Chronic rhinosinusitis (CRS) and asthma are collectively called unified airway diseases. Periostin has been implicated in the pathophysiologic link of these conditions but only by serum measurements. We sought to investigate sputum levels of periostin and their association with upper airway inflammation and olfactory function in CRS patients.We prospectively recruited 56 CRS patients who underwent endoscopic sinus surgery (20 with and 36 without comorbid asthma), and 28 healthy controls between October 2015 and December 2017. Lower and upper airway indices such as sputum periostin levels and eosinophil and neutrophil counts, exhaled fractional nitric oxide (FeNO) levels, and olfactory function were evaluated in the three groups. Radiological severity of CT images and tissue eosinophilia of surgical specimens were also assessed in the CRS patients.Sputum periostin levels were highest, and olfactory function was most impaired, in the CRS patients with comorbid asthma, followed by those without asthma and controls in this order. CRS with asthma group showed higher sputum eosinophils and FeNO levels than the other two groups, while CRS patients without asthma showed significantly higher neutrophils in sputum than the other two groups. When confined to CRS patients, olfactory dysfunction was correlated with sputum eosinophil counts. Eosinophil counts of nasal polyps showed a significant positive correlation with sputum periostin and FeNO levels. Radiological severity of CRS was correlated with sputum eosinophil counts and FeNO levels.Periostin levels and inflammatory cells such as eosinophils and neutrophils in the lower airways are increased in patients with CRS, suggesting the presence of mutual interactions between upper and lower airways even if asthma does not coexist. Olfactory dysfunction and eosinophilic nasal polyps may be potential indicators of Th2-driven inflammation in the lower airways.This study was registered on the UMIN Clinical Trials Registry (Registry ID UMIN000018672). Indeed, it has been reported that 41–51% of patients with asthma have comorbid CRS,Previous studies have demonstrated the interaction between upper and lower airways inflammation. Acute allergen exposure conducted out of hay fever seasons into nasal cavity could facilitate the infiltration of eosinophils in nasal and bronchial mucosa in patients with seasonal allergic rhinitis but without asthma.,,Periostin, a 90-kD extracellular protein which is mainly produced by fibroblasts in response to interleukin (IL)-4 and IL-13, is a notable biomarker which reflects the pathophysiology of both asthma and CRS. It acts as a matricellular protein, and it is involved in the chronicity of allergic inflammation. In patients with asthma, serum periostin levels were higher when patients suffered from comorbid CRS.In this study, we sought to examine periostin levels in the lower airways with induced sputum samples in CRS patients as compared to healthy subjects. CRS patients were subdivided into those with or without comorbid asthma. Other biomarkers of lower airways  were also compared among the three groups. Association of sputum periostin levels with upper airway indices  were also analysed, along with sputum cells and FeNO levels.,2 agonists for their symptoms previously. The diagnosis of CRS was made according to radiological and endoscopic findings with physical symptoms lasting for 12 weeks or longer.We prospectively recruited CRS patients and those with comorbid asthma who visited our hospital to undergo endoscopic sinus surgery (ESS) between October 2015 and December 2017. Patients were diagnosed as having asthma when they complained of asthma-related symptoms such as cough, dyspnoea, chest tightness and/or wheezing with the presence of clinical reversible airway obstruction or airway hyperresponsiveness (AHR) to inhaled methacholine.Alternaria alternata, and Staphylococcus aureus enterotoxin A and B], sinus computed tomography (CT) scan, and ESS. Patients were considered to have atopic predisposition if one or more specific IgE antibody titer showed ≥0.35 UA/ml. All measurements except for tissue sample collections were conducted before ESS.All participants underwent spirometry, FeNO measurement, olfactory function test and sputum induction, and answered the Sinonasal Outcome Test-22 (SNOT-22). Only one CRS patient with comorbid asthma failed to conduct the NO measurement because of apparatus failure. Furthermore, all CRS patients underwent blood analyses [eosinophils, total IgE, and specific IgE antibody against 9 aeroallergens; house dust mite, cat, dog dander, Japanese cedar pollen, mixed Gramineae pollens , mixed weed pollen , ,Olfactory function was evaluated using the Open Essence method.SNOT-22 is a validated questionnaire which is composed of the most 22 CRS-related symptoms regarding quality of life (QoL).The Lund–Mackay score (LMS) was adopted to evaluate radiological severity of CRS. Briefly, scores ranging from 0 to 2 assigned into each of unilateral sides of the maxillary, anterior ethmoid, posterior ethmoid, sphenoid and frontal sinuses , and the ostiomeatal complex . The total scores range from 0 to 24. Higher scores indicate more severe CRS .All of ESS were performed, and inflamed sinus tissue samples were taken from 54 patients under general anesthesia by otorhinolaryngology specialists. The remaining 2 patients, all without asthma, underwent resection of NPs only because there was no mucopurulent discharge in sinuses when ESS was performed. NPs were resected from 38 patients. After fixing in formalin and embedding in paraffin, 4-μm paraffin sections were stained with Hematoxylin-Eosin. The number of eosinophils in NPs and sinus tissues per high-power field  was counted by one pathologist. Radiological and histological evaluations were independently performed under a blinded manner, respectively.1 according to the ATS/ERS recommendations using Chestac-8900 .Spirometry was performed to assess prebronchodilator FEV,FeNO levels were measured with an oral expiratory flow rate of 50 ml/s using a Sievers NOA 280i chemiluminescence analyzer .,The sputum samples were obtained from 65 participants  with 15 minute inhalation of 3% saline after 400 μg of inhaled salbutamol.Data were analyzed using JMP 11.2.0 Start Statics . Data were presented as median . Kruskal-Wallis test followed by Steel-Dwass analysis or Chi square test was applied when the difference in indices among the 3 groups was evaluated. Comparisons of CRS patients with or without asthma were made using Wilcoxon rank-sum test. For categorical variables, chi-square tests or fisher exact tests were applied. A p value ≤ 0.05 was considered significant when α error was set at 5%.Spearman rank correlation was used to assess association of sputum periostin with other lower airways variables, and association between upper and lower airways indices. When a ρ value showed < |0.40|, we considered that a correlation between variables might not mean a lot even if a p value was significant.Eighty-four participants  were eligible for this study. Characteristics of participants were shown in CRS patients showed lower Open Essence scores and higher SNOT-22 scores than healthy subjects, indicating that their olfactory function and QoL were impaired by CRS . ParticuWhen confined to CRS patients, 38 had NPs. Patients with asthma had significantly higher prevalence of NPs, radiologically more severe CRS, more prominent infiltration of eosinophils in NPs and sinus tissues, as compared with those without asthma . These sWhen they were stratified according to the presence or absence of NPs , patient1 values were lower in patients with comorbid asthma than the other groups.To evaluate the impact of CRS on the lower airways, inflammatory and functional markers of lower airways were compared among the three groups . Sputum 1 also showed a significant correlation with sputum periostin, though it was weak .Additionally, olfactory function, CRS-related QoL, and eosinophils in NP or sinus tissues were unrelated to FEVWe have demonstrated, for the first time to the best of our knowledge, that periostin levels are increased in the lower airways, as examined by sputum, of patients with CRS, even when asthma does not coexist. These levels, as well as FeNO levels, were significantly associated with eosinophilia of NPs. Moreover, the impairment of olfactory function was prominent when CRS patients had comorbid asthma. These results strongly indicate the existence of mutual interaction between upper and lower airways, which would affect the pathophysiology of unified airway diseases.CRS patients showed a significant increase of sputum levels of periostin as compared with healthy controls, but these levels were comparable when the patients were stratified by the presence or absence of NPs. In the gene expression analysis of periostin comparing between NPs and inflamed sinuses of patients with CRSwNP, the expression was five-fold higher in NPs than in inflamed sinuses,There is another explanation of increased expression of periostin in lower airways even when asthma does not coexist. In experimental models using rabbits, artificial sinusitis established by a complement fragment could elicit AHR to histamine.,Anosmia is a major symptom of CRS and it is often refractory to topical corticosteroids.,Dermatophagoides pteronyssinus levels.14,We have firstly demonstrated the relevance of sputum periostin levels in the pathophysiology of unified airway diseases. In the present study, sputum periostin levels were significantly higher in CRS patients with comorbid asthma than those without asthma. This may be the consequence of asthma. Periostin could facilitate not only the recruitment of allergen-induced eosinophils to the lung tissue but also a 5- to 8- fold increase of eosinophil adhesion to fibronectin.14We would like to point out some limitations to our study. First, 33 of 56 CRS patients had past smoking history. Although smoking is one of the most important factors of the development of CRS, the development of the lower airway inflammation may be affected by past smoking rather than CRS-related factors such as naso/sino-bronchial crosstalk and post-nasal drips. However, the influence of smoking on sputum periostin levels has not been confirmed yet; one study of poorly-controlled asthma showed similar periostin levels between never smokers and past smokers.In conclusion, we have demonstrated that periostin levels and inflammatory cells such as eosinophils and neutrophils in the lower airways are increased in patients with CRS, suggesting the presence of mutual interactions between upper and lower airways even if asthma does not coexist. Eosinophilic NPs may be associated with Th2-driven inflammation of the lower airways through naso/sino-bronchial crosstalk and post nasal drips, indicating that eosinophilic NPs may be related to the pathophysiology of unified airway diseases. Moreover, olfactory dysfunction could be a potential indicator of eosinophilic inflammation in lower airways and asthma. Further longitudinal studies are necessary to clarify how mutual interaction between upper and lower airways affects the pathophysiology of unified airway diseases.Novartis Pharma, Japan; Tanabe Mitsubishi pharma, Japan; and KOBAYASHI FOUNDATION, Japan.This study was supported in part by research grants from Y.K. reports research grants from Novartis Pharma, and Tanabe Mitsubishi pharma for the submitted work, and grants from MSD and Kyowa-Kirin corporations outside the submitted work. M.S. reports research grants from Kobayashi Foundation for the submitted work. S. F. reports personal fees from AstraZeneca, personal fees from Eli Lilly Japan outside the submitted work. H.O reports research grant from Boehringer Ingelheim outside the submitted work. K.M. reports personal fees from Pfizer and Chugai Pharmaceutical outside the submitted work. T.O reports personal fees from AstraZeneca, Eli Lilly Japan, Taiho Pharmaceutical, Pfizer, Chugai Pharmaceutical, MSD, Daiichi Sankyo, and Asahi Kasei Pharma, and research grants and personal fees from Kyowa Hakko Kirin, Boehringer Ingelheim, Ono Pharmaceutical, and Novaltis outside the submitted work. K.I. reports research grants from Shino-Test Corporation for the submitted work. M.T reports research grant from Pfizer outside the submitted work. A.N. reports personal fees from Astellas, AstraZeneca, Kyorin, GSK, and Boehringer Ingelheim, and research grants from Astellas, Kyorin, Boehringer Ingelheim, Novartis, MSD, Daiichi Sankyo, Taiho, Teijin, Ono, Takeda, Maruho Pharmaceutical outside the submitted work.Not applicable.None.This study was approved by the Ethics Committee of Nagoya City University (Number 1165) and was registered on the UMIN Clinical Trials Registry (Registry ID UMIN000018672). Written informed consent was obtained from all participants.YK: established the conception of the whole study, and contributed to the performance of diagnostic tests, the collection of data, the recruitment of patients, disease diagnosis and management, the acquisition and interpretation of data, and drafting the manuscript. KF, NT, RK, HN and JY contributed to the performance of diagnostic tests, the collection of data, and the acquisition and interpretation of data. YN, TA, and MT contributed to the recruitment of patients, disease diagnosis and management, and revision of the manuscript. YO contributed to assess the radiological severity of CRS. AM made specimens and assessed the infiltration of eosinophils in upper airway tissues. SF, HO, KM, YI, and TO contributed to the diagnostic tests, the collection of data, and management of patients. KI, SO, and JO carried out the measurement of periostin. MS and AN contributed to the recruitment of patients, disease diagnosis and management, interpretation of data, and revision of the manuscript.


