.Participants had no history of cardiopulmonary, renal, neurological or other systemic disease. Caffeine, alcohol, and heavy exercise were prohibited for 24 h prior to testing. A medical history, physical exam, and pregnancy test were performed on all participants.−1·min−1 physostigmine; 0.1 μg·kg−1·min−1 neostigmine), Dose 2 (0.6 μg·kg−1·min−1 physostigmine or 0.3 μg·kg−1·min−1 neostigmine), and Dose 3 (1.0 μg·kg−1·min−1 physostigmine or 0.5 μg·kg−1·min−1 neostigmine) or placebo (0.9% NaCl) for all three infusion levels . Drugs were mixed at the research pharmacy and provided in an unlabeled bag so that study staff and participants were blind to what infusion was being performed. Each test day consisted of baseline and three dosage levels: baseline (no infusion), Dose 1 , and anterior cerebral (CFVACA) arteries , and end-tidal CO2 (Datex-Ohmeda) was continuously recorded.Each test session comprised four 5-min tilts (60°) preceded by 10 min supine rest and followed by 5 min of recovery. Following each recovery period, the infusion was increased so that participants received a total of three dose levels and four tilts Figure . Heart r2 during testing including a 6 s delay between end-tidal and flow velocity changes. Plots were created of breath-by-breath end-tidal CO2 vs CFV was created over both the baseline, hypercapnia and hypocapnia periods. Cerebrovascular reactivity was determined as the linear best fit for the data.Signals were sampled at 500 Hz and processed using data acquisition (WinDaq) and analysis (MATLAB) software. Cerebrovascular reactivity was determined by plotting cerebral flow velocity vs end-tidal CObrain (BP at heart level minus hydrostatic gradient) was used to reflect cerebral perfusion pressure since intracranial pressure remains relatively unchanged . Data are presented as mean ± SEM, p < 0.05 considered significant.To examine the role of cholinergic activity on the cerebrovascular response to tilt, comparisons were made between drugs as well as dose and body position, i.e., supine vs upright. A three-way repeated-measures ANOVA was performed (Drug × Dose × Tilt), with a Bonferroni Eight participants  completed 12 tilts over 3 visits without developing presyncope.2 during the third tilt compared to the first (<1 mmHg difference), see Table Blood pressure while upright was similar during all tilts as was HR Figures . It also2 were unaffected by dosage level during the 5 min prior to tilt , when upright, was unaffected by dosage but diastolic BP increased. During Dose 3, the trial was stopped in one participant due to the development of nausea.Supine BP and end-tidal COlt Table . In cont2 and cerebral flow velocity were unaffected by dose level during the 5 min prior to tilt . This was determined by subtracting the autoregulatory CVR (CVR necessary to maintain 100% of baseline flow during pressure changes) from the actual CVR obtained during each tilt. Since measures of autoregulation (transfer function gains) demonstrated no changes with infusion (data not shown), we assumed autoregulation was intact. Comparison of the upright response during the first three tilts demonstrated that in contrast to the saline and neostigmine Dose 2 tilts where CVRNA was greater, during Dose 2 physostigmine CVRNA was lower, suggesting improved vasodilation, which would explain the better maintenance of cerebral flow velocity . Cerebrovascular reactivity was not significantly different between trials (P = 0.50) and did not differ between arteries (P = 0.70).Examination of middle cerebral and anterior cerebral artery velocity demonstrated that both arteries had similar changes associated with repeated tilt for both neostigmine and physostigmine Figure . Decreasvia physostigmine) attenuates the decrease in CBF associated with repeated exposure to short duration orthostatic stress.This study provides the first evidence that enhancement of central, not peripheral, cholinergic activity attenuates the physiological decrease in CBF seen during upright tilt. We also found that enhancing central cholinergic activity  cerebral vessels have dense cholinergic innervation ; (2) stiWhile no previous work has examined the effect of physostigmine on the cerebrovascular response to orthostatic change, pyridostigmine, which does not cross the blood brain barrier, improves standing BP in patients with orthostatic hypotension due to autonomic failure  and atteThus, the role played by cerebral cholinergic vasodilatory mechanisms in the features of orthostatic tolerance in autonomic failure patients is not known. The present data raise the possibility that cholinergic activation may enhance CBF. Whether this enhancement of CBF could then improve symptoms of orthostatic intolerance in this patient population needs to be examined. Further work is required to confirm this in patients and determine the dose–response given the narrow therapeutic window.However, some support for a role for CBF in orthostatic intolerance in these patients is provided by examining current treatments. Midodrine, which has been found to be effective for treating orthostatic intolerance, has also been shown to increase CBF in patients with chronic hypotension  and spinIt is interesting that Does 2 of physostigmine resulted in higher HRs when upright. We would expect that physostigmine should reduce HR since it enhances cholinergic inputs to HR control. However, previous work in humans has also found that physostigmine infusion results in increased HRs , 40. TheSeveral other explanations for the increase in CBF can be considered. If participants had impaired autoregulation, an increase in MAP during physostigmine infusion could have resulted in increased cerebral flow; however, there was no significant increase in pressure seen. Also, we did not find any indications of impaired autoregulation, which is consistent with evidence in primates where direct parasympathetic stimulation results in cerebral vasodilation without affecting autoregulation .In addition, middle cerebral artery flow was increased during the last minute of tilt during the lowest physostigmine dose Figure , suggestOne limitation of this study is we were unable to assess sex differences due to the small number of participants (six women vs two men). Previous research has demonstrated CBF regulation may differ between women and men with older women demonstrating better cerebral autoregulation  and younThis work provides the first evidence that increasing central cholinergic activity improves the maintenance of CBF in the upright posture in healthy participants. These data raise the interesting possibility that use of centrally acting acetylcholinesterase inhibitors may improve symptoms in patients with symptomatic orthostatic intolerance. Further, work in patient populations is necessary to determine whether enhancing central cholinergic activity will improve CBF and if this could possibly reduce symptoms of orthostatic intolerance.JS and RF conceived and designed the study, interpreted the data, and wrote the manuscript. JS performed the study, analyzed the data, had full access to all of the data in the study, and took responsibility for the integrity of the data and the accuracy of the data analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We aimed to explore the diagnostic value of urinary microalbumin (mALB) level in postpartum acute kidney injury.A total of 127 maternity patients were selected from December 2013 to January in 2016 in Binzhou Central Hospital, Binzhou, Shandong, China and divided into two groups: the kidney injury and normal kidney group. The dynamic changes and diagnostic value of urine microprotein in postpartum acute kidney injury were analyzed.P<0.05). The mean age of the kidney injury group was 32.3 ± 11.6 years, which was significantly higher than that of the normal kidney group (P=0.006). In the kidney injury group, the postpartum glomerular filtration rate (GFR) was 78.4 ± 11.5 mL/min, which was significantly lower than the normal group (P=0.001), and urinary microalbumin was 2.87 ± 1.24 mg/mmol·Cr. The difference was statistically significant (P=0.002). mALB/GFR, Cr, urinary mALB, and GFR were the independent risk factors of postpartum acute kidney injury. The area under the ROC curve for mALB/GFR was 0.759, whereas the area under the ROC curve for Cr was 0.681, which was smaller (P = 0.042). The area under the ROC curve of mALB was 0.785 (P=0.027), which was close to the area under the ROC curve of mALB/GFR.The postpartum mean arterial pressure of maternity patients in the kidney injury group was 104.3 ± 11.6 mmHg, which was significantly higher than that of the normal kidney group (Urinary mALB test is noninvasive and has high diagnostic value for postpartum kidney injury. Postpartum acute kidney injury is a clinical syndrome denoted by decreased glomerular filtration rate (GFR), increased proteinuria, and renal dys-function from a variety of causes. However, patients do not present with apparent clinical manifestations of renal dysfunction during pregnancy or before giving birth . Unlike According to our clinical observations, postpartum blood urea nitrogen (BUN) and creatinine (Cr) were high to some extent in maternity patients without postpartum kidney injury, which might be associated with birth injury or muscle contraction. The false positive results derived from the aforementioned situations can be distracting for early diagnosis of postpartum acute kidney injury. Urinary microalbumin (mALB) is a noninvasive diagnostic marker that has previously been shown to have good sensitivity and specificity  for the The aim of the present study was to investigate the clinical value of urinary mALB in the diagnosis of postpartum acute kidney injury.A total of 127 maternity patients with normal labor in the Obstetrical Department of Binzhou Central Hospital, Binzhou, Shandong, China were selected from December 2013 to January 2016. Among the 127 maternity patients, 31 experienced elevated kidney function that lasted 48 h without apparent improvement, and were diagnosed with postpartum acute kidney injury. The maternity patients were divided into two groups: the kidney injury group and normal kidney group. Informed consent was obtained from the patients and their families. The inclusion criteria were as follows: 1. over 22 years old; 2. full term, normal labor; 3. diagnosis of acute kidney injury. The exclusion criteria were as follows: 1. prenatal kidney injury or suspected kidney injury; 2. preterm labor or induced labor; 3. test results were severely affected by postpartum lochia contamination.The study was approved by the Ethics Committee of Binzhou Central Hospital and written informed consents were signed by the patients and/or guardians.The diagnostic criteria for acute kidney injury were as follows: 1. a clinical syndrome characterized by sudden (1–7 d) and sustained (>24 h) reduction in renal function; 2. An increase of serum creatinine (SCr) by over 0.5 mg/dL; 3. Showing clinical symptoms of azotemia, and disturbances of water-electrolyte and acid-base balance; 4. May present with oliguria (<400 mL/24 h or 17 mL/h) or anuria (<100 mL/24 h).Midstream fasting urine samples (10 mL) were collected in the morning from maternity patients, 24 h before and 48 h after labor. Urine samples were centrifuged at 1,500 rpm for 10 min, and the supernatant was collected to test for physiological parameters such as urinary mALB, Cr level, GFR, urine glucose (GLU), and white blood cell count (WBC). Among these tests, urinary mALB was determined with a rate nephelometric immunoassay using a Beckman Array Protein System 360. The measurement was carried out according to the manufacturer’s instructions and the urine mALB kit . According to the reference range provided by the manual, an albumin level of higher than 19.0 mg/L was regarded as positive. For blood tests, peripheral blood samples were collected from maternity patients 24 h before and 48 h after labor. Blood samples were centrifuged at 4°C, and the supernatant was collected for measuring BUN. Except for mALB, the other urine and blood tests were performed using an Abbott Architect C16000 clinical chemistry analyzer. Mean arterial pressure (MAP) was measured using a YUWELL YE680A electronic sphygmomanometer.2-test was used for comparisons between groups. P<0.05 was considered statistically significant. Pearson’s correlation coefficient was used for correlation analyses. Multivariate analysis was performed using the logistic regression model. The diagnostic value of the urinary mALB test in postpartum acute kidney injury was evaluated by log-rank test.Statistical analysis was performed using the SPSS 13.0  software package. Experimental data are presented as mean ± standard deviation. Independent samples χP>0.05). The mean age of the kidney injury group was significantly higher than that of the normal kidney group (P<0.05), (There were no significant differences in the numbers of pregnancies and deliveries between the two groups (P<0.05), .P<0.001). There were no significant differences in the levels of GLU and WBC before and after labor in the two groups .As shown in Unconditional multivariate logistic regression analysis was carried out, in which the independent variables were those shown by univariate analysis to be statistically significant, such as MAP, mALB/GFR, Cr, mALB, BUN, and GFR. The dependent variable was the occurrence of postpartum kidney injury . As shown in An ROC curve was plotted to analyze the diagnostic value of the commonly used parameters of renal function  for postpartum acute kidney injury .P<0.001), whereas the area under the ROC curve for Cr was 0.681, which was smaller . The area under the ROC curve of mALB was 0.785 (P<0.05), which was close to the area under the ROC curve of mALB/GFR (P<0.01).The area under the ROC curve for mALB/GFR was 0.759 , IgG, and α-1-microglobulin. Microalbuminuria refers to the presence of microalbumin in urine . AlbuminP<0.001) than those of healthy non-pregnant women as measured by rate nephelometry  were significantly higher  have been completely observed by the authors.


