Introduction. Unlike Rockall scoring system, AIMS65 is based only on clinical and laboratory features. In this study we investigated the correlation between the AIMS65 score and Endoscopic Rockall score, in cirrhotic and noncirrhotic patients. Methods. This is a retrospective study of patients admitted with overt UGIB and undergoing esophagogastroduodenoscopy (EGD). AIMS65 and Rockall scores were calculated at the time of admission. We investigated the correlation between both scores along with stigmata of bleed seen on endoscopy. Results. A total of 1255 patients were studied. 152 patients were cirrhotic while 1103 patients were noncirrhotic. There was significant correlation between AIMS65 and Total Rockall scores in patients of both groups. There was significant correlation between AIMS65 score and Endoscopic Rockall score in noncirrhotics but not cirrhotics. AIMS65 scores in both cirrhotic and noncirrhotic groups were significantly higher in patients who died from UGIB than in patients who did not. Conclusion. We observed statistically significant correlation between AIMS65 score and length of hospitalization and mortality in noncirrhotic patients. We found that AIMS65 score paralleled the endoscopic grading of lesion causing UGIB in noncirrhotics. AIMS65 score correlated only with mortality but not the length of hospitalization or endoscopic stigmata of bleed in cirrhotics. Patients with acute upper gastrointestinal bleeding (UGIB) commonly present with either hematemesis or melena. The most important step in initial evaluation of such patients involves risk stratification with emphasis on assessing the hemodynamic status and its appropriate remediation. It is also imperative to examine the need for endoscopic intervention immediately after stabilization. There have been multiple scores that have been put forth to prognosticate the risk of rebleeding and inpatient mortality rate. These scores could be broadly divided into two categories: scores involving weighted endoscopic findings along with clinical and laboratory features  and scores without the endoscopic criteria (AIMS65 and Blatchford scores). Katschinski et al.  proposedThe score proposed by Rockall et al.  incorporClinical criteria included in computing these prediction scores often are confounded by existence of multiple coexisting comorbidities such as liver dysfunction and heart failure. Blatchford and Rockall scores include and give weightage to these comorbidities unlike AIMS65 score. Multiple studies have shown that AIMS65 singularly predicted few or all of the outcome measures in UGIB such as timing of endoscopy intervention, mortality, length of stay, and cost of hospitalization –10. PrelPatients with advanced liver disease often have hyperdynamic circulation with low blood pressure and systemic vascular resistance secondary to undermetabolized circulating vasodilators , 12. PatIn this retrospective study, we intended to see the correlation between the AIMS65 score and Endoscopic Rockall score. We looked at this correlation in cirrhotic patients and noncirrhotic patients separately. We wanted to examine the potential confounding role that underlying advanced liver disease could play while computing and interpreting AIMS65 scores.This retrospective study was performed according to the Declaration of Helsinki with the Institution Review Board (IRB) approval at the study location. The period of study was five years from 2008 to 2012. Electronic medical records of all patients admitted to the hospital with overt UGIB who underwent esophagogastroduodenoscopy (EGD) were included in the study. The data was tabulated in Microsoft Excel. The patients who had minimal, self-limited UGIB not requiring a diagnostic or interventional endoscopic procedure were excluded from the study. The study patients were divided into two groups: patients with cirrhosis and patients without cirrhosis.Baseline demographic data including age, gender, and ethnicity were collected for all patients in the study. AIMS65 scores were calculated at the time of admission. Endoscopic findings of each patient were reviewed and a weighted score was given as per Rockall Criteria. A separate weighted score for endoscopic stigmata of bleeding where applicable, as per Forrest classification (for ulcer bleeding only), was given as well. Etiologies of bleeding in cirrhotics and noncirrhotics ; etiologWe intended to see the correlation between AIMS65 scores and Endoscopic Rockall score in patient with and without cirrhosis separately. We also looked at these correlations separately in different genders and ethnicities.age ;hemodynamic shock ;major comorbidities ;diagnosis on endoscopy ;stigmata of recent hemorrhage .A score of 2 or less was shown to be associated with a low risk of further bleeding or death.The following variables were included for the computation of the score. The weightage given for each individual variable is included within the brackets:albumin );INR ;altered mental status ;systolic blood pressure ;age .The validation cohort showed that the mortality risk increased from 0.3% in patients with AIMS65 score of 0 to almost 25% in patients with AIMS65 score of 5.The following variables were included for the computation of the score. The weightage given for each individual variable is included within the brackets:active arterial bleeding (Forrest Ia—score of 5), oozing without visible vessel (Forrest Ib—score of 4);nonbleeding visible vessel (Forrest IIa—score of 3), adherent clot (Forrest IIb—score of 2), and flat spot (Forrest IIc—score of 1);clean ulcer base (Forrest III—score of 0).The classification was based on stigmata of bleed seen on endoscopy. The weightage given for each individual variable is included within the brackets: t-test was used for comparison of means. A P value < 0.05 was considered statistically significant. Linear regression was used to look at the relationship between two continuous variables.Continuous variables were stated as mean and standard deviation. UnpairedA total of 1255 patients with diagnosis of overt UGIB presented to the hospital and underwent EGD during the study period between January 2008 and