This review presents the analytical techniques, processing and analytical steps used in metabolomics phenotyping studies, as well as the main results from epidemiological studies on the associations between metabolites and high blood pressure.A variety of metabolomic approaches have been applied to a range of epidemiological studies to uncover the pathophysiology of high blood pressure. Several pathways have been suggested in relation to blood pressure including the possible role of the gut microflora, inflammatory, oxidative stress, and lipid pathways. Metabolic changes have also been identified associated with blood pressure lowering effects of diets high in fruits and vegetables and low in meat intake. However, the current body of literature on metabolic profiling and blood pressure is still in its infancy, not fully consistent and requires careful interpretation.Metabolic phenotyping is a promising approach to uncover metabolic pathways associated with high blood pressure and throw light into the complex pathophysiology of hypertension. High blood pressure is the leading modifiable cause of death worldwide; even small increments in blood pressure are associated with an increased risk of cardiovascular disease (CVD) •, 2. ExtMetabolic phenotyping (metabolomics), the study of low molecular weight molecules or metabolites produced within cells and biologic systems, offers a promising approach to measure biological effects of environmental and other exposures and discover novel disease biomarkers •• with aHigh-throughput metabolic phenotyping or profiling is a powerful tool in systems biology  that is 1H NMR) spectroscopy, and Mass Spectrometry (MS) coupled to an array of separation techniques including Gas Chromatography (GC) and Liquid Chromatography (LC). These methods are complementary to each other [Low molecular weight metabolites are intermediates or end products of cellular processes and as an ensemble characterise the function of an organism. The main analytical methods used are proton Nuclear Magnetic Resonance . In metabolic phenotyping, where small molecules are studied, z is equal to one, so that m/z ratio coincides with the mass. Different ionisation techniques can be used, with Electrospray Ionization Technique (ESI), both in negative and positive mode, being the most applicable in metabolic phenotyping research [By contrast, MS is characterised by high sensitivity (1 pmol/L), allowing the detection of less abundant metabolites. It is particularly useful for global metabolite profiling, as thousands of metabolites can be detected in a single run , 28. Itsresearch , 30. Majresearch •. Moreovresearch . The latMetabolic phenotyping through NMR or MS can be hypothesis driven, named as a targeted approach , where oThe most frequently used samples in human metabolomics studies are blood and urine as they are relatively easy to collect and provide a comprehensive overview of various system level metabolic pathways , 37. MetData analysis of metabolic phenotyping data is relatively complex Fig. . It may Applications of metabolic phenotyping to blood pressure research have been multifaceted, including the study of lifestyle and environmental factors on blood pressure levels through biomarkers of exposure –61, inve1H NMR-based untargeted metabolic phenotyping of urine was performed on the stored 24-h urine collections from the 4630 participants. These analyses highlighted discriminatory metabolites across the four countries, of which four metabolites  were associated with blood pressure of individuals. Two of these metabolites were inversely related to blood pressure, formate (a byproduct of fermentation of dietary fibre by the gut microbiome), and hippurate . Alanine, on the other hand, which is higher in people who predominantly consume animal rather than vegetable products, was directly associated with blood pressure. Hippurate and 2-hydroxy-isobutyrate, derived from microbial degradation of dietary proteins, also discriminated between North and South Chinese populations, at differing cardiovascular risk (higher blood pressure and rates of stroke in North vs South China) [By far, the largest piece of evidence regarding small metabolites and pathogenesis of high blood pressure comes from the INTERnational collaborative study on Macro/micronutrients And blood Pressure (INTERMAP) that included 4630 men and women aged 40–59 years from 17 population samples in the USA, UK, Peoples’ Republic of China, and Japan ••. The sh China) .N-oxide (TMAO) and atherosclerosis [The importance of the gut microbiome in cardiovascular phenotypes such as blood pressure is further supported by studies showing a link between trimethylamine-clerosis ; TMAO, aclerosis , 80. In clerosis • while iclerosis .A role for the gut microbiome in high blood pressure was also reported in analysis of data from 896 normotensive black participants in the Atherosclerosis Risk in Communities (ARIC) study . Serum sIn the European Prospective Investigation into Cancer and Nutrition (EPIC)-Postdam study ••, 127 mn = 1494) and Hertfordshire (n = 1515) [Finally, a number of studies have supported the associations between lipid , 83 and  = 1515) •• showed = 1515) , 69.The response of blood pressure regulation to dietary interventions has been investigated through metabolic phenotyping approaches in several studies, where different dietary patterns were adopted including the DASH Diet –52, Opti1H NMR of stored 24-h urine samples among 58 individuals with prehypertension or stage 1 hypertension. In a randomised crossover design, participants received a carbohydrate rich (OMniCarbo), a protein rich (OmniProt), or a monounsaturated fat-rich (OmniMFA) diet, for 6 weeks each. Blood pressure was significantly associated with six urinary metabolites reflecting (i) dietary intake: proline-betaine (inverse) and carnitine (direct); (ii) gut microbial co-metabolites: hippurate (direct), 4-cresyl sulfate (inverse), and phenylacetylglutamine (inverse); and (iii) tryptophan metabolism: N-methyl-2-pyridone-5-carboxamide (inverse). These results demonstrate, in a trial setting, changes in metabolic profiles from manipulation of dietary macronutrient content that lowers blood pressure levels.The metabolic response to OmniHeart diet •• was stMetabolic phenotyping in relation to dietary sodium reduction has also been studied. The response of dietary sodium reduction (DSR) was studied in a 10-week crossover RCT study among 17 adults with elevated systolic blood pressure (130–159 mmHg) . Ten  from the Genetics of Drug Responsiveness in Essential Hypertension (GENRES) study received in a double-blind rotational design amlodipine, bisoprolol, hydrochlorothiazide (HCTZ), and losartan, each as monotherapy for 1 month, with 1-month placebo cycles between each treatment . TreatmeA variety of metabolomic approaches applied to a range of epidemiological studies has been used to uncover the pathophysiology of high blood pressure. Several pathways have been suggested in relation to blood pressure including the possible role of the gut microflora ••, 57, iThe work presented was carried out within the framework of a Stavros Niarchos Foundation grant to Aikaterini Iliou at the National and Kapodistrian University of Athens. Dr. Elliott is Director of the Medical Research Council-Public Health England Center for Environment and Health and acknowledges support from the Medical Research Council and Public Health England (MR/L01341X/1). He also acknowledges support from the National Institute of Health Research Biomedical Research Center at Imperial College London, and the National Institute of Health Research Health Protection Research Unit in Health Impact of Environmental Hazards (HPRU-2012–10141). Dr. Elliott is a UK Dementia Research Institute Professor, UK Dementia Research Institute at Imperial College London. This work was supported by the UK Dementia Research Institute which receives its funding from UK Dementia Research Institute Ltd. funded by the UK Medical Research Council, Alzheimer’s Society and Alzheimer’s Research UK. Dr. Elliott is associate director of the Health Data Research (HDR-UK) London which receives its funding from a consortium led by the UK Medical Research Council. This work used the computing resources of the UK MEDical BIOinformatics partnership (UK MED-BIO) which is supported by the Medical Research Council (MR/L01632X/1).