To study urethral pressure variations during the whole filling phase among different groups of patients.2O were considered as ‘urethral instability’. We investigated 79 consecutive patients from January 2011 to June 2012. All patients were recruited within our routine practice in our continence clinic and were evaluated with urodynamic exam according to the standards of the International Continence Society (ICS) with an additional continuous measurement of the urethral pressure profile (cUPP) that was done in a supine position. Patients with genital prolapse >grade I, as well as patients with impaired cognitive function or neurogenic disorders were excluded. Bacteriuria at the time of investigation was excluded by urine analysis. Urethral pressure changes higher than 15cmH From 79 investigated patients, 29 were clinically diagnosed with OAB syndrome, 19 with stress urinary incontinence (SUI) and 31 with mixed (OAB and SUI) incontinence. The prevalence of ‘urethral instability’ as defined in this study was 54.4% (43/79). The mean Δp in patients with OAB (36.5cmH2O) was significantly higher (p<0.05) than in groups with pure stress (14.9cmH2O) and mixed urinary incontinence (19.3cmH2O). Etiology of ‘urethral instability’ is unknown, but high prevalence among patients with overactive bladder syndrome, especially concomitant with detrusor activity can raise a fair question and direct further diagnostic as well as treatment efforts. Overactive bladder (OAB) syndrome has a great impact on health-related quality of life with a high prevalence of up to 13%, in the female population over 18 years . But at Ethical approval (EK 085/11-Universityclinic Aachen) and patient consent was obtained and studies were done in accordance to the declaration of Helsinki. The study evaluated 79 consecutive female patients with lower urinary tract symptoms (LUTS), including signs of overactive bladder syndrome (OAB), stress (SUI) and mixed urinary incontinence (MUI). Patients were referred to the Continence clinic of the University Hospital (RWTH) Aachen, an interdisciplinary unit for incontinence diagnostics. Period of enrollment was from January 2012 through June 2012.Patients with genital prolapse >grade I, as well as patients with impaired cognitive function or neurogenic disorders were excluded. Bacteriuria at the time of investigation was excluded by urine analysis. All patients underwent pressure/flow studies followed by a conventional urethral pressure profile measurement with a triple lumen 9Fr catheter and a continuous urethral pressure profile (cUPP) registration for 60s during a second complete filling phase with the catheter positioned at the site of the maximum urethral closure pressure. The bladder was filled with medium filling speed of 15 to 30mL/min. The cUPP was done in a supine position to reduce movement artifacts and the patient was asked to lie relaxed without movement if possible. Throughout the investigation, pelvic floor electromyography (EMG) was registered by surface electrodes.2O were defined as ‘urethral instability’ (2O), maximum urethral closing pressure (cmH2O), minimum urethral closing pressure (cmH20) and functional urethral length were determined for each patient group .The difference between the highest and lowest urethral pressure during cUPP was calculated. A urethral pressure drop with urgency to void before micturition was neglected, because focus of analysis was on the cUPP during filling phase. Urethral pressure variations exceeding 15cmHability’ -12. UretThe 60s of raw data was obtained through the ASCII-exportation of Laborie UDS data into a standard spreadsheet program and included time and corresponding urethral pressure with a sample rate of 10Hz. Area under the curve (AUC) was calculated with the trapezoidal rule and corresponding minimum pressure values. Data were pooled for every patient group .ura into the frequency domain and thereby allowed the reviewer to visualize, from the spectral density perspective, the frequency content of the signal under review. While no specific frequency component was expected to be identified during a ‘urethral instability’, we were looking for large clusters of frequency content to be uniquely differentiated from normal Pura measurements. The FFT samples were calculated and plotted for a visual review.Raw data were used for the application of Fast Fourier Transform (FFT) and graphic functions. Basic control data  was also used to validate the FFT process to ensure that the frequency domain transformation was correct. Applying a Fast Fourier Transform (FFT) converted the temporal information of PStatistical analysis was performed using NCSS  and GraphPad Prism Ver. 5 . Data were analyzed using the Shapiro-Wilk normality test and non-parametric Mann-Whitney u-test. Relationship between ‘urethral instability’ and functional urethral length was quantified by Spearman-rank test and Pearson r-squared correlation. A p-value of <0.05 was considered statistically significant. All statistical tests reported in this study were two tailed.Of the 79 female patients, 29 presented with OAB syndrome, 19 with SUI and 31 with mixed (OAB and SUI) symptoms. Patient’s characteristics are shown in 2O) in this cohort was 54.4% (43/79). For those with OAB syndrome, ‘urethral instability’ occurred in 23 of 29 (79.3%) patients, in 9 of 19 (47.4%) of those with stress incontinence and in 11 of 31 (36.6%) with mixed incontinence. Typical urodynamic traces of a patient with OAB and DO and a patient with SUI without DO are shown in The prevalence of ‘urethral instability’ (pressure variance over 15cmH2O) was significantly higher (p<0.05) than in groups with pure stress (14.9cmH2O) and mixed urinary incontinence (19.30cmH2O) (2O (mean±SD) was significantly higher than in OAB patients without DO (45.2±30.65cmH2O) (p<0.05) (The mean Δp (delta pressure) in patients with a sensory component related to OAB syndrome (36.5cmH30cmH2O) . Patient(p<0.05) .The analysis of the area under the curve showed that urethral pressure curves of OAB patients are in sum either longer or higher than those of mixed or stress urinary incontinence (1195.7±985.6 (OAB) vs. 429.3±214.5 (MUI) vs. SUI 549.4±273.0 (SUI) .Statistical analysis revealed significant differences with p<0.005 (OAB vs. MUI) and p<0.01 (OAB vs. SUI). Fast Fourier Transformation generated FFT-Plots for every patient and visual review revealed higher magnitudes and more peaks in the range of 0-0.5Hz within the group of patients with OAB .Our study revealed that patients with OAB have statistically significant higher range of urethral pressure variation than in SUI and MUI patient groups, moreover we found that in patients with OAB and concomitant DO urethral pressure variation range was even higher than without DO (p<0.05) .2O, which provoked urge , the focus regularly lies on the bladder pressure changes neglecting the fact that in the process of urine storage, the external urethral sphincter may play an important role. In 1959, the “guarding reflex” by the external urethral sphincter was brought into discussion by Garry et al. and was attributed a main role in prohibiting stress incontinence . Referriked urge . Neverthked urge . Moreoveked urge . Despite finding -12 the sIn accordance with our own data, Sørensen et al. demonstrated that mean maximum urethral pressure and the mean maximum urethral closure pressure are significantly reduced in women with stress incontinence compared to women with detrusor overactivity .Our study is not without limitations. First limitation is in the study design-small sample size, absence of assessors blinding, absence of a healthy patients group. Second is that the neurophysiologic explanation of urethral pressure variation is unclear. Urethral pressure variation may be caused by diminished sympathetic influence or by increased parasympathetic activity. It has been reported that neuronal nitric oxide (NO) synthase, known for its significant role in nociceptive pathways in the bladder has also been found in human female striated urethra sphincter . It may Further investigation of urethral pressure variation with high-speed urethral pressure urodynamics will let to sample at up to 1000Hz and not 10 to 50Hz used today in conventional equipment and possibly shed some more light on that issue.Given the growing relevance of OAB syndrome and widely expanding armamentarium of treatment modalities and drugs as well the outcomes are still quite disappointing  and it s