Uncontrolled blood pressure remains an urgent issue in clinical practice worldwide. This study aimed to compare the characteristics and effectiveness of hypertension control in family medicine pratice in the first treatment year, in relation to the geographical position, socio-economic standard, and access to medical services and public pharmacies in urban, rural and island environments .A historical cohort study included 213 patients diagnosed from 2008 to 2014 with essential arterial hypertension (AH) and without related complications or diabetes mellitus. Each patient was followed up for 365 days from the visit when the diagnosis of hypertension was ascertained. Normotension was defined as arterial pressure < 140/90 mmHg. The annual cost of drugs prescribed for treating newly diagnosed hypertensive patient and the total price for defined daily dose per patient were also evaluated.P = 0.981). Higher initial systolic blood pressure was a positive predictive prognostic factor on achieveing normotension (odds ratio (OR) 0.96, 95% confidence interval 0.95–0.98). ACE inhibitors were the most commonly prescribed antihypertensive agents in monotherapy (35.1%), as well as considering overall prescriptions (25.2%). Calcium channel blockers were the most commonly prescribed initial BP-lowering single agents in urban areas (28.6%), whereas angiotensin-converting enzyme inhibitors were more common in rural (28.0%) and island areas (22.7%) (P = 0.037). The median annual antihypertensive drug cost was 169.4 (95% CI 151.5–201.8) Croatian kunas and was similar across the study sites.More than half patients achieved normotension within a year from the initial diagnosis in all family medicine practices (57.3%), without significant differences among the three geographic regions  contains supplementary material, which is available to authorized users. High systolic blood pressure (BP) was one of the most frequent Level 3 risk factors for global burden of disease according to the systematic analysis published in 2016 –10. The This historical cohort study included patients of either sex, aged ≥18, whose arterial hypertension was first diagnosed from 2008 to 2014. According to clinical practice guidelines for the managament of AH valid in the time of our research, participants with the mean systolic arterial pressure ≥ 140 mmHg and/or diastolic arterial pressure ≥ 90 mmHg were classified as hypertensive –19, and Hypertensive patients were not included in the study if they had 1) AH diagnosed in the period before 2008, 2) incomplete medical records for the studied period, and 3) serious acute and chronic diseases . Since various abnormalities present in diabetes mellitus and arterial hypertension have significant pathogenetic contribution to the development and exacerbation of each other , 28, andThe data were collected from family medicine offices files. Included practices were long-standing and led by a single-physician, who had individual contracts with the mandatory national Croatian Health Insurance Fund (CHIF). Family medicine practices in Croatia provide health care for an average 1840 patients, with minimum 1275 and maximum 2125 patients allowed .Each patient was followed for 1 year after the initial diagnosis. The urban area included the city of Split and the rural area included the town of Imotski and municipalities Lećevica, Muć, and Runovići . Southern Croatian islands of Brač  and Korčula (town of Korčula) represented the island environment (Table The primary outcome measures were: 1) rate of achieving normotension after one-year treatment, 2) mean arterial pressure (MAP) before and after one-year treatment, and 3) complications of treatment, including cardiovascular complications and side effects of medications. The achieved blood pressure control was defined as the proportion of participants whose average systolic and diastolic blood pressure 365 days after the initial diagnosis  was less than 140/90 mmHg. The secondary outcome measures were: 1) choice of initial treatment, 2) diagnosis by a physician or a medical specialist , 3) length of sick leave days, 4) full or partial coverage of prescribed medications by the national insurance fund, CHIF, 5) total price for defined daily dose (DDD) of all prescribed medications per each patient, and 6) total annual cost of prescribed drugs for treating one newly diagnosed hypertensive patient.CHIF provides the mandatory health insurance in Croatia, with the obligatory health insurance contributions of employed citizens as the major source of its revenue . This puTo estimate the cost of antihypertensive drugs prescribed during 1 year, original drug packacking prices (including VAT) and prices for defined daily dose (DDD) were taken from the Basic and the Supplementary List, which were valid during data extraction, both in force since 30 May 2015 until 19 July 2015 for the Basic List and until 19 August 2015 for the Supplementary List . The totWe also recorded whether the initial antihypertensive treatment focused on lifestyle changes (Dietary Approaches to Stop Hypertension)  without 2 test. Patients’ age, MAP before and after one-year treatment, number of visits to the family medicine office and sick leave days were compared according to the patients’ place of residence, using analysis of variance (ANOVA) with the post-hoc Scheffé test. Kruskal-Wallis test and post-hoc Mann-Whitney U test were used for the median comparison of the total annual number of prescribed medications per patient and the total annual cost of drugs prescribed for treating one newly diagnosed hypertensive patient by a physician. Mann-Whitney and χ2 test were used to determine which variables were significantly different in controlled and uncontrolled hypertensive patients; those variables were further analysed by logistic regression. P-values less than 0.05 were considered statistically significant. All statistical analyses were performed using MedCalc, version 12.5 .The data were presented as a median or a mean, with 95% confidence interval (CI), depending on the data distribution; the normality of distribution was checked using the Kolmogorov-Smirnov tests. For the comparison of categorical variables we used χn = 41, 64.1%), where patients had significantly higher prevalence of dyslipidemia, the most common comorbidity  and the highest rate of patients with only primary education  from urban, 78 (36.6%) from rural and 71 (33.3%) from island environment of South Croatia  compared to the rural  and island areas  . Analysis of the outcome variables in logistic regression model indicated higher initial systolic blood pressure as a positive predictive prognostic factor on achieveing normotension .The patients in the whole sample showed a significant reduction in systolic and diastolic blood pressure . There were no differences in the participants with average systolic and diastolic blood pressure lower than 140/90 mmHg: 37 (57.8%) in urban, 45 (57.7%) in rural and 40 (56.3%) in island environment (P < 0.001). Individual physicians did not differ in prescribing medications from two Croatian National Medicine Reimbursement Lists  Croatian kunas. Only a single physician from the rural area had significantly higher annual cost than the others , whereas angiotensin-converting enzyme inhibitors (ACEI) were more common in rural  and island areas .Pharmacotherapy approaches to the first-line treatment differed in urban, rural and island environment , β-blockers ranked second , followed by calcium channel blockers  and thiazide-like diuretics .Within the first year of therapy, a total of 77 patients (39.1%) out of 197 patients who received pharmacological therapy received monotherapy, whereas 120 patients , followed by β-adrenergic receptor antagonists , calcium channel blockers  and diuretics  and ramipril  were the most widely prescribed. Thiazide-like diuretics, chlortalidone  and indapamide , were the most commonly used among single-agent diuretics. Thiazide diuretics were prescribed only in fixed-dose combinations that were available on the Croatian drug market. Among fixed-dose combinations, the most frequently applied in the first year of treatment was lisinopril in combination with hydrochlorothiazide .In the case of overall pattern of all prescribed antihypertensive agents , ACEI were again the most commonly prescribed  and bisoprolol  and similar in different geographical settings: in the second largest city in Croatia (Split) and its more geographically isolated hinterland and islands, regardless of socioeconomic inequalities , 38, accIn an indirect manner, these findings correspond to a recent study in this region, which found that general health status in this area did not differ with respect to the geographical and socioeconomic factors . It is iThe second important finding of our study was that the different antihypertensive drugs and treatment choices led to similar effectiveness in BP control. ACE inhibitors were the most widely prescribed antihypertensive single drug therapy in the first-line in rural (28.0%) and island areas (22.7%), whilst calcium channel blockers predominated in urban setting (28.6%). The choice of initial treatment was in line with the 2013 guidelines of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC), which recommended the following five pharmacotherapeutic groups for the initiation and maintenance of antihypertensive treatment – diuretics, β-blockers, calcium channel blockers, ACE inhibitors and angiotensin receptor II blockers, as monotherapy or combined polytherapy . HoweverDiuretics are the first-line therapy choice for most hypertensive patients according to the recommendations of the Seventh Joint National Committee (JNC 7) guidelines  as well Since better BP reduction is often achieved by combining drugs from two different classes in comparison with doubling the dose of one drug  and withTaking into account that we found only a single physician from rural area with significantly higher total annual cost of prescribed drugs for treating one newly diagnosed hypertensive patient, it is difficult to make judgements on differences in the costs of AH treatment across different regions. However, comparing the highest annual average antihypertensive drugs cost in this study  with the cost of €258 during follow-up period of 36 ± 3 months in French general practices , it coulPrimary care is an important interface between the patients and the health care system, shown to be associated with improved health outcomes . The resThe key strenght of this study lies in its comprehensive analysis of the effectiveness of newly diagnosed arterial hypertension treatment in primary care setting. It provides insight into the impact of primary care in the achieving control of uncomplicated essential hypertension in the real-life socio-economic conditions. The major limitation of the study is its retrospective character. Furthermore, due to the inability to access two Croatian National Medicine Reimbursement Lists valid in time periods that involved one-year following intervals, original drug packaging prices were taken from the Croatian National Medicine Reimbursement Lists which were valid during the data extraction, in force since May 2015 . FinallyTo conclude, there is a remarkable lack of association between socioeconomic conditions and uncomplicated arterial hypertension control in primary care setting. Different antihypertensive prescribing patterns seem do not have an impact on the effectiveness in blood pressure control after the one-year treatment. Family physicians seem to be able, without any intervention by medical specialists, to achieve normotension in newly diagnosed patients with arterial hypertension, emphasizing their key role in dealing with this major public health problem.Additional file 1:Table S1. General characteristics of patients according to their blood pressure control after one-year treatment. Table S2. Prescribed pharmacological subgroups for patients with and without achieved blood pressure control after one-year treatment. Table S3. Prescribed generic names for patients with and without achieved blood pressure control after one-year treatment. (DOCX 68 kb)


Kidney transplantation is the only curative treatment option for end-stage renal disease. The unavailability of adequate organs for transplantation has resulted in a substantial organ shortage. As such, kidney donor allografts that would have previously been deemed unsuitable for transplantation have become an essential organ pool of extended criteria donor allografts that are now routinely being transplanted on a global scale. However, these extended criteria donor allografts are associated with significant graft-related complications. As a result, hypothermic oxygenated machine perfusion (HOPE) has emerged as a powerful, novel technique in organ preservation, and it has recently been tested in preclinical trials in kidney transplantation. In addition, HOPE has already provided promising results in a few clinical series of liver transplantations where the liver was donated after cardiac death.The present trial is an investigator-initiated prospective pilot study on the effects of HOPE on extended criteria donor allografts donated after brain death and used in kidney transplantation.A total of 15 kidney allografts with defined inclusion/exclusion criteria will be submitted to two hours of HOPE via the renal artery before implantation, and are going to be compared to a case-matched group of 30 patients (1:2 matching) who had kidneys transplanted after conventional cold storage. Primary  and secondary  endpoints will be analyzed within a six-month follow-up period. The extent of ischemia-reperfusion injury will be assessed using kidney tissue, perfusate, and serum samples taken during the perioperative phase of kidney transplantationThe results of this trial are expected in the first quarter of 2020 and will be presented at national and international scientific meetings and published in international peer-reviewed medical journals. The trial was funded in the third quarter of 2017 and patient enrollment is currently ongoing.This prospective study is designed to explore the effects of HOPE on extended criteria donor kidney allografts donated after brain death. The present report represents the preresults phase.Clinicaltrials.gov NCT03378817; https://clinicaltrials.gov/ct2/show/NCT03378817 Since Joseph Murray’s pioneering efforts in 1954, allogenic kidney transplantation has evolved as the standard treatment for end-stage renal disease . SeveralDynamic organ preservation approaches, such as machine perfusion, hold promise for improving organ preservation and resuscitation of marginal donor allografts -9. AlthoIn the preclinical setting, the positive effects of HOPE have recently been demonstrated through a reduction in the incidence of tubular damage, macrophage activation, and functional optimization of cellular energy-status in vitro and in vivo ,9,11. ThThe aim of this prospective cohort study is to investigate the effects of HOPE on ECD kidney allografts donated after brain death. This study utilizes a comprehensive sample collection protocol to assess the subcellular mechanisms of HOPE in the clinical setting.The present trial is an investigator-initiated pilot study on the effects of HOPE on ECD-allografts in donated after brain death kidney transplants. Patients older than 18 years of age, suffering from end-stage renal disease (ESRD), listed for kidney transplant, and receiving ECD organs at the Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany, are eligible for the study. Informed consent was obtained from all subjects participating in the trial by a qualified member of the study team. Inclusion and exclusion criteria are listed in Inclusion Criteria:Signed informed consent18 years or olderSuffering from ESRD Listed for kidney transplantReceiving ECD (extended criteria donor)-allograftsExclusion criteria:Recipients of living donor kidney transplantsPrevious solid organ transplantationCombined procedures Participation in other kidney-related trialsThe subject received an investigational drug within 30 days prior to inclusionThe subject is unwilling or unable to follow the procedures outlined in the protocolThe subject is mentally or legally incapacitatedNon-German or non-English speakersFamily members of the investigators or employees of the participating departmentThe subject suffers from uncontrolled bacterial or viral infectionin situ flushing of the abdominal organs and the beginning of cold ischemia time), allografts will be removed and transported in a standardized fashion on packed ice. Required data regarding the donor and the organ will be collected and will be transferred to designated case report files (CRFs).ECD kidney allografts will be retrieved by local procurement teams with the Eurotransplant network. Following cross-clamping  transplanted with ECD organs after conventional cold storage, using identical surgical techniques and perioperative treatment at the Department of Surgery and Transplantation, University Hospital RWTH Aachen. The present trial comprises two groups, a perfusion  and a control conventional cold storage group . Patients on the waiting list for kidney transplant with proven written consent will be recruited. HOPE will be applied to the allograft in the operating room after regular organ procurement, transport, and back-table preparation .2), with a partial pressure of oxygen (pO2) of 60-80 kilopascals (kPa), by an oxygenator included as a disposable part of the setup. Perfusion parameters registered by the device will be stored automatically and evaluated for possible patterns. Immediately prior to perfusion, grafts will be flushed with perfusate solution to wash out the residual histidine-tryptophan-ketoglutarate (HTK) solution. Storage, management, and use of the medical products will be carried out according to the manufacturer’s guidelines.We adapted a protocol based on clinical studies with nonoxygenated hypothermic machine perfusion, and on preclinical experience with HOPE ,18,19. HDonor urine output over the last 24 hours before retrieval, cold ischemic time (CIT), and the recipients Charlson comorbidity index  have beeKidney grafts will be implanted heterotopically to the iliac fossa, as per our institutional protocol. The renal vein is anastomosed first, end-to-side to the external iliac vein, followed by renal artery anastomosis to the external iliac artery in the same fashion. After reperfusion of the kidney, the ureter is implanted into the bladder, according to Lich-Gregoir, and the uretero-cystostomy is stented with a 6-French double-J stent.Ischemia reperfusion injury will be assessed using kidney tissue samples taken upon arrival of the organ (before HOPE) and at the end of implantation after reperfusion, but before closure of the abdomen, to evaluate the extent of IRI . In totaAll patients will be treated according to our institutional protocol. Aside from HOPE for the donor kidneys, all procedures, including peri- and intraoperative management, are conducted in accordance with standard surgical kidney transplant management. The applied immunosuppressive regimen is based on intraoperative induction therapy with intravenous methylprednisolone and either basiliximab or thymoglobulin followed by corresponding oral doses of prednisolone, tacrolimus, and mycophenolate mofetil.The primary endpoint is DGF, which is defined as the need for dialysis in the first 7-days posttransplantation. The secondary endpoints of the study include: (1) duration of DGF  and functional DGF ; (2) creatinine reduction ratio day 2 ([creatinine day 1−creatinine day 2]/creatinine day 1) and Creatinine reduction ratio day 5 ([pretransplant creatinine−creatinine day 5]/pretransplant creatinine); (3) incidence of postoperative complications, as assessed by the Clavien-Dindo complication score and the comprehensive complication index ; (4) durTo the best of our knowledge, aside from a sole case of HOPE-treated dual kidney transplant reported recently, no experience of HOPE in human donation after brain death kidney transplant has been published yet . In the P<.05.Patients will be given consent forms while in our outpatient clinic. Data will be obtained using study specific CRFs completed by the members of the study team. Subjects will be informed about data protection, including pseudonymization. Encoded data will only be provided to authorized persons . The study will be prematurely terminated for any individual subject in case of study-related complications or if the subject withdraws informed consent. Parametric and nonparametric tests will be done according to the normality of the data distribution. Two-way analysis of variance will be used for the time-course analysis of laboratory parameters. The log-rank test will be used for comparisons between Kaplan-Meier curves of six-month graft survival. Statistical significance will be defined as P<.05 using the Chi-squared test) in the HOPE group compared to the matched conventional cold storage group (efficacy).Exclusively certified medical products will be used. Blood sampling and tissue biopsies during the transplant procedure will be performed according to clinical standards, preventing any relevant study-related risks or additional burden on the subjects. An interim analysis will be performed as soon as 10 patients are HOPE-treated. The trial will be terminated immediately if the following criteria is fulfilled: significantly higher DGF rate , and all national legal and regulatory requirements. The institutional review board of the University RWTH Aachen has approved the study protocol, including consent form and