The hemodynamic effects of intravenous (IV) paracetamol in patients undergoing cardiac surgery are unknown. We performed a prospective single center placebo controlled randomized study with parallel group design in adult patients undergoing elective cardiac surgery. Participants received paracetamol (1 gram) IV or placebo  preoperatively followed by two postoperative doses 6 hours apart. The primary endpoint was the absolute change in systolic (SBP) 30 minutes after the preoperative infusion, analysed using an ANCOVA model. Secondary endpoints included absolute changes in mean arterial pressure (MAP) and diastolic blood pressure (DPB), and other key hemodynamic variables after each infusion. All other endpoints were analysed using random-effect generalized least squares regression modelling with individual patients treated as random effects. Fifty participants were randomly assigned to receive paracetamol (n = 25) or placebo (n = 25). Post preoperative infusion, paracetamol decreased SBP by a mean (SD) of 13 (18) mmHg, p = 0.02, compared to a mean (SD) of 1 (11) mmHg with saline. Paracetamol decreased MAP and DBP by a mean (SD) of 9 (12) mmHg and 8 (9) mmHg (p = 0.01 and 0.02), respectively, compared to a mean (SD) of 1 (8) mmHg and 0 (6) mmHg with placebo. Postoperatively, there were no significant differences in pressure or flow based hemodynamic parameters in both groups. This study provides high quality evidence that the administration of IV paracetamol in patients undergoing cardiac surgery causes a transient decrease in preoperative blood pressure when administered before surgery but no adverse hemodynamic effects when administered in the postoperative setting. Paracetamol  is ubiquitously used in hospitals as an antipyretic and analgesic. It is frequently administered intravenously (IV) to patients undergoing major surgery and to critically ill patients, where oral intake and rectal suppositories may not be possible . IntraveHowever, in both a healthy volunteer setting , in critth March 2013. The Austin Health Research and Ethics Committee approved this study on June 6th 2013 (number: 05006/2013). The first participant was enrolled on 7th June 2103 and the last participant enrolled on 19th November 2014. We registered the study with the Australian New Zealand Clinical Trials Registry on 19th October 2015 (number: ACTRN12615001099516). Registration was approved retrospectively due to an inadvertent and genuine error in submission. The authors confirm that all ongoing and related trials for this drug/intervention are registered.The study design and final Trial protocol was completed on 26st July 2013 and 14th October 2014, we conducted a prospective, double-blind, single center, placebo controlled randomized study with a two-arm parallel group design at a university metropolitan hospital with a dedicated cardiac surgery service. Participants were identified from elective cardiac surgery waiting lists. Inclusion criteria included adult patients undergoing elective primary coronary artery bypass grafting (CABG) or valve surgery. Exclusion criteria included administration of paracetamol or non-steroidal anti-inflammatory drugs within 24 hours of surgery, caffeine consumption less than 10 hours prior to surgery, pregnancy, derangement in any liver function test, severe chronic renal impairment (preoperative creatinine >150 μ L-1) and morbid obesity (body mass index >35 kg m-2).The study was conducted according to the principles expressed in the Declaration of Helsinki. All participants provided informed written consent. Between 1-1 and fentanyl IV 0.5 ug kg-1 for mild pre-operative sedation. Local anesthesia solution was used for the insertion of all invasive lines. Using a standardized technique, all patients had a 15cm 20G arterial line  inserted into their non-dominant brachial artery for continuous blood pressure measurements, and a continuous cardiac output pulmonary artery catheter  inserted via the right internal jugular vein for continuous cardiac output, central venous (CVP) and pulmonary artery pressure measurements. After the insertion of invasive lines, participants were placed 15-degree head up, with their head resting on a pillow for comfort. The use of a forced air warming device, IV fluids, or any other medications, were prohibited to avoid confounders.All patients were fasted two hours for clear fluids and six hours for a light meal. Preoperative data collection was conducted in a dedicated anesthesia monitoring room, with standardized illumination intensity and noise, and with an ambient air temperature set to 21°C. On the day of surgery, an independent clinical pharmacist prepared three 100 mL IV infusions, which contained paracetamol (1 g paracetamol + 3.91 g mannitol/100 mL) , or saline 0.9% (100 mL) (placebo)  as a control. On arrival, participants were placed on a standard operating table and administered midazolam IV 0.025 mg kg-1 min-1 m2; Cardiac index: 2.5–4.0 L min-1 m2; HR: 60–90 beats min-1.Participants were given a 15 minutes stabilisation period before baseline hemodynamic measurements were recorded. The paracetamol or saline infusion was then administered over a 15 minute period. After a 30 minute observation period participants were then transferred into the operating room and underwent anesthesia and surgery as per standard anesthesia and surgical care. Postoperatively, all participants were transferred to the intensive care unit (ICU) for routine care. One hour after arrival two further doses paracetamol or placebo were administered over a 15 minute period, each 6 hours apart. The primary endpoint was the absolute change in systolic blood pressure (SBP) 30 minutes (T30) after the infusion of paracetamol or saline. Secondary endpoints included changes in mean and systolic blood pressures, cardiac index, pulmonary artery pressures, systemic vascular resistance index (SVRI) and heart rate (HR). Pulmonary artery pressure was measured directly from the pulmonary artery catheter. Cardiac index was measured continuously via the continuous cardiac output pulmonary artery catheter. Systemic vascular resistance index was calculated from the MAP, CVP and cardiac index using standardized formulae. Normal reference values for the endpoints were: MAP: 70–105 mmHg; SBP: 100–140 mmHg; DBP: 60–90 mmHg; SVRI: 1970–2395 mmHg LMeasurements were recorded at the following time points after the baseline measurement: i) 5 (T5), 8 (T8), 15 (T15) and 30 (T30) minutes after the start of the preoperative infusion and ii) 15 (T15) and 30 (T30) minutes after the start of the postoperative infusions, with hourly measurements for six consecutive hours. Other data collected included baseline patient characteristics, intraoperative use of fluids and vasoactive medications, cardiopulmonary bypass time, aortic cross-clamp time, surgery duration, postoperative use of fluid and vasoactive medications during, ventilator times, and length of ICU and hospital stay. Study participants, surgeons, anesthetists, nurses and all peri-operative staff were blinded to treatment assignments. The randomization sequence was decoded only after data analysis.https://www.stat.ubc.ca). With a mean preoperative systolic blood pressure of 135 mmHg, and a SD of 10mmHg, assuming two-tailed alpha value of 0.05, the total sample of 36 participants  would yield 80% power to demonstrate the clinically important difference between the paracetamol and saline group of 10 mmHg, assuming common variance between the groups. To allow for violations or breaches in the study protocol, we received ethics approval to recruit 50 participants. An independent statistician generated a computerized sequence of 50 allocation codes, 25 for each group via 5 randomly permuted blocks of 10 participants each. We used a first plan generator (randomization.com) using treatment labels as “Paracetamol” and Saline” with the initial participant identification number being 1. Independent pharmacy staff received the randomization order and prepared all study drugs along with sealed allocation codes in sequentially-numbered opaque envelopes. All study participants and researchers were blinded to these codes until the end of data collection.Sample size calculations were based on our institution’s pilot data evaluating patients undergoing cardiac surgery. We used inference for means comparing two independent samples with a t test  were analysed using an ANCOVA model. For the primary end point, we used the SBP value at 30 min as an outcome, the treatment group as a factor, and the baseline SBP value as a treatment covariate. In addition, longitudinal data modelled over time were analysed using random-effect generalized least squares regression modelling (GLS) due to the repeated measures nature of the data. Both the effect of treatment adjusted for time and treatment-by-time interaction were estimated using respective GLS models. We tested two separate questions: “what is the average difference in the outcome between the groups (adjusting for time)?”—this is the group effect, and “is the rate of increase/decrease in outcome over time similar or different between two groups?”—this is the time-by-treatment interaction. Model adjustments for patient’s age, body mass index (BMI), gender and Euroscore (for pre-operative dose) and for age, BMI, gender, Euroscore, surgery duration, cardiopulmonary bypass, aortic cross-clamp time, fluid intervention and vasoactive medications (for post-operative doses) were performed to estimate the robustness of the results. The study was reported in accordance with the CONSORT Guidelines for reporting randomized trials . No chanSixty-one participants were screened for eligibility, eight patients required more complex cardiac operations and were withdrawn, and three patients had surgery cancelled. Twenty-five participants were randomized to IV paracetamol and twenty-five participants to saline . There wRegarding the primary end point, the absolute mean (SD) change in systolic blood pressure 30 minutes after the infusion of paracetamol or saline was -13 (18) mmHg and for saline was -1 (11) mmHg. The mean between-group difference (estimated from the linear mixed effects model) in absolute change at 30 min adjusted for the baseline values was -11 mmHg . There were no significant changes in SBP between the groups after adjustments for age, BMI, gender and Euroscore. Between baseline and 30 minutes after the infusion, there were a total of 14 hypotensive events i.e. reduction of ≥ 20% SBP from the baseline value, all of which occurred in paracetamol group. These events were self-limiting in all but 2 patients, who both required treatment with a single dose of intravenous metaraminol (0.5mg). Changes in SBP are presented graphically in -1 cm-5 m2 in the paracetamol group compared to 166 dynes sec-1 cm-5 m2 in the saline group (p = 0.20). Analyses of cardiac index, pulmonary artery pressures, SVRI, and HR showed no statistical significance in their interaction between the treatments over time. Changes DBP and MAP after the preoperative dose from baseline to the 30 minute (T30) endpoint are presented graphically in Figs Paracetamol also decreased MAP and DBP by a mean (SD) of 9 (12) mmHg and 8 (9) mmHg compared to a mean (SD) of 1 (8) mmHg and 0 (6) mmHg, respectively with saline (p = 0.01 and 0.02). SVRI decreased by 332 dynes secAfter the two postoperative infusions of paracetamol there were no significant differences in pressure or flow based hemodynamic parameters compared to saline. Analyses of cardiac index, pulmonary artery pressures, SVRI, and HR also showed no statistical significance in their interaction between the treatments over time. After adjustments for age, BMI, gender, Euroscore, surgery duration, cardiopulmonary bypass time, aortic cross-clamp time, use of fluids and vasoactive medications, there were still no hemodynamic differences between the groups. Longitudinal data of the endpoints of the infusion of paracetamol after cardiac surgery are presented in S5 and S6 Tables. The mean (SD) length of ICU stay was 47.0 (22.4) hours in the paracetamol group and 43.8 (26.7) hours in the saline group (p = 0.13). Duration of hospital stay was 8.8 (4.1) days in the paracetamol group vs. 10.4 (6.9) days in the saline group (p = 0.03).We performed a randomized blinded controlled trial comparing the effects of IV paracetamol and placebo  on hemodynamics during and after cardiac surgery. This study provides plausible physiological evidence that the preoperative administration of 1 gram IV paracetamol administered before induction of anesthesia in patients awaiting cardiac surgery, causes a transient decrease in preoperative blood pressure 30 minutes after the start of infusion. However, administration of two consecutive six hourly paracetamol doses given after surgery, caused no significant hemodynamic adverse effects, findings similar to Avellaneda et al., who administered 1 gram of propacetamol (a prodrug of paracetamol) after tracheal extubation post-elective cardiac surgery and observed no clinically significant impairment in hemodynamic function .Recently, the use of IV paracetamol in the context of cardiac surgery has been examined. Douzjian and Kulik  providedIn the context of critical illness, multiple clinical studies have suggested that IV paracetamol may cause hypotension –13. MostIn contrast, in the context of critical illness, Krajcova et al., found IV paracetamol produced a reduction of MAP. However, there were only 6 patients in this study . More reWe have demonstrated in the present study, that similar to our previous findings  and thosFinally, in a recent large randomized controlled trial regular paracetamol was given to critically ill patients with fever or suspected infection  however,Our study has several methodological strengths compared to previous studies. It is blinded and randomized, thus minimizing allocation, selection and assessment bias and increasing internal validity. All hemodynamic variables measured were assessed invasively and were not amenable to ascertainment bias or derivation. The concealment of the intervention to all clinicians further decreased bias. The standardisation of study setting during the pre-operative period was strictly adhered to in all patients, ensuring accuracy of hemodynamic data in the absence of analgesic, anesthetic, vasoactive drugs and IV fluids, all of which could confound the measurements of blood pressure. Finally, we used robust statistical methods to adjust for important variables that frequently impact on blood pressure in a cardiac surgical setting. There are also come limitations to our study. First, observations were only continued for 30 minutes after the first administration preoperatively. Extending this study time beyond 30 minutes would have delayed surgery, therefore was not approved by our ethics committee. As evident from In summary, in a randomized blinded trial comparing the effects of IV paracetamol and placebo  on hemodynamics before and after cardiac surgery, we found that the preoperatively administration of paracetamol caused a transient decrease in blood pressure, but that six-hourly postoperative administrations caused no significant hemodynamic adverse effects. Our findings provide plausible physiological evidence that the administration of IV paracetamol should be used cautiously before cardiac surgery but can be safely used when clinically indicated after elective cardiac surgery, without adversely impacting hemodynamics.S1 Protocol(PDF)Click here for additional data file.S1 Checklist(DOC)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.S1 TableData analysed using a random-effect generalized least squares regression model.(DOCX)Click here for additional data file.S2 TableData analysed using a random-effect generalized least squares regression model. Changes in postoperative.(DOCX)Click here for additional data file.S3 TableData analysed using random-effect generalized least squares regression model.(DOCX)Click here for additional data file.


Current conventional wisdom suggests that when it comes to good blood pressure control, the lower the better. However, because a pressure of zero over zero is incompatible with life, there would appear to be a J-shaped curve and therefore there must be a point at which lower is not necessarily better.‘This implies that we need to identify the nadir of that curve to ensure that we don’t inadvertently increase risk when lowering blood pressure by intervening too intensively’, said Dr Meredith. He was addressing a meeting at the South African Heart Association’s annual conference at Sun City in August.Most blood pressure treatment is guided by epidemiological data that suggest that for every 20-mmHg rise in systolic blood pressure, there is a doubling of cardiovascular mortality risk. Dr Meredith feels that too much of current practice is guided by data that might well be inappropriate. ‘We can’t be certain of the therapeutic implications and it requires a leap of faith to translate epidemiology into treatment, especially in the case of blood pressure that is not especially high to begin with. Matters are complicated by the fact that patients are not homogeneous. Heart failure patients, for example, are not the same as hypertensives and in the context of heart failure, higher blood pressure is indicative of better cardiac function. A cautious approach is therefore needed in these patients, and all factors need to be monitored.’Dr Meredith cited a number of studies, but underscored their limitations. ‘We really need outcomes trials, of which there are a relative paucity. As a result, much of what we think we know is based on retrospective interpretations of existing trials.In a 1987 study, Cruickshank argued that the J-shaped curve was more apparent in ischaemic heart disease. In the INVEST study, Messerli found that a diastolic blood pressure lower than 70 mmHg was associated with an increased risk of myocardial infarction, an interesting but far-from-definitive finding.Sleight’s analysis of the ONTARGET trial showed that while higher blood pressure was associated with a linearly higher stroke risk, when it came to composite outcomes , there was virtual equivalence between those with the highest and lowest blood pressures, seemingly supporting the idea of the J-shaped curve.’Dr Meredith was directly involved in a similar post-hoc analysis of the ACTION trial, the first ever randomised, placebocontrolled clinical trial of an anti-anginal drug, nifedipine XL. The study’s overall finding was that blood pressure is an important risk factor in angina patients and that treatment with nifedipine was beneficial.While Dr Meredith’s findings in respect of stroke echoed Sleight’s on ONTARGET, this was not the case with regard to the other endpoints where the lowest blood pressure was consistently associated with the smallest risk. ‘The prognostic value of baseline systolic and diastolic blood pressure was such that lowest risk was equated with lowest pressure, a different finding from both INVEST and ONTARGET.’Turning to cardiovascular outcomes with more- versus less-intensive blood pressure lowering, Dr Meredith stated that there were relatively consistent findings in favour of the former, especially in highrisk patients. ‘Intensively treated diabetic patients in the ACCORD study, for example, suffered no deleterious effects and all their outcomes showed a trend in a favourable direction.’He feels that, in the main, researchers are too obsessed with p-values and that statistical significance may not necessarily translate into therapeutic benefit. ‘I am firmly in the camp that believes lower to be better. Nothing suggests that this is bad for the patient, when therapy is tailored to the individual needs of the patient in question.’He argued too that in the older placebo-controlled trials that seem to show a J-shaped curve, the increased risk of events was not related to antihypertensive treatment, but rather to poor health conditions at baseline. ‘Our evidence from ACTION suggests that there is no J-shaped curve. Neither is there a nifedipine-induced curve. That said, I acknowledge that there are limitations to our findings, but the same is true for all the other analyses.’He concluded by advising that some caution should be exercised in accommodating the individual needs of patients. ‘However, failure to control blood pressure remains a major problem and, instead of getting side-tracked and enmeshed in debates about the J-shaped curve, we need rather to focus our energies on achieving good control.’