patient information leaflet (EK 184/17). Members of the study team have completed a course in good clinical practice as certified by the German Medical Chamber.The study group of the present trial comprises the trial sponsor  and the principal investigator (GL) of the University Hospital RWTH AachenIRI is an inevitable event in organ transplantation. Reduction of oxygen delivery because of blood flow interruption leads to anaerobic metabolism and the production of oxygen-free radicals and oxidative stress as a respiratory burst at the onset of reperfusion. IRI plays a key role in DGF and primary graft nonfunction following kidney transplantation, depending on initial organ quality ,9,24,25.Results of this trial will be presented at national and international scientific meetings and published in international peer-reviewed medical journals. The trial was funded in the third quarter of 2017. Patient enrollment is currently ongoing, and the first results are expected in the first quarter of 2020.Allogenic kidney transplantation has evolved as the mainstay of treatment for end-stage renal disease ,28. The We identified four active clinical trials exploring the effects of HOPE in kidney transplantation. In a pilot study by Ravaoili et al, 20 subjects were recruited to receive either HOPE-treated ECD-kidney or ECD-liver allografts. Whether the organs used were donated after cardiac death or donated after brain death remains unclear (NCT03031067; Although we have designed our trial carefully, nonrandomization of the study groups and nonblinding of the transplant team, as well as matching with a historical group, are limitations of the present study. Nevertheless, conclusive clinical data about end-ischemic HOPE in human kidney transplantation are still missing and larger multi-center studies on this topic are currently underway. Therefore, it seems plausible to conduct this trial as a pilot study with a focus on short-term outcomes as well as translational research aspects of HOPE in ECD-kidney transplantation.The present trial, nevertheless, possesses some specific strengths in that it focuses on patients solely receiving ECD-allografts, a population in which we anticipate the best cost/benefit ratio from the utilization of HOPE. Kidney transplant outcomes stem from a combination of various factors. Our matching criteria have been carefully selected based on previous clinical evidence to include both donor and recipient factors, which have a key role to play in posttransplant outcome ,31. Rega


Resistant hypertension (RH) is defined as uncontrolled blood pressure despite treatment with three or more antihypertensive medications, including, if tolerated, a diuretic in adequate doses. It has been widely known that race is associated with blood pressure control. However, intense debate persists as to whether this is solely explained by unadjusted socioeconomical variables or genetic variation. In this scenario, the main aim was to evaluate the association between genetic ancestry and resistant hypertension in a large sample from a multicenter trial of stage II hypertension, the ReHOT study. Samples from 1,358 patients were analyzed, of which 167 were defined as resistant hypertensive. Genetic ancestry was defined using a panel of 192 polymorphic markers. The genetic ancestry was similar in resistant  and nonresistant hypertensive patients  (p > 0.05). However, we observed a statistically suggestive association of African ancestry with resistant hypertension in brown patient group. In conclusion, increased African genetic ancestry was not associated with RH in Brazilian patients from a prospective randomized hypertension clinical trial. Many studies have correlated the predisposition to hypertension with African ancestry5. In particular, apart from the association with Black race (which has been extensively described), much discussion persists on the reasons for this association. For one point, socioeconomically inequalities are pervasive in most Western populations and known to be very difficult to adjust for in epidemiological studies6. Nonetheless, several lines of evidence also point to a higher frequency of potentially deleterious alleles in individuals with high African ancestry, leaving the question of into what degree the association between hypertension and race is biologically defined7. This may have wide impact on the future management of hypertension from a medical standpoint, as well as in the development of health policies targeted as reducing the impact of chronic disease in the general population.Hypertension is one of the predominant driver of cardiovascular diseases9. Patients with RH have even higher risk of cardiovascular complications than hypertensive patients10. It is estimated that 10–20% of people with hypertension are resistant, underscoring the importance of understanding the determinants of this condition13.Resistant hypertension (RH) is defined by uncontrolled blood pressure despite treatment with three or more antihypertensive medications, including, if tolerated, a diuretic in adequate doses15. Of particular importance to the present work most Brazilians are defined as a mosaic of these three main ancestries and a much higher degree of discordance between self-referred race and genetic ancestry is seem as compared to the US18.In Brazil, self-declared race/color is based on a complex subjective phenotypic and cultural assessment because the Brazilian population is highly admixed with the main ancestral contributing populations being European, African and Amerindian19. These measurements were taken until two consecutive measurements differing less than 4 mmHg between them, with a very controlled methodology and prospectively, being a robust way to identify RH patients. Thus, with a significant number of diagnosed RH patients, we sought to evaluate a possible association of genetic ancestry with RH in a large multicenter prospective randomized clinical trial from the ReHOT study20.In this scenario, we have an interesting hypertensive population to evaluate, with systolic blood pressure >160 mmHg and <220 mmHg, and/or diastolic >100 mmHg, in the seated position20. The Ethics Committee for Human Medical Research of the Clinical Hospital of the School of Medicine, University of São Paulo approved the study protocol (protocol number 0758/09) and all individuals signed an informed consent form in accordance with the Declaration of Helsinki and good clinical practice guidelines. This study was registered at clinicaltrials.gov under the number NTC1643434.The patients come from a prospective randomized clinical trial  that was conducted between 2012 and 2014. It included hypertensive patients from 26 sites located in different states in BrazilTM. A commercial genotyping custom chip from Applied BiosystemsTM, containing 192 single nucleotide polymorphisms  are important tools to differentiate populations and estimate proportions of ancestry. These analyze are based on genetic ancestry (GA) whose allelic polymorphisms frequencies vary markedly in different racial and ethnic groups and they can be used to control wrong results from stratifications and analyses by race24, which is a tool for estimating the maximum likelihood of individual ancestors of data sets of multilocus SNP genotypes. The ancestry proportions were estimated for our samples using the panel of AIMs and samples from HapMap, HGDP and 1000 Genomes projects as reference for European, African and Native American populations21.The analysis of GA was performed using the Admixture program24.The reference populations used for African were ASW, LWK and YRI from HapMap3 ; Bantu and Mandenka from HGDP (Sub-Saharan Africa). The populations used for European were CEU and TSI from HapMap3 ; GBR and IBS from 1000 Genomes  and Orcadian, Russian from HGDP (Northern Europe). In the end, the populations used for Amerindian were MEX from 1000 Genomes (Mexican Ancestry from Los Angeles USA); Pima, Maya, Karytiana and Surui from HGDP (Mexico and Brazil). After choosing the populations, the GA of each patient in the Admixture program was calculated25. For the statistical analysis, we used the R program (version 3.0.0). Chi-square or Fisher’s exact tests were used to compare categorical variables. Resistant hypertension was used as a binary variable. T-test, Mann-Whitney, Anova and Kruskal-Wallis were used to determine differences between the means of numerical variables.Manipulation of the genotypic database was done by the PLINK programSamples from 1,358 patients were analyzed for the proportions of EUR, AFR and AMR ancestry. From these, 165 were resistant hypertensive patients. Table A stratified analysis was performed on two groups (white and non-white) Table . The groIn an analysis stratified by white, brown and black, no significant association of the GA with RH was observed 32. In addition, a meta-analysis, which analyzed the global prevalence of RH from data of 3.2 million patients, did not observe differences33. Some studies have observed genetic variants associated with risk for resistant hypertension35. However, to the best of our knowledge, studies of genetic ancestry and RH are not identified in the literature. Our hypothesis was that an increased proportion of African ancestry might be a risk factor for RH, in the overall group or even in subgroups among self-declared race/color, but this was not confirmed. However, in brown patient group, we identified a statistically suggestive association of African ancestry with resistant hypertension. This statistically suggestive association suggests that the criteria applied to segregate the race/color groups, according Brazilian Institute of Geography and Statistics, are possibly distorting the real distribution and, at least in part, leading a limitation for dividing into homogeneous groups. Thus, further investigations and new hypothesis should be tested to elucidate possible associations.On the other hand, some studies, including the present study, did not find an association of self-reported race/color with RH. A study with 9,361 hypertensive patients from the US, did not find differences in RH proportions according to race36. In addition, the cutoff blood pressure criteria for RH was reduced from 140/90 mmHg to < 130/80 mmHg9. Thus, prevent damages by RH and identify better treatments is important, because the number of RH patients can increase with this new cutoff40. A possible limitation of our study is the low statistical power to differentiate mean values of African ancestry among patient groups.The prevalence and incidence of RH will grow considerably because there is a large number of overweight/obese individualsIn the present study, genetic ancestry was not associated with resistant hypertension in Brazilian patients from a prospective randomized clinical trial.Supplementary infomation.