T-cell-mediated rejection (TCMR) remains a major cause of kidney allograft failure. The characterization of T-cell repertoire in different immunological disorders has emerged recently as a novel tool with significant implications. We herein sought to characterize T-cell repertoire using next generation sequencing to diagnose TCMR.In this prospective study, we analyzed samples from 50 kidney transplant recipients. We collected blood and kidney transplant biopsy samples at sequential time points before and post transplant. We used next generation sequencing to characterize T-cell receptor (TCR) repertoire by using illumina miSeq on cDNA synthesized from RNA extracted from six patients’ samples. We also measured RNA expression levels of FOXP3, CD8, CD4, granzyme and perforin in blood samples from all 50 patients.n = 7) had significantly higher RNA expression levels of FOXP3, Perforin, Granzyme, CD4 and CD8 in blood samples than those with no TCMR (n = 43) .Seven patients developed TCMR during the first three months of the study. Out of six patients who had complete sets of blood and biopsy samples two had TCMR. We found an expansion of the TCR repertoire in blood at time of rejection when compared to that at pre-transplant or one-month post transplant. Patients with TCMR (Our study provides a potential utilization of TCR clone kinetics analysis in the diagnosis of TCMR. This approach may allow for the identification of the expanded T-cell clones associated with the rejection and lead to potential noninvasive diagnosis and targeted therapies of TCMR. Kidney transplantation remains the treatment of choice for patients with end stage renal disease (ESRD) and advanced chronic kidney disease (CKD). In spite of the improvement in short term allograft survival due to the newer potent immunosuppression  in the rThe diagnosis of acute kidney rejection still relies on obtaining kidney biopsy. In addition to the risks of this procedure, such as bleeding, obtaining kidney biopsy is costly and time consuming for the physicians, staff and patients. Therefore, research efforts have focused on identifying biomarkers that can be easily obtained from patient’s fluid (blood or urine), and can serve as markers for acute rejection –10. HoweT cell-mediated rejection (TCMR) is the most common cause of acute rejection , and is With the recent feasibility of high throughput sequencing, investigations have been directed toward a comprehensive analysis of TCR repertoire in the transplant setting. In this study, we utilized an mRNA-based, 5′RACE (rapid amplification of cDNA ends) PCR method followed by next generation sequencing (NGS) technology approach , 20 to iThis is a prospective multi-center study approved by the Institutional Review Boards of Johns Hopkins Hospital, University of Chicago, and Osaka University. Patients were recruited after written consents at Johns Hopkins Hospital and Osaka University Hospital. We enrolled 50 patients who receive kidney transplantation between September 2013 and June 2014. Table We collected blood samples before kidney transplantation, at 24–48 h, one week, one month and three months after transplantation, and at time of confirmed TCMR. We also obtained kidney graft biopsy samples from the patients who had TCMR.We collected 15 mL of blood sample from each patient at each time point in two Cell Preparation Tubes (CPT). These samples were processed in our laboratory within one hour of collection. After collecting the blood samples, we processed the samples using this centrifuging setting: temperature of 21 °C; speed of 3000 revolutions per minute (RPM), for 20 min with breaks on. After the first round of centrifugation we collected the cells carefully and wash them twice with PBS. We added PBS to fill the tube up to 15 mL and centrifuged it . We did a second wash by discarded the supernatant PBS and disturbed the cell pellet at the bottom by gentle tapping; we added 10 mL of PBS and centrifuged at the same setting. Finally, we collected the cell pellet in the small tube and centrifuged it for 2 min in the cold room to remove supernatant fluid, and preserved it at −80 °C until used for sequencing.We used frozen section of the kidney biopsies and saved them in −80 °C. We extracted the RNA from these tissue samples.Total RNAs were isolated from peripheral blood mononuclear cells (PBMCs) and from graft biopsies using RNeasy mini kit  and treated with DNase to remove genomic DNA contamination. cDNA was then synthesized using the SMART cDNA library construction kit , according to the manufacturer’s instructions. A common adaptor (SMART IV oligonucleotide) was ligated to the 5′ end of cDNA. PCR was then performed to amplify all the possible combination of TCR beta from cDNA, using one common forward primer, which is designed based on the sequence of SMART IV adaptor and a reverse primer specific to the constant region of TCR beta , 22.Six patients had complete sets of blood and tissue samples at the intended time points; these samples were sequenced. Out of these six patients, two had TCMR. Each sample was barcoded at both ends of the library with different combination of index 1 and index 2 using Nextera XT kit . Several samples were pooled together into single sequencing run on the Illumina MiSeq using Miseq Reagents Kits v3 600 cycles (Illumina).http://www.imgt.org), using Bowtie2 aligner (Version 2.1.0) [Sequences analysis were performed using Tcrip algorithm , 22. Seqn 2.1.0) , 22. TheTo analyze markers of activated T-cells in kidney transplant patients and correlate these markers with graft rejection, we measured mRNA levels of the following genes: FOXP3, Perforin, Granzyme, CD4 and CD8 by RT-PCR in all blood samples of the whole cohort.The inverse Simpson’s index was calculated based on the following equation:K is the total number of clonotypes, n is the number of sequences belonging to the i-th type, and N is the total number of sequences for which clonotypes are determined [t-test (two-tailed) was performed for comparison of total proportion of the most abundant ten CDR3 sequences or the diversity index between groups, using GraphPad Prism version 6.0. A p value of less than 0.05 was considered statistically significant.Where termined , 22. PaiTable Figure To examine whether enrichment of certain T-cells may be involved in the development of graft rejection, we analyzed changes over time from baseline at the time of transplant and sequentially at one month and three months after transplant. On the basis of their V(D)J combination and defined CDR3 sequences, we sorted independent cDNA sequences according to their number of appearance in the sequence reads from the most to least abundant. We noted the ten most abundant CDR3 sequences at each time point. We combined the top ten clones that appeared at each time point and generated a recurrent CDR3 profile for each patient of all combined time points. We compared the recurrent CDR3 profile from blood samples obtained at the time of transplant with that from samples obtained at time of TCMR. We found that only the two patients with TCMR showed significant expansion of their recurrent CDR3 profiles Fig. .Fig. 2ExWe tracked the top ten clones of the TCRB repertoire obtained from the graft tissues at time of TCMR, and we examined their presence in the repertoire obtained from blood and graft tissues at earlier time points . We found that among the top 10 clones, at least six clones were observed at earlier time points either in the blood or in the graft samples Fig. .Fig. 3Trn = 4), we found that three patients showed an increase in the diversity of TCR repertoire in graft samples obtained three months after transplant in comparison with that obtained just before transplant. Interestingly, in five patients who had graft biopsy samples at 1 and 3 months after transplant, we found that the TCR repertoire was less diverse at three months post transplant compared to that at 1 month post-transplant  where higher values suggest a diversity increase of the TCR repertoire. TCR repertoire diversity was lower in graft samples compared to that in blood samples Fig. . Three pn = 7) had significantly higher levels of FOXP3, Perforin, Granzyme, CD4 and CD8, comparing to the 43 patients without rejection ; Fig. We found that at any time point, blood samples of patients with TCMR (T-cell immune response is a major cause of post kidney transplant complications. Although the introduction of newer potent immunosuppressive drugs in the last two decades resulted in significant decrease in early acute TCMR, late TCMR and chronic rejections remain common causes of allograft failure . To prevOur data herein, constitutes a very promising step toward identifying T-cell markers that can be utilized in the diagnosis of TCMR to enable clinicians to treat it promptly; and also to potentially provide the tools to individualize immunosuppressive therapy. We have previously applied NGS techniques to comprehensively analyze T-cell repertoire in blood samples from patients who underwent hematopoietic stem cell transplant . We founOur study demonstrated a large turnover of the T-cell populations over time consistent with conditioning immunosuppressive treatments that the patients received. Importantly, high correlation of the TCR repertoire was observed between blood and graft at the time of rejection. Although they cannot precisely point out clones responsible for the graft rejection, our data suggest the feasibility of tracking such clones once identified in the blood. We identified top ten clones profile or recurrent CDR3 profile, which included all the top clones that appeared at each time point in blood and graft samples. We found an expansion of the recurrent CDR3 profile from blood samples obtained at the time of rejection compared to earlier time points in patients with TCMR. Since this phenomenon was not observed in non-TCMR patients, it suggests that TCR clones that cause TCMR could be tracked to earlier time points; therefore identification of such clones can possibly provide a diagnostic value.The utility of T-cell sequencing in the transplant field has been increasingly investigated. A recent study assessed kidney allograft dysfunction and T cell response to different viral infections using NGS-DNA-based platform demonstrated the feasibility of tracking single antigen-specific T-cell clones in tissues to facilitate differential diagnosis . Morris Other techniques such as microarrays , 27 wereYap et al.  showed tOur data confirmed that patients with TCMR had significant increase in blood FOXP3, perforin, granzyme and the T-cell sub-types CD4 and CD8 comparing to those without rejection. Previously, one-step real-time PCR method was utilized as a non-invasive tool to detect the expression of the T-cell activation markers, granzyme B, perforin, and HLA-DRA in PMC . Heng etUnlike previous studies that utilized genomic DNA-based NGS to characterize the TCR repertoire, our study is the first to utilize NGS techniques in detecting TCMR by analyzing mRNA obtained from blood and kidney biopsy samples in a prospective study of kidney transplant recipients. Furthermore, examination of this repertoire in the graft shed a light on the function of the infiltrated T-cells involved in TCMR. Our data confirmed the correlation of upregulation of T-cell markers in the blood with the pathological changes of TCMR. We acknowledge that our findings are limited by the small number of patients who developed TCMR during the study period. Therefore, a follow-up study would be essential to assess delayed TCMR and long term outcome. Nevertheless, our findings constitute a novel tool in utilizing non-invasive next generation T-cell sequencing in the diagnosis of TCMR and in further understanding the T cells characterization as an immune response in the renal transplant in comparison to conventional tools.In addition of the potential role of the NGS methods in the diagnosis of TCMR, using these techniques in identifying different specific T-cells clonotypes that correlate with different types of pathogenesis may lead to the discoveries of new immunosuppressions and other T-cell targeted therapies.


In critically ill patients at risk for organ failure, the administration of intravenous fluids has equal chances of resulting in benefit or harm. While the intent of intravenous fluid is to increase cardiac output and oxygen delivery, unwelcome results in those patients who do not increase their cardiac output are tissue edema, hypoxemia, and excess mortality. Here we briefly review bedside methods to assess fluid responsiveness, focusing upon the strengths and pitfalls of echocardiography in spontaneously breathing mechanically ventilated patients as a means to guide fluid management. We also provide new data to help clinicians anticipate bedside echocardiography findings in vasopressor-dependent, volume-resuscitated patients.To review bedside ultrasound as a method to judge whether additional intravenous fluid will increase cardiac output. Special emphasis is placed on the respiratory effort of the patient.Point-of-care echocardiography has the unique ability to screen for unexpected structural findings while providing a quantifiable probability of a patient’s cardiovascular response to fluids. Measuring changes in stroke volume in response to either passive leg raising or changes in thoracic pressure during controlled mechanical ventilation offer good performance characteristics but may be limited by operator skill, arrhythmia, and open lung ventilation strategies. Measuring changes in vena caval diameter induced by controlled mechanical ventilation demands less training of the operator and performs well during arrythmia. In modern delivery of critical care, however, most patients are nursed awake, even during mechanical ventilation. In patients making respiratory efforts we suggest that ventilator settings must be standardized before assessing this promising technology as a guide for fluid management. A routine but challenging task facing acute care physicians is to identify and treat patients at risk for acute organ failure as a result of inadequate systemic perfusion and oxygen delivery. The decision to administer supplemental intravenous fluids to the patient at risk is built upon the belief that additional volume expansion will, or will not, increase cardiac output. Although there are many unknowns in a critically ill patient, fundamental cardiovascular physiology represents a touchstone from which decisions can be made.One important premise is that during the time it takes to administer bolus intravenous fluid, one can assume a constant cardiac contractility. Changes in stroke volume in response to intravenous fluids are therefore mainly determined by changes in ventricular end-diastolic volume. At constant cardiac contractility, the relationship between stroke volume and ventricular end-diastolic volume has been classically described by Patterson and Starling , SarnoffClinical prediction of fluid responsiveness was first studied using single measurements of cardiac filling volumes (preload). These include the direct measurement of right atrial pressure as a surrogate of volume, also referred to as central venous pressure (CVP) and less commonly as the pulmonary capillary wedge pressure, which in ideal situations is synonymous with left atrial pressure as a surrogate of left ventricular end-diastolic volume. As has been extensively reviewed elsewhere, static measures of preload perform no better than chance in patients who are critically ill. It is now recognized that bedside maneuvers which rapidly change preload are more discriminative than static measures. Currently, passive leg raising (PLR) and respiratory variation in thoracic pressure are the two techniques used to vary preload. Within 1 minute of bilateral PLR, there is an effective increase in preload through recruitment of blood pooled in the legs . In the Variation in intrathoracic pressure during tidal breathing is the other cause of varied right or left cardiac preload. It is important to recognize that the type of respiration (spontaneous versus controlled) will determine the resultant physiology. In mechanically ventilated patients with no respiratory effort, the positive inspiratory pressure transfers blood from the lungs to the left heart, resulting in an increase in stroke volume. This is seen as a rapid increase in pulse pressure. At high levels of positive intrathoracic pressure one can also decrease the venous return, and after transit of this reduced blood volume from the right to left heart there can be a decline in pulse pressure. The larger the fluctuations in pulse pressure as a result of respiration, the greater the chance that the patient will increase cardiac output in response to fluid. This method cannot be used during arrhythmias such as atrial fibrillation or with very rapid heart rates.Respiratory changes in intrathoracic pressure also occur in the dimensions of both the inferior and superior vena cavae. These changes also depend on the degree of intrathoracic pressure change and on the compliance of the vena cavae. Positive intrathoracic pressure increases the size of the inferior vena cava (IVC), while negative intrathoracic breaths reduce its size. When the vena cava is distended, the compliance markedly reduces. A large, nonfluctuant IVC therefore suggests that the patient is not on the steep (volume responsive) portion of the Starling curve. The IVC diameter is easily and reproducibly measured 1–2 cm from the right atrial junction using transthoracic ultrasound –21.Venous return, central venous pressure, and cardiac output are tightly coregulated as described by Patterson and Starling , Sarnoff2O/18 mmHg [In addition to the direct influence of the cardiovascular system, cardiopulmonary interactions play a crucial role in establishing the equilibrium of venous return, central venous pressure, and cardiac output. This is because 70–90 % of patients with shock require mechanical ventilation , 27. In /18 mmHg  have sigCentral venous pressure in health is tightly governed at 0–5 mmHg –6, resulA central venous pressure of 9–15 mmHg.Maximum IVC diameter of 17–29 mmHgAccording to the increase in IVC diameter upon mandated inspiration, 2/3 patients will be deemed nonresponsive to fluid.o (supine). This maneuver transfers blood from the legs and the splanchnic reservoir to the intrathoracic compartment, rapidly increasing the preload, thereby testing the preload dependency of the heart. Using PLR, 250–350 ml of blood is transferred from the legs to the heart and this method is entirely reversible [Passive leg raising (PLR) is one of the most versatile techniques to assess fluid needs in ICU patients. PLR can be performed at the bedside in both mechanically ventilated patients and in spontaneously breathing patients , 29–31. versible . It is eversible . Cardiacversible , but thiversible .PLR can be performed regardless of arrhythmia or mode of ventilation.The PLR is not simply “positive” versus “negative”; the degree of increase in stroke volume to PLR predicts the increase in these parameters to fluids.The interobserver and intraobserver reliability of measurements in cardiac output is highly operator dependent. A skilled operator is required to achieve high-quality measures of aortic blood flow.Aortic flow variations during mechanical ventilation may be a superior measure of what is observed clinically as stroke volume variation (SVV), a parameter correlated with fluid responsiveness . FeisselNo additional maneuvers are required; standard mechanical ventilation provides the dynamic changes in preload.The interobserver and intraobserver reliability of measurements in cardiac output is highly operator dependent. A skilled operator is required to achieve high-quality measures of aortic blood flow.Not accurate during arrhythmia.Of limited utility with “open lung” ventilator strategies which reduce pleural pressure swings.Under controlled mechanical ventilation, positive pressure is applied into the thorax. The superior vena cava (SVC) is therefore subjected to this positive pressure during mechanical insufflation. Vieillard-Baron et al.  demonstr2O above PEEP. Immediately following this scan the patient began a spontaneous breathing trial with 0 cmH2O additional support. Clearly both the IVC diameter and fluctuation are highly influenced even at modest levels of pressure support. This intuitive but under-recognized fact has important implications when interpreting the results of an ultrasound examination in awake patients with the intent of guiding fluid therapy. Reports of changes in IVC diameter in spontaneously breathing patients have found that these failed to accurately predict fluid responsiveness. For instance, IVC respiratory variations >42 % in spontaneously breathing patients demonstrated a high specificity (97 %) and a positive predictive value (90 %) to predict an increase in CO after fluid infusion with a cutoff value >42 % [Following the initial resuscitation, most patients in the modern era are nursed while awake and are encouraged to breathe in collaboration with the ventilator. This means that in awake, spontaneously breathing patients the swings in pleural pressures during inspiration which are transmitted to the IVC can vary from deeply negative  to neutral/positive in cases with high levels of pressure support or neuromuscular weakness. It has recently been shown in healthy volunteers that the change in IVC diameter is highly correlated with respiratory effort . In our ue >42 %  but a loue >42 % .Fig. 1A No additional maneuvers are required; the standard mechanical ventilation provides the dynamic changes in preload.Of limited utility in controlled modes of ventilation using “open lung” strategies which reduce pleural pressure swings.In awake patients, the IVC diameter and collapse are highly dependent upon the patient’s respiratory effort and levels of ventilatory support.While echocardiography is of great value in the diagnosis of right ventricular failure, more direct measures of left ventricular performance such as descending aortic Doppler flow are required in this population.In a recent study, Chauvet et al.  found thUltrasound imaging of vena caval diameter fluctuation with respiration is a safe, noninvasive method to assess fluid responsiveness in apneic patients on controlled mechanical ventilation. Two-thirds of patients will not be fluid responsive following an initial volume resuscitation of 30 ml/kg. In spontaneously breathing patients the degree of IVC fluctuation is a function of both respiratory effort and the pressure applied to assist ventilation, and without standardized ventilator settings it has not been proven a reliable indicator of fluid responsiveness.AUROC, area under the receiver operator curve; IVC, inferior vena cava; LVOTO, left ventricular outflow tract obstruction; PLR, passive leg raising; PPV, pulsed pressure variation