Asthma is a heterogeneous disease which is usually associated with chronic airway inflammation. Saffron has anti-inflammatory effects and may has beneficial effects on asthma.The present study was intended to survey the effects of saffron supplementation on blood pressure, lipid profiles, basophils, eosinophils and clinical symptoms in patients with allergic asthma.Our study was a clinical trial.N = 80, 32 women and 48 men, 41.25 ± 9.87 years old) with mild and moderate allergic asthma were randomized into two groups: the intervention group who received two capsules of saffron (100 mg/d), and the control group who received two capsules of placebo for 8 weeks. SPSS software (version 16.0) was used for the data analysis.Subjects (p < 0.001). Besides, asthma severity decreased almost significantly in the saffron group (p = 0.07). It was also found that saffron, in comparison with the placebo, significantly reduced the systolic and diastolic blood pressure, triglycerides and low density lipoprotein cholesterol. Moreover, eosinophils and basophils concentration reduced in the saffron group (p = 0.06 and 0.05 respectively).Saffron improved the frequency of clinical symptoms of the patients  in comparison to the placebo (Saffron seems to be an effective and safe option (in 8 weeks supplementation) to improve clinical symptoms of patients with allergic asthma but the toxicity and/or long-term effects of saffron intake are not known. Registration ID in IRCT (IRCT2017012132081N2). There is some evidence supporting the role of inflammation in the pathogenesis of allergic asthma. According to previous studies, saffron has been found to have anti-inflammatory effects.Saffron was found to be effective in alleviating clinical pulmonary symptoms in allergic asthmatic patients. Moreover, asthma severity improved following saffron supplementation.This study implies that saffron may have beneficial effects on allergic asthma.Asthma, as a heterogeneous disease is usually associated with chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, chest tightness, shortness of breath and cough that vary over time and in intensity, together with variable limitations in expiratory airflow. Allergic asthma is the most easily recognized phenotype of asthma which often starts in childhood .It is esOne of the risk factors of asthma isgenetic. andSome triggers of asthma symptoms which are usually associated with environmental factors include exposure to allergens and access to healthcare services .It is be(Crocus sativus L.) has been used for the treatment of heart disease, depression, stress and sleep disorders [In traditional medicine, saffron isorders . Saffronisorders , anti-inisorders  and muscisorders . Active isorders . It is risorders . Besidesisorders . Resultsisorders . In turnisorders .According to the anti-inflammatory and antioxidant activity of saffron, it seems that saffron supplementation can beneficially affect asthmatic patients. Thus the present study, which is to our best knowledge the first clinical trial in the relationship between asthma and saffron, investigated the effect of saffron supplementation on asthma clinical symptoms, asthma severity score, blood pressure and lipid profiles in patients with mild and moderate persistent allergic asthma in arandomized clinical trial.1 = 0.231 and p2 = 0.0, the sample size of 29 subjects in each group was calculated. Considering the probability of filling 25% of the samples, the final sample size of 39 subjects in each group (78 subjects) was calculated. The sample size calculation was based on the asthma severity change.This was a randomized, double blind, and placebo-controlled clinical trial with a parallel design. The sample size was calculated based on the comparison of ratios formula with α = 0.05 and β = 0.2. As there is no similar study to our trial, we used the data of our pilot study and by рThe comparison of ratios formula Considering the length of the treatment, 40 subjects were finally enrolled in each group (1: 1 ratio) according to a computer-generated blocked randomization list with a block size of 6. To decrease the probable bias, we used an allocation concealment technique. A researcher, who did not have any clinical participation in the study placed the saffron and placebo capsules into numbered bottles based on a random list. Another researcher, who was not aware of the random sequences and was not involved in the trial, assigned the numbered bottles to the patients. After the allocation was done, the participants were asked to fill in all the questionnaires during the baseline visit. The blood samples were then collected in the next day and the participants were accordingly allowed to start having treatment capsules. Filling the questionnaires and taking blood samples were repeated again at the end of the study. Every two weeks all the participants were contacted to remind them about taking the treatment capsules and also ask them to report possible side effects of the treatment. Anthropometric measurements including weight and height were determined pre- and post-intervention. Disease history, demographic data, history of using medications and supplements, history of smoking and physical activity level  were also assessed. All the participants, researchers, and the physicians were blind to the allocations using the random codes until the statistical analyses were completed. In the eight-week study period, all the participants were given dietary advices such as avoiding consumption of saffron (from food), fast foods, sausage, smoked and canned foods. Patients were also asked not to change their energy intake and physical activity during the study. To control the energy intake, we used the 24-h recalls of 3 days (2 work days and one weekend day). According to the doctor recommendations, patients were asked not to go out when the air was polluted and use filter masks in emergencies. The lung specialist used the same drugs for the patients in this study. Compliance was monitored during a weekly call, assessing compliance by asking the number of capsules consumed. Those subjects who did not take their capsules regularly or were intolerant to the medication were excluded from the study. Our patients had no disease except asthma and consumed no drug except asthma drugs. Personal information of participants collected, shared and maintained in order to protect confidentiality before, during, and after the trial by coding the patients.2. The exclusion criteria included smoking, pregnancy, lactation, diabetes, autoimmune disease, malignancy and other pulmonary diseases. The chemical drugs which our patients consumed were not significantly different between saffron and placebo groups (p = 0.66). All the patients provided written informed consent, and the whole protocol met the requirements of Ahvaz Jundishapur University of Medical Sciences Ethics Committee.Participants included 80 men and women between the ages of 18 and 65 years. According to the Global Initiative for Asthma (GINA) diagnostic criteria for asthma, 80 patients with mild and moderate allergic asthma were examined by an attendant pulmonologist in May and October 2017, and were then recruited from the outpatient clinic at Imam Khomeini Hospital, Ahvaz, Iran. After that, the participants were provided with information about the study by both verbal explanation and written information sheets. They were asked to take the capsules regularly, provide adequate tracking information, and complete the questionnaires and the treatment procedure until the end of the study. To collect information on their socio-demographic status, occupation, smoking behavior, medical history and medication, all patients were also interviewed. The inclusion criteria were an age range of 18–65 years, with mild and moderate persistent allergic asthma according to the GINA criteria and body mass index (BMI) up to 27 kg/m(Crocus sativus L.) stigma or a placebo . The placebo capsules contained edible colors similar in color, shape, size, and package to the saffron ones. Dried saffron stigma was taken from Estahban, Fars province, Iran (Herbarium code: JPS018118). It was formulated as a capsule containing 50 mg of dried saffron stigma and starch (as fillers). The placebo capsules contained starch and permitted food colors to trace amount . The patients received the capsules at the start of the trial in the pulmonary clinic of Imam Khomeini hospital.During the intervention, all the patients received either two oral capsules including 50 mg dries saffron The primary outcomes were to measure asthma clinical symptoms  and asthma severity at the baseline and post-intervention. Secondary outcomes were to measure eosinophils, basophils, blood pressure and lipid profiles pre- and post-intervention.Diagnosis of the allergic asthma was done through measuring the serum levels of immunoglobulin E (IgE) total by IgE enzyme-linked immunosorbent assay (ELISA) kit  and the values over than 30 international units are known as allergic patients . ClinicaBlood samples were collected at the baseline and at the end of the study. Each time, 5 mL of blood sample was drawn. The serum samples were frozen at − 20 °C immediately, and were then stored at − 80 °C until further laboratory analyses were done. Blood samples of each patient were collected in the morning after a 12-h fasting, and then the haemolyzed samples were excluded from each analysis and in these cases blood sampling were repeated.We used ELISA, as a validated method, (BIO TEK ELX 800 (microplate reader), Highland Park Winooski, VT 05404–0998, USA) for measuring IgE total. During each laboratory analysis, the technicians were blind to the saffron–placebo status. Eosinophils and basophils were evaluated in the results of Complete Blood Count (CBC)-diff. For CBC analysis, 2 ml whole blood in the tubes containing anticoagulant EDTA were placed in the automatic counting machine (Convergy® X5 made in Germany). Lipid profiles  were measured by enzymatic method kit . All laboratory tests were done in the Central Laboratory at Ahvaz Jundishapur University of Medical Sciences.We assessed the intake of calorie and the percentage of calorie from carbohydrate, protein and fat in all the patients at the baseline and at the endpoint of the trial by 24-h food recalls for two work days and one weekend. The diets were analyzed by the modified nutritionist 4 (NUT4) software. We assessed the calori intake because can affect weight gain and weight gain can affect asthma symptoms and percentage of calori intake from fat is important in respiratory disease because fats have lower work load on respiratory system. Blood pressure was measured in standard method with mercury barometer and after 15 min rest.The amount of crocin in saffron samples was measured via high performance liquid chromatography (HPLC) method . FollowiHPLC instrument was done using Agilent technology . The column used for separation was ZORBAX Eclipse plus C 18 (Rapid Resolution 4.6 × 100 mm 3.5-Microns). All the experiments were done at room temperature, and the mobile phase composition included a mixture of formic acid (0.2%), acetonitrile and methanol. Linear gradient solution system was used as 76.5% formic acid (0.2%), 13.5% acetonitrile and 10% methanol which changed into 100% methanol by 60 min. The detector was adjusted at different maximum wavelengths including 250 nm, 308 nm and 440 nm. The amount of crocin in the saffron samples was found to be 304.3 mg/kg.p-values < 0.05 were considered statistically significant.All analyses were done on the intention-to-treat population corresponding to the subjects having consumed at least one dose of the treatment. The normal distribution of the data was assessed using a Kolmogorov–Smirnov test. Blood pressure, lipid profiles, eosinophil and basophil count and dietary factors were analyzed by paired t-test or Wilcoxon paired rank test  for the within-group comparisons . On the other hand, comparisons of changes (endpoint minus baseline) after 8 weeks of intervention between the two groups were done by independent t-test or Mann–Whitney U-test . Data were reported as mean ± SD or median  for parametric and non-parametric data, respectively. Chi-squared test, or Fisher’s exact test were used for clinical symptoms of asthma and its severity and also for the baseline characteristic data. All statistical analyses were carried out using SPSS version 16 statistical software . The most important outcomes were presented at 95% confidence intervals (CI). For all the tests, two-sided From 80 patients who enrolled the trial, 76 completed the study during the 8-week supplementation period. Among the enrolled ones, 4 discontinued the study . The flow diagram describes the patients’ allocation throughout the study . In addition, there were no differences between the intervention and placebo groups regarding the age of onset of asthma at the baseline (Table p > 0.05. Data not shown)During the study, there were also no serious adverse events. A few minor feeling of warming up were reported in both groups . The drugs consumed by our patients were salbutamol, symbicort, Seroflo and telfast. There was no significant difference between two groups in regard to the drug consumption (p = 0.65).The mean age of the patients was 41.25 years old (range 18–65 years) and 60% of them were male. In the saffron group, 35% of the patients and in the placebo group 37.5% had mild asthma. Those patients with moderate asthma were 65 and 62.5% in the saffron and placebo groups, respectively. No significant differences were identified in terms of demographic, clinical characteristics, anthropometric, dietary variables, physical activity and asthma severity between the two groups, as indicated in Table p = 0.23, 0.20 and 0.40, respectively). Calorie percentage from protein was statistically significant between the two groups, however the effect of the observed difference was removed with ANCOVA (Table p = 0.28) . Besides, asthma severity improved in the saffron group (18.40% reduction in asthma severity in the saffron group in comparison to 2.60% in the placebo group), but there were no significant differences with regard to the mean change of severity of asthma between the two groups (p = 0.076)  Table .Table 3Wp = 0.005), however the changes were not significant in the placebo group (p = 0.58) and between the groups (p = 0.12). Basophil count significantly increased in the placebo group (p < 0.001), but the changes in the saffron group and also between the two groups were not significant  (Table Eosinophils significantly decreased in the saffron group (y) Table .p = 0.03). It also decreased diastolic blood pressure in comparison to the placebo group (p = .04). Besides, Triglyceride and LDL-C levels in the saffron group decreased significantly, when compared to those in the placebo (p = 0.002 and < 0.001 respectively). Saffron also decreased total cholesterol and increased HDL-C, however the changes were not significant between the two groups  2 lymphocytes which release interleukins  .Generally, according to the previous studies on animal models of allergic airway disease,saffron has several beneficial effects on asthma; such as anti-inflammatory , 11, 19,Gholamnezhad et al., (2013) showed that the saffron extract decreased serum levels of endothelin 1(as an inflammatory marker) in sensitized guinea pig  . These fIn conclusion our findings showed the beneficial effects of 100 mg saffron daily on asthma symptoms, severity, and also on systolic and diastolic blood pressure, triglyceride and LDL-C.. As our trial is the first study investigating the effects of saffron on asthma in human models; thus more studies with longer supplementation periods are required to provide additional evidence supporting the use of saffron in clinical settings.


Pulse transit time (PTT) has received considerable attention for noninvasive cuffless blood pressure measurement. However, this approach is inconvenient to deploy in wearable devices because two sensors are required for collecting two-channel physiological signals, such as electrocardiogram and pulse wave signals. In this study, we investigated the pressure pulse wave (PPW) signals collected from one piezoelectric-induced sensor located at a single site for cuffless blood pressure estimation. Twenty-one features were extracted from PPW that collected from the radial artery, and then a linear regression method was used to develop blood pressure estimation models by using the extracted PPW features. Sixty-five middle-aged and elderly participants were recruited to evaluate the performance of the constructed blood pressure estimation models, with oscillometric technique-based blood pressure as a reference. The experimental results indicated that the mean ± standard deviation errors for the estimated systolic blood pressure and diastolic blood pressure were 0.70 ± 7.78 mmHg and 0.83 ± 5.45 mmHg, which achieved a decrease of 1.33 ± 0.37 mmHg in systolic blood pressure and 1.14 ± 0.20 mmHg in diastolic blood pressure, compared with the conventional PTT-based method. The proposed model also demonstrated a high level of robustness in a maximum 60-day follow-up study. These results indicated that PPW obtained from the piezoelectric sensor has great feasibility for cuffless blood pressure estimation, and could serve as a promising method in home healthcare settings. Blood pressure (BP) is a vital physiological parameter for clinical diagnosis and treatment of hypertension, with values varying between systolic blood pressure (SBP) and diastolic blood pressure (DBP). Hypertension is one of the key risk factors for cardiovascular disease (CVD), as it is reported to be the primary cause of death and disability worldwide . The WorThe most precise method to continuously measure BP is by using arterial cannula, in which a catheter is inserted into the blood vessel , but thiCuffless BP measurement based on a one-channel pulse wave is an effective approach to reduce the complexity and inconvenience of PTT-based methods. Generally, there are optical and pressure sensing technique in pulse wave measurement. For optical technique, a photoelectric sensor is used to measure a photoplethysmogram (PPG) by calculating the light absorption changes induced by blood volume changes in arterioles . PressurIn this paper, we investigated the modeling of BP from PPW for cuffless BP estimation based on the piezoelectric technique. This study makes several contributions to the cuffless BP measurement fields. First, this study presents a comprehensive evaluation on the performance of PPW signals measured by piezoelectric sensor in BP estimation for the first time to our best knowledge, various BP indicators are extracted from PPW, and their performances in estimating BP are investigated and compared with that of existing PTT features. Second, a number of middle-aged and elderly participants (including hypertensive subjects and hypotensive subjects) are involved in our study and followed up on for a maximum of 60-day period to verify the performance of the model, thus indicating the high reliability of the proposed approach.Periodic contraction and relaxation of the heart creates rhythmic intermittent blood ejection, which leads to pulsation changes in the pressure of the artery, and then causes action–reaction processes such as vibrations of the skin surface . The pulWith the advancement of modern sensor advances in sensor technology, the pulsation changes can be recorded by a pressure sensor such as capacitive, piezoresistive, and piezoelectric device. The piezoelectric sensor has a diaphragm structure, which is an ideal design for measuring fluctuating input pressure signals . It has A typical PPW waveform is a composite of the forward wave created when the left ventricle contracts, and the reflected wave is produced when the forward wave is reflected from the peripheral vessels . It compPulse waveform analysis based on PPW is an effective diagnostic tool in medical applications. Researchers have investigated the link between the PPW character and the cardiovascular system functional status ,33,34. WA total of 65 participants (29 men and 36 women) were recruited in this study, with a mean age of 49.74 ± 8.12 years. Among them, eight subjects had hypertension (mean SBP greater than 140 mmHg or mean DBP greater than 90 mmHg over three-time BP collection via oscillometric technique) and 10 subjects had hypotensive (mean SBP less than 90 mmHg or mean DBP less than 60 mmHg over three-time BP collection via the oscillometric technique). None had taken antihypertensive drugs recently before the study was conducted. In the experiments, each participant was asked to lie down quietly to avoid motion artifacts. As shown in Finally, 1216 datasets obtained in the training set, with ranges of 121.53 ± 15.97 mmHg in SBP and 72.65 ± 10.63 in DBP, and 1040 datasets obtained in the testing set, with ranges of 119.31 ± 15.55 mmHg in SBP and 70.76 ± 10.13 mmHg in DBP. To avoid the unpredictable effects of noise and artifacts from raw signals, the signals were preprocessed to filter and denoise them. ECG signals and PPW signals were first preprocessed using a low-pass filter with a cutoff frequency of 50 Hz to remove high-frequency interference, and then the baseline drift of PPW was removed based on wavelet transformation . SubsequBased on the pulse wave analysis, 22 (numbered from 1 to 22) informative features were calculated from each beat of PPW and ECG. The first derivative of PPW (1st dPPW), the second derivative of PPW (2nd dPPW), and the ECG signals that potentially influenced BP were analyzed in the present study by using one PTT feature for comparison and 21 other PPW features, as shown in For each feature, the average beat-to-beat feature during the 1-min recording was calculated for each dataset, and then corresponded to the reference BP measurement in that dataset. A BP estimation model was firstly constructed through univariate linear regression by using the least squares method for each feature. A total of 21 PPW-based BP estimation models were constructed based on each of the above 21 features  and standard difference (SD) of the estimation errors across all of the participants . The MD and SD were defined by Equations (5) and (6), respectively. The cumulative percentage (CP) of BP estimation errors by the proposed models falling within the values of ±5 mmHg, ±10 mmHg and ±15 mmHg was calculated according to the British Hypertension Society standard (BHS) , and thet-test. The results showed that the difference was statistically significant at the level of 0.0001, indicating that the features calculated from PPW have the potential to estimate BP and exhibit a more efficient performance than that of the existing PTT feature. In the rest of the paper, the MPF model (model 22) was used for further comparative analysis with the best PTT-based BP estimation model (model 25).p < 0.0001) and 0.85 (p < 0.0001), respectively, which were higher than those of the PTT-based model . The Bland–Altman plot indicates that the estimated BP by the proposed MPF method approximated the reference BP measured by cuff-based device.To evaluate the robustness of the proposed BP estimation model, we compared the estimation accuracy at different time intervals for all 65 participants; that is, at (T + 1), (T + 3), (T + 6), and (T + 8) days after model construction. In addition, we investigated the estimation accuracy for 10 participants randomly selected from the 65 participants (T + 60) days after model construction to validate the long-term performance of the proposed model.PPW measured by the pressure sensing technique is another form of pulse wave, which not only provides information about intra-arterial pressure changes but also offers body cardiovascular system status and has the potential for the early diagnosis of vascular diseases ,24. PPW Feature extraction from the original pulse wave and the derivative of pulse wave for BP estimation has been commonly used in the literature ,14,49. TPPW is collected by using a piezoelectric sensor pressed on a single measuring point of the radial artery in our study, and thus may have suffered from high derivation. Flexible pressure sensor arrays, which can be collected in a multipoint way by affixing a group of flexible sensors to the skin, have great potential to substitute existing PPW sensors ,22. The Although this study validated the feasibility of PPW in cuffless BP estimation, some limitations require further investigation to ensure that the method is fully applicable. First, to better reconstruct the relationship between PPW and BP, the experiment was designed in a controlled scenario, with subjects required to lie down quietly for 16 measurements in the calibration process to avoid motion artifacts. Simplified experimental procedures should be considered in reality; for example, to reduce the number of measurements for training, and to allow the subjects to be in a sitting position. Second, the PPW signals were obtained using a piezoelectric pressure sensor placed on a single measuring point of the radial artery, which was complicated to operate. However, we believe that it can be operated in a wearable and stable way with the development of a flexible pressure sensor array. In addition, due to the limited number of samples in the training dataset, linear regression was used in our study. Nonlinear regression algorithms might improve the performance if enough samples are available.It this study, we evaluated the potential of utilizing a piezoelectric-induced sensor to measure PPW for BP estimation method in a cuff-less, noninvasive manner on a signal site of one hand. Based on pulse wave analysis, 21 informative features calculated using PPW that potentially influence BP were analyzed and used to develop a PPW-based BP estimation model, which was validated experimentally. A maximum 60-day follow-up study was conducted on 65 middle-aged and elderly participants, and the experimental results revealed that the PPW-based model achieved an estimation error of 0.7 ± 7.78 mmHg for SBP estimation, and 0.83 ± 5.45 mmHg for DBP estimation in terms of MD ± SD. Compared with the PTT-based model, the proposed model achieved higher accuracy, with a decrease of 1.33 ± 0.37 mmHg in SBP and 1.14 ± 0.20 mmHg in DBP in terms of estimation errors. This study thus demonstrated that PPW obtained from piezoelectric sensor could provide an effective method for cuffless BP estimation and could potentially be widely used in wearable devices for BP management.In our future work, we will focus on using a simpler and more effective sensor to collect PPW signals and to validate the accuracy of the PPW-based method for BP measurement further, with more participants to make the PPW-based model more reliable. Furthermore, some machine-learning techniques such as artificial neural networks , support