However, serum creatinine concentration is also influenced by non-GFR determinants. This case report presents two elderly patients with normal Scr but elevated serum cystatin C concentration (Scys) where the exclusive assessment of Scr would have lead to an overestimation of GFR and would have misclassified the patients as having a normal kidney function.Serum creatinine concentration (Scr) and creatinine based GFR estimating equations (eGFR2 (Δ-eGFR).Patient 1, a 102-year-old woman, presented with a Scr of 0.45 mg/dl, while her Scys was elevated (1.55 mg/l). Depending on which of the five GFR estimating equations was used, the patient could be classified into four different CKD-Stages . The largest difference between the eGFR-results was 94 ml/min/1.73 m2. Four out of five GFR equations would have overestimated the patient’s kidney function.Patient 2, an 88-year-old man, also had normal Scr (0.93 mg/dl) but elevated Scys (1.55 mg/l). An iohexol clearance measurement yielded a measured GFR (mGFR) of 44 ml/min/1.73 mcr alone can lead to false estimation of kidney function. In these situations, cysC based GFR equations may provide improved accuracy of GFR assessment and may protect patients from drug overdosing and the abundant use of contrast agents.The presented cases highlight the influence of non-GFR determinants on Scr and demonstrate the variability of eGFR results depending on the filtration marker and GFR equation used. Especially for older adults, it shows the great clinical importance of understanding the limitations of each filtration marker and of identifying situations in which relying on eGFR Generally, the serum concentration of an endogenous filtration marker, such as creatinine, is used as a rough estimate of the glomerular filtration rate (GFR) and is also the central element of all GFR estimating equations. In an equilibrium of endogenous production and renal elimination, creatinine correlates inversely with GFR. Its serum concentration however, can be influenced by non-GFR determinants such as muscle mass. Cystatin C is another endogenous filtration marker but only very rarely routinely monitored. This case report presents two elderly patients with perfectly normal serum creatinine concentration (Scr), but clearly elevated serum cystatin C concentration (Scys). The exclusive assessment of creatinine would have most probably misclassified these patients as being “kidney-healthy”. Thus, it highlights the importance of putting serum creatinine levels into the individual patient context and of identifying situations in which further assessment of kidney function, using ScysC or even direct measurement of GFR (mGFR), is needed.2. Her resting blood pressure and pulse were 151/69 mmHg and 78/min, respectively. The patient’s lab results revealed haemoglobin 10.6 g/dl, CRP 1.28 mg/l, urea 28 mg/dl, albumin 30.2 g/l, calcium 2.27 mmol/l, phosphate 1.12 mmol/l. Albumin-creatinine-ratio (ACR) was below 30 mg/g.A 102-year-old woman (patient 1) took part in the Berlin Initiative Study (BIS), a large prospective population-based cohort study focusing on the epidemiology of chronic kidney disease in older adults. Her only pre-existing condition was a peripheral artery disease. Permanent medication included pantoprazole and novaminsulfon on a regular basis and magnesium as needed. The physical examination yielded a height of 156 cm and weight of 42 kg corresponding to a body mass index (BMI) of 17 kg/m2, CKD-Epicr [2, FAS [2, BIS1 [2, CKD-Epicr/cys [2, BIS2 [2, and CKD-Epicys [2. The largest difference between creatinine-based eGFR-results (Δ-eGFRcr) was 49, between all equations 94 ml/min/1.73 m2. Thus, based on eGFR results the patient could at the same time be classified into four different CKD-stages , depending on the GFR estimating equation used , while Scys was elevated 1.55 mg/l). GFR estimating equations (eGFR) yielded the following results: MDRD [.55 mg/l. [2, FAS : 79 ml/m5 mg/dl, 2). His resting blood pressure was 213/89 mmHg, his heart rate 89 bpm. Blood analysis yielded the following results: haemoglobin 13.1 g/dl, CRP 0.61 mg/l, urea 43 mg/dl, albumin 35.5 g/l, calcium 1.98 mmol/l, phosphate 0.98 mmol/l. ACR was below 30 mg/g.Patient 2 was an 88-year old male participant of the BIS study. Beside a diagnosis of arterial hypertension, he had no history of further chronic illnesses. A beta-blocker was his only permanent daily medication. His height was 167 cm and he weighed 69 kg . This patient belonged to the BIS subgroup in which measurement of GFR using iohexol plasma clearance had been conducted. His measured GFR (mGFR) was 44 ml/min/1.73 m2, which demonstrated that four out of five eGFR-equations would have overestimated his kidney function , while his Scys was elevated to 1.77 mg/l. This corresponded to the following eGFR-results: MDRD: 77 ml/min/1.73 mn = 2096, mean age 80.4 years) 607 participants showed the combination of a normal Scr concentration  and an elevated Scys level . This resulted in 29% of the BIS participants being classified as having a normal kidney function in case only Scr had been taken into consideration.When analyzing the population of the Berlin Initiative Study (cr) alone can lead to false estimation of kidney function. The presented cases demonstrate impressively the strong influence of non-GFR determinants on creatinine concentration. In addition, they highlight the variability of eGFR results depending on (1) the filtration marker and (2) eGFR equation used. It is thus of great clinical importance to understand the value and shortcomings of each filtration marker to be able to identify situations in which certain markers, in this case eGFRcr, are less accurate [Scr has been abundantly used for the assessment of GFR for almost 100 years. However, glomerular filtration is only one of several variables that determine creatinine concentration. In certain clinical situations, relying on creatinine based GFR estimating equations  may therefore provide an improved accuracy of GFR assessment and CKD-classification. Scys is produced at a constant rate in all nucleated cells [In certain situations , Scys based GFR estimating equations  autoimmune disease, hyperthyreosis, malignoma and nicotine consumption . Some ofIn conclusion, especially in older adults clinicians should appreciate the limitations of endogenous filtration markers. Their awareness needs to be sharpened to take individual patient characteristics  into consideration in order to identify constellations where creatinine is insufficient. In such situations cystatin C-based eGFR equations should be preferred. In other situations, i.e. states of inflammation Scys might not be the ideal marker. Thus, in older vulnerable adults where sometimes crucial decisions have to me made such as dosage of nephrotoxic drugs or the eligibility of kidney donation, direct clearance measurement should be considered as a reasonable alternative since the accurate determination of renal function can be vitally important.The presented case report demonstrates impressively the strong influence of non-GFR determinants on creatinine concentration and highlights that the choice of renal markers for assessing kidney function should be considered very cautiously, especially in older adults. Also, it indicates circumstances where cystatin C may be a superior biomarker for clinical decision-making and refers to situations where measured GFR should be considered.


Telomere length is an emerging novel biomarker of biologic age, cardiovascular risk and chronic medical conditions. Few studies have focused on the association between telomere length (TL) and kidney function.We investigated the association between TL and kidney function/prevalent chronic kidney disease (CKD) in US adults.The National Health and Nutrition Examination Survey (NHANES) participants with measured data on kidney function and TL from 1999 to 2002 were included. Estimated glomerular filtration rate (eGFR) was based on CKD Epidemiology Collaboration (CKD-EPI) equation. Urinary albumin excretion was assessed using urinary albumin-creatinine ratio (ACR). We used multivariable adjusted linear and logistic regression models, accounting for the survey design and sample weights.n=5020) were men. Their mean age was 44.1 years. eGFR significantly decreased and ACR significantly increased across increasing quarters of TL . The association between TL and kidney function remained robust even after adjusting for potential confounding factors, but the association between TL and ACR was only borderline significant .Of the 10568 eligible participants, 48.0% (The association of kidney function with a marker of cellular senescence suggests an underlying mechanism influencing the progression of nephropathy. Telomere is a repeat of specific short sequences of nucleotides found at the end of chromosomes. The length of telomere is so considerable, hence telomere shortening has been correlated with various pathological disorders and processes such as biological aging, oxidative stress and inflammation –6. The sThere is great interest in studying telomere length in relation with kidney health , 13, butThe mechanism through which creatinine is regulated by the kidney, and the relationship between kidney function and TL are not fully understood, while existing data have been controversial . HoweverIn this study we investigated the association of TL, a marker for biological age, with kidney function and prevalent CKD using data from the National Health and Nutrition Examination Survey (NHANES).n = 5020) were men. The mean age was 44.1 years overall, 43.5 years in men and 44.8 years in women (p = 0.063). With regard to education 52.5% (n = 4022) of the participants had completed more than high school, 25.6% (n = 2178) had completed high school, while 21.7% (n = 3248) had completed less than high school. White (non-Hispanic) represented 70.4% (n = 4864) of the participants, African-Americans - 10.9% (n = 2103) and Mexican-Americans - 6.9% (n = 2690). Overall, 20.8% were current smokers (24.8% of the men and 16.6% of the women). The mean and standard error of mean (SEM) for the TL in the overall sample was 1.08±0.015 (1.07±0.014 in men and 1.08±0.016 in women).Of the 10568 eligible participants, 48.0% (2. Table p < 0.001).The distribution of participants by stage of CKD based on eGFR and ACR levels was the following: CKD stage 1 - 65.3%, CKD stage 2 - 26.5%, CKD stage 3 - 7.1%, CKD stage 4 - 0.6%, and CKD stage 5 - 0.4%. Overall, 8.1 % of the participants had eGFR less than 60 ml/min/1.73mp < 0.001), while high-density lipoprotein cholesterol significantly increased across increasing TL quarters .The association age- and sex-adjusted cardiometabolic factors, kidney function tests across quarters of TL analyzed are summarized in Table p < 0.001), and positively associated with serum creatinine and eGFR (both p < 0.001). In multivariable adjusted models, the association remained significant between TL and eGFR, and borderline significant between TL and Urea Albumin . Logistic regression was used to determine the association between quartile of the TL and chance of CKD, however we have failed to find any significant association between quartile of the TL and odds of CKD neither in crude nor in adjusted  models.Further univariable and multivariable  regression analysis were performed to examine the association of TL with kidney function Table . UnivariIn this large representative sample of adults Americans, eGFR decreased while urinary albumin excretion increased across decreasing TL quarters. These patterns were robust to adjustment for potential confounding factors. Although, these findings did not translate into significant association between TL and prevalent CKD, our study findings suggest that telomere shortening could be an independent predictor of deteriorating kidney function.In accordance with our findings, recent systematic review proposed that shortening TL might be related with CKD prevalence/occurrence or declining kidney function, however this relation is probably balanced by the cellular telomere reparative process in those surviving longer with CKD, furthermore stated that Short TL was independently related with increased risk of prevalent micro albuminuria in diabetic men with CKD . FurtherHowever, Pykhtina etal stated that no associations have been found between telomere length and inflammatory markers and the levels of glomerular filtration rate, urea and creatinine except for albuminuria which is associated with telomere length .In line with our study, previous reports have suggested that TL is shorter in patients with end-stage renal disease patients on dialysis compared with the general population. For example, in a study of 15 patients on haemodialysis and 15 age-matched controls, the authors found an accelerated telomere shortening in patients on dialysis . AnotherInterestingly, recent investigation conducetd by Karin Luttropp concluded that Telomere attrition after 12 months was significantly greater in patients with renal replacement therapy compared to dialysis patients in addition non-CKD patients had meaningfully longer telomeres than CKD patients .n = 866, median age was 74)  was estimated using the CKD Epidemiology Collaboration (CKD-EPI) equation. CKD was defined as eGFR less than 60 (ml/min/1.73m2) [The NHANES are ongoing repeated cross-sectional surveys conducted by the US National Center for Health Statistics (NCHS). The NCHS Research Ethics Review Board approved the NHANES protocol and consent was obtained from all participants , 31. Dat/1.73m2) .Aliquots of purified DNA, isolated from whole blood using the Puregene (D-50 K) kit protocol , were obtained from participants. TL assay was performed using the quantitative polymerase chain reaction method to measure TL relative to standard reference DNA  ratio) , 40. EacChi-square tests. All tests were two sided, and p < 0.05 used to characterise statistically significant results. Data were analysed using SPSS® complex sample module version 22.0 .We conducted the analyses according to the CDC guidelines for analysis of complex NHANES data, accounting for the masked variance and using the proposed weighting methodology . To inve