The inter-arm systolic blood pressure difference (IASBPD) is closely related to cardiovascular mortality and morbidity. The SYNTAX score indicates the extent and complexity of coronary artery disease, which are determined by coronary angiography. The aim of our study is to examine the relationship between the IASBPD  and the SYNTAX score. 104 patients were included in this cross-sectional study. The IASBPD was calculated by blood pressure measurements obtained simultaneously from both arms. The SYNTAX score was calculated by coronary angiography. Patients were divided into two groups: those with a high SYNTAX score (≥20) and those with a low SYNTAX score (<20). The mean IASBPD values were significantly higher in the group with a high SYNTAX score (≥20) (p<0.001). The patients with IASBPD≥10 were more likely to have a high SYNTAX score compared to the patients with IASBPD<10 (p<0.001). Multiple logistic regression analysis revealed that only the IASBPD values were found to be independently associated with high SYNTAX score (OR: 1.717 (CI: 1.307-2.257), p<0.001). The IASBPD values obtained by only blood pressure measurements are closely related to the extent of coronary artery disease. The Synergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) score is a commonly used tool for both short- and long-term risk classifications in patients undergoing percutaneous coronary intervention (PCI) , 2. AlthThe inter-arm systolic blood pressure difference (IASBPD) is associated with increased subclinical atherosclerosis in different areas of the arterial tree. According to a meta-analysis, inter-arm systolic blood pressure difference (IASBPD)≥10 mmHg was found to be related to cerebrovascular disease, vascular damage, and increased cardiovascular mortality . It is aOur study had a cross-sectional study design. The IASBPD was calculated by obtaining blood pressure measurements in patients before coronary angiography (CAG). From among patients undergoing planned elective CAG because of the symptoms of ischemic heart disease and ischemic findings on the treadmill test or myocardial perfusion scintigraphy, 104 patients who met inclusion/exclusion criteria were included consecutively in the study. We excluded patients with a history of myocardial infarction, PCI, or coronary arterial bypass surgery. Patients with a history of congenital heart disease, severe valvular disease, cardiomyopathy, atrial fibrillation, impulse conduction disturbances or aortic coarctation, hemiplegia, and pulseless disease and those with history of transradial coronary intervention were not included. Informed consent was obtained from all patients. The study was approved by Institutional Ethics Committee and the investigation conformed to the principles of the Declaration of Helsinki.All patients underwent CAG through transfemoral approach. Coronary anatomy was examined by two experienced invasive cardiologists. As a result of these evaluations, the same opinion was reached. The SYNTAX score for each patient was calculated by scoring all coronary lesions with a stenosis diameter as 50% in vessels 1.5 mm, using the SYNTAX score algorithm, which is described in full elsewhere . SYNTAX Height and body weight values were measured to calculate the Body Mass Index (BMI). HT was defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg or use of antihypertensive medication. Diabetes Mellitus was defined as fasting blood glucose level ≥126 mg/dL or use of insulin or an oral hypoglycemic medication. Coronary artery disease was assessed from patients' medical reports. Hyperlipidemia was defined by a total cholesterol of greater than 240 mg/dL and triglyceride of greater than 200 mg/dL. Current smoking was defined as smoking at least one cigarette per day in the year preceding the examination.The patients were made to sit for 5 minutes, with feet flat on the ground and back supported before BP measurements were taken. Two separate oscillometric blood pressure (BP) monitors with their own cuffs were used randomly, placed at the appropriate location on the arm and measured by the same trained nurse . BP deviBlood collection was performed after a 12-hour fasting. All biochemical analyses were performed within the first two hours after blood collection. Glucose, creatinine, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL), and triglyceride levels were measured. Blood count analysis was performed using an automated cell counter . t-test was used to compare continuous variables with normal distribution, and the Mann–Whitney U test was used to compare the continuous variables without a normal distribution. Correlations were sought with the Spearman's and Pearson correlation test. Binary logistic regression analysis (backward stepwise method) was performed to identify independently associated factors with high SYNTAX score (≥20). Variables with a p value <0.1 in univariate analysis were incorporated in the binary logistic regression analysis. Receiver-operating characteristic (ROC) curve analysis was performed to determine the optimum IASBPD cut-off value for predicting high SYNTAX score. A two-sided p value <0.05 was considered significant within a 95% confidence interval (CI).SPSS 17.0 for Windows  software package was used in all analyses. The continuous variables were expressed as mean ± standard deviation (SD)  and median  , and categorical variables were expressed as percentages. The Chi-Square test was used to compare the categorical variables between the groups. Analysis of normality was performed with the Kolmogorov-Smirnov test. The independent samplesA total of 104 patients were included in our study. The mean age of the patients was 58.9 ± 9.5 years. 67 (64.4%) were male. While 99 (95.2%) patients had dominant right hand, the remaining 5 (4.8%) were left-handed. The mean SYNTAX value for all patients was 9.5 ± 8.2. In addition, 15 of the patients (14.4%) had a SYNTAX score ≥20.When evaluated for the inter-arm blood pressure difference, the mean right arm systolic blood pressure (SBP) (p=0.012) and mean left arm systolic blood pressure (SBP) (p=0.019) and mean IASBPD values were significantly higher in the group with a high SYNTAX score (≥20) compared to the group with a low SYNTAX score (<20) . The numConsidering the relation between inter-arms blood pressure and SNYTAX II score, among the people whose SYNTAX II score are more than 20, mean of right arm SBP , mean value of left arm SBP , and mean IASBPD  values are measured higher.Correlation was found between SYNTAX score and mean right arm SBP , IASBPD , and LDL levels .Univariate regression analysis showed that LDL, IASBPD, gender, BMI, and exaggerated IASBPD (>10 mmHg) were significant at the p<0.1 level. However, since IASBPD and exaggerated IASBPD (>10 mmHg) are relative variables, the IASBPD values from these two variables were included in multiple logistic regression analysis. Multiple logistic regression analysis revealed that only the IASBPD values were found to be independently associated with high SYNTAX score (OR: 1.717 (CI: 1.307-2.257), p<0.001).The receiver-operating characteristic analysis showed that the optimal IASBPD cut-off value for predicting high SYNTAX score was 8.5 mmHg with a sensitivity of 86.0% and specificity of 89.1%  .In this study, we found a close association between the inter-arm blood pressure difference and the SYNTAX score (which indicates the severity and extent of coronary artery disease). We can obtain important data about the atherosclerosis severity of coronary artery disease and thus about the prognosis by blood pressure measurement in both arms, which is a simple and inexpensive method routinely recommended by HT guidelines.Blood pressure measurement in both arms is recommended for each patient. It is important for determining the true value of blood pressure and thus the need for antihypertensive treatment especially in those with cardiovascular diseases. As in our study, simultaneous blood pressure measurement in both arms has a vital significance in determining the IASBPD . SequentThe SYNTAX score provides information on the choice of optimal revascularization type through coronary anatomy and on the short- and long-term prognosis in those undergoing coronary interventions. However, the SYNTAX score gives a prognosis according to only coronary anatomy. On the other hand, systemic atherosclerosis has proven to be closely associated with prognosis in those undergoing PCI . It was Our study has some limitations. The number of the patients was relatively low. It was conducted in a single center. Since the SYNTAX score is relatively low, cut-off values may be different for groups with complex and diffuse coronary artery disease. Routine radiological evaluation was not performed for the aorta and its branches in those with IASBPD>10 mmHg. However, performing radiological examinations in all these patients is not appropriate in terms of both time and cost. In addition, most of these patients do not have pathologies such as anomaly, arthritis, and aneurysm in their arterial system . Power aWe found that the IASBPD that would be obtained by a simple and easy blood pressure measurement was associated with the extent of coronary artery disease obtained by coronary angiography. This situation, which is a reflection of systemic involvement of atherosclerosis, gives information about the extent of coronary artery disease in patients and also may provide us with information on prognosis as a result of prospective studies to be performed.