High value of neutrophil lymphocyte ratio (NLR) is a strong independent predictor and biomarker of ongoing vascular inflammation in various cardiovascular disorders. The main focus of the study is to investigate the effect of nebivolol on NLR in mild to moderate hypertensive patients in comparison with metoprolol. In addition, BMI, blood pressure, TLC count, blood sugar, and lipid profile were also assayed before and after treatment. In this 12-week prospective double-blinded randomized study, 120 patients with mild to moderate hypertension were randomly divided into two groups to prescribed daily dose of tab nebivolol 5–10 mg and metoprolol 50–100 mg, respectively, for 12 weeks. The data were analyzed using SPSS 16 software.p < 0.001) from baseline. Regarding inflammation, nebivolol reduced total leukocyte count (p = 0.005) and neutrophil count (p = 0.003) and increased lymphocyte count (p = 0.004) as compared to metoprolol. Similarly, nebivolol but not metoprolol significantly reduced NLR ratio (p = 0.07). Nebivolol improved lipid profile and blood sugar compared to metoprolol, but values were nonsignificant. A total of 100 patients completed the study. Both drugs lowered blood pressure significantly, nebivolol 20.5/10.5 and metoprolol 22.5/11.2 ( Nebivolol has a strong impact on reducing NLR, a marker of subclinical inflammation in hypertensive patients. Moreover NLR can be used as a disease and drug monitoring tool in these patients. Hypertension affects about one-fourth of the adult population globally and this number will increase to 29% by year 2025. The prevalence of hypertension will be much higher in developing countries in upcoming years because of strong influence of urbanization and lifestyle changes to its underlying risk factors. In addition, healthcare facilities in developing world for routine screening of hypertensive patients are grossly underutilized. Approximately one-third of deaths in the world population are mainly due to cardiovascular disease with hypertension being one of its route cause. High blood pressure itself initiates a chain of events in vessels wall in the form oxidative stress, inflammation, and endothelial dysfunction that plays a fundamental role in initiation, progression, and complication of atherosclerosis in the form of cardiovascular diseases. Therefore multifaceted and multipronged strategies are needed to handle this health issue in both developed and developing nations in order to reduce economic and social disease burden , 2.α, and interleukin-1 in the detection of subclinical inflammation and endothelial dysfunction in various clinical trials [The role of increased leukocytes count in the pathogenesis of atherosclerosis is well understood that initiates a cascade of inflammatory reaction in the vessel wall. Increased leukocyte counts are reliable markers of systemic inflammation in clinical practice that has very strong association with coronary heart disease, cerebrovascular disease, and vascular complications associated with diabetes , 4. In rl trials –9.Nebivolol is a highly cardioselective 3rd-generation long acting -1 blocker which is usually prescribed once a day as monotherapy or in combination with other antihypertensive drugs. It is only beta-blocker that has vasodilating properties and is safely prescribed in diabetics patients too as it does have any adverse effect on insulin sensitivity and serum lipid profile. It also does not cause sexual dysfunction like other beta-blockers even though it improves sexual dysfunction in diabetic patients. It also inhibits platelets aggregation, improves endothelial and left ventricular systolic dysfunction, and improves arterial stiffness, coronary and peripheral blood flow in patients of angina, myocardial infarction, chronic heart failure, and various arrhythmias , 11.α in various clinical studies [Apart from their beneficial effects on blood pressure, nebivolol has a very strong anti-inflammatory and antioxidant potential. Nebivolol reduces the level of various oxidative and inflammatory markers like oxidized LDL, 8-isoprostanes, CRP, interleukin- (IL-) 6, adiponectin, leptin, intercellular adhesions molecule (ICAM-1), vascular cell adhesions molecule (VCAM-1), and tumor necrosis factor- studies , 13. HowThis twelve-week prospective randomized double-blinded clinical trial was carried out at cardiology outdoor of Sheikh Zayed Medical College/Hospital, Rahim Yar Khan, from 5 November 2016 to 5 January 2017. An ethical committee permission and written informed consent was obtained from all patients before enrollment. Initially two hundred and forty patients were recruited in cardiology outdoor unit on the basis of chief complaints of headache, dyspnea, dizziness, and insomnia. Out of which 120 patients, aged 32–56 years with mild to moderate hypertensions according to World Health Organization (WHO)/International Society of Hypertension (ISH) criteria , who werA randomization was done by allocation of random number in ascending order in blocks to all patients generated by computed software. All patients remained unknown about the treatment plan to each other throughout the study period. After randomization patients were divided into two equal groups to prescribe daily dose of tablet nebivolol 5–10 mg and metoprolol 50–100 mg, respectively. The dose was adjusted according to their blood pressure which was kept below 140/90 mmHg. Those patients were excluded from the study if their targeted blood pressure was not achieved in spite of dose adjustment during first two weeks of therapy.2 without shoes and wearing light clothes. Blood sample was calculated from the median cubital vein after an overnight fasting of 12 hours. The samples were used for analyzing TLC count, blood sugar, lipid profile, serum total cholesterol (TC), HDL-cholesterol (HDL-C), serum triglycerides (TG), and LDL-cholesterol (LDL-C). Lipid profile and blood sugar were estimated by calibrated semiautomated analyzer. Total leukocyte count was analyzed by automated hematology analyzer Sysmex KX-21. Neutrophil lymphocyte ratio (NLR) was calculated by dividing the absolute neutrophil ratio to absolute lymphocyte ratio.Brachial blood pressure was measured in right arm in sitting posture by auscultatory method using standard mercury sphygmomanometer apparatus as a mean of three consecutive readings at an interval of 10 minutes. BMI was calculated by standard formula weight in kg/height in m U and independent t-test as appropriate. The comparisons between two groups in terms of statistical significance were done by chi-squared, Mann–Whitney U and independent t-test. Continuous variables were compared by two-tailed paired t-test by pre- and posttreatment. Data were analyzed by using SPSS 16 software. A p < 0.05 was considered to be statistically significant.All numeric data were presented as mean ± standard deviation and percentages. Continuous variables for normal distribution were assessed by using Kolmogorov-Smirnov test. With respect to these test results, we used Mann–Whitneyp < 0.001) from baseline. In comparison with metoprolol, nebivolol caused a significant reduction in total leukocyte count (p = 0.005) and neutrophil count (p = 0.003) and increased lymphocyte count (p = 0.004). Similarly, nebivolol but not metoprolol significantly reduced NLR ratio (p = 0.07). Nebivolol in comparison with metoprolol also improved blood sugar and lipid profile but values were found to be nonsignificant (A total of 120 patients were enrolled in the study, out of which, 10 patients, 4 in the nebivolol and 6 in metoprolol, cannot complete the study because they were lost of follow-up. Both groups tolerated the drug very well with no major adverse effects being reported during the study; however, two patients in nebivolol group and one patient in metoprolol group developed symptomatic bradycardia and withdrawal from the study. Three patients in nebivolol and four patients in metoprolol group were found to be nonresponders to drug regime and also withdraw from the study. A total of 100 patients completed the study, 51 in nebivolol and 49 in metoprolol group. There was no significant difference in both groups in terms of baseline demographic and clinical parameters . Both drnificant .The present study was conducted to investigate the effect of nebivolol on NLR, a subclinical inflammatory marker in hypertensive patients. Subclinical inflammation is a silent killer in hypertensive patients which cannot manifest clinically for years but it can cause endothelial dysfunction that predispose to atherosclerosis and its related complication in the form of various cardiovascular and cerebrovascular disorders in future .NLR is a new addition in the list of inflammatory markers and has got special attention in recent years because it has strong independent diagnostic as well as prognostic value for atherosclerosis related vascular diseases and its associated risk factors such as hypertension, diabetes, metabolic syndrome, and dyslipidemia . StudiesIn this study, nebivolol caused a significant reduction in NLR after 12-week treatment. Nebivolol has a strong potential to reverse hypertension associated inflammatory changes by a variety of suspected mechanisms. First nebivolol improves endothelial dysfunction that causes endothelial cells to initiate inflammation by the generation of reactive oxygen species and proinflammatory cytokines . Second Regarding antihypertensive drugs, a very limited work has been done in the past to see their effect on NLR. A study conducted by Karaman et al.  revealedMost of the beta-blockers have adverse effect on glucose and lipid metabolisms. In this study nebivolol did not disturb lipid and glucose metabolism. Although it improved lipid profile to some extent in comparison with metoprolol but values were found to be nonsignificant. This has additional beneficial effect as both deranged blood sugar and lipid profiles themselves initiate a process of vascular inflammation. Seeing these beneficial effects of nebivolol, it should be considered in hypertensive patients in order to prevent its future complications. Moreover, NLR, a routine test, can be used as a drug and disease monitoring tool in these patients as it has diagnostic as well as prognostic value in various cardiovascular disorders.Nebivolol has a strong potential to decrease NLR reverse subclinical inflammation in hypertensive patients.