December 2012. Out of the study population, 152 patients were found to have cirrhosis while the remaining 1103 patients were without cirrhosis. Out of the study population 761 patients were male while 494 were female. There were 719 Hispanics, 484 African Americans, 45 Caucasians, 4 Asians, and 3 people of Indian origin in the study population. We looked at the correlation of AIMS65 score with Total Rockall score and Endoscopic Rockall score separately within each ethnicity . StatistWe also computed the correlation of AIMS65 score with Total Rockall score and Endoscopic Rockall score separately within each gender . StatistWe also found that there was significant correlation between AIMS65 score and Total Rockall score in patients both without and with cirrhosis .We performed correlation analysis between AIMS65 score and Endoscopic Rockall score in patients without cirrhosis and with cirrhosis separately . We founOut of the 152 patients with cirrhosis, 96 patients had nonvariceal bleed whereas 56 had variceal bleed. There was no significant correlation between AIMS65 scores and Endoscopic Rockall scores in either of these groups .There were 715 patients in the study group (618 patients without cirrhosis and 97 with cirrhosis) who were diagnosed with UGIB secondary to peptic ulcer disease. The endoscopic stigmata of bleeding were given weighted scores as per Forrest Criteria. We performed correlation analysis between AIMS65 score and the weighted Forrest Criteria scores in patients without cirrhosis and with cirrhosis separately. There was a statistically significant correlation between the AIMS65 score and weighted Forrest score in noncirrhotics, but it was not the case in cirrhotics; no such correlation was found .P value < 0.0001) but not in cirrhotic patients   patients required admission. We examined the correlation between the AIMS65 score and length of stay in patients admitted with UGIB. There was significant correlation between these two variables in noncirrhotic patients ( 0.1792) .P value = 0.0002) but not in cirrhotic patients with nonvariceal bleed   .P value = 0.0003). Similarly in the cirrhotic group, average AIMS65 score in patients who died from UGIB (mean AIMS65 score: 2.14 ± 0.37) was significantly higher than that of patients who did not (mean AIMS65 score: 1.08 ± 0.82)   than in patients who did not (mean AIMS65 score: 0.80 ± 0.85) ( 0.0011) .AIMS65 score has been shown to predict mortality in multiple studies , 9; howeOur study was beset by disadvantages inherent to a retrospective study. Even though we took only patients with UGIB as primary admitting diagnosis, possible multiple unrecognized confounding variables could have influenced the lengths of hospitalization. The contribution of underlying intrinsic liver disease and other medical comorbidities  to the length of hospitalization could not be individually ascertained. The system of grading endoscopic stigmata using Forrest Criteria is partly subjective and has potential for significant interobserver variability. AIMS65 score has been shown to predict the need for endoscopic intervention in patients with UGIB. We only included patients who had an endoscopic intervention in our study. This could have biased our results significantly, as performing an endoscopic intervention in itself could have contributed to lengthening the hospital stay.In conclusion, we observed statistically significant correlation between AIMS65 score and length of hospitalization as well as mortality in noncirrhotic patients. We also found that AIMS65 score paralleled the endoscopic grading of lesion causing UGIB in such patients. In cirrhotic patients, AIMS65 score correlated only with mortality but not endoscopic stigmata of bleed . AIMS65 score correlated with length of hospitalization in variceal bleeders but not cirrhotic nonvariceal bleeders. AIMS65 score, computation of which is influenced by underlying liver disease, is not a strong predictor for severity of gastrointestinal lesion on endoscopy or length of hospitalization in cirrhotics. We cannot make a comment on value of AIMS65 score in determining the need for endoscopic intervention (even as AIMS65 score poorly correlated with endoscopic findings), as we designed the study to include only patients who underwent endoscopy. This is especially true in cirrhotics who present with UGIB where a simplified preendoscopy risk stratification system that predicts necessity of endoscopy and hospitalization is often irrelevant as almost all patients are hospitalized and undergo urgent diagnostic or therapeutic endoscopy. However, AIMS65 score may be predictive of mortality and postendoscopic clinical course in cirrhotics including length of hospitalization. In view of the limitations of this study, further investigation is needed to clearly elucidate the role of scoring systems such as AIMS65 in predicting clinical outcomes in patients with cirrhosis.


The hemodynamic effects of adaptive servoventilation (ASV) in patients with pulmonary hypertension (PH) are unknown.2O, pressure support 4–10 cm H2O) during right heart catheterization. Hemodynamics were measured at rest, at the end of a 15-min episode of ASV therapy, and 15 min after ASV completion. Hemodynamic variables included heart rate, blood pressure, right atrial pressure (RAP), mean pulmonary artery pressure (PAPm), pulmonary arterial wedge pressure (PAWP), cardiac output and pulmonary vascular resistance (PVR).A series of clinically stable patients with pre- or post-capillary PH underwent ASV therapy (endexpiratory positive airway pressure support 12–14 cm Hn = 8) or chronic thromboembolic pulmonary hypertension (n = 13). ASV was well tolerated by all patients and resulted in reductions in systolic blood pressure , PAPm  and PVR . Right and left filling pressure increased, while the cardiac output decreased . The hemodynamic effects of ASV were similar in both patient populations.The study enrolled 33 patients; 12 patients with post-capillary PH due to heart failure with preserved ejection fraction, and 21 patients with pre-capillary PH due to pulmonary arterial hypertension (ASV had moderate hemodynamic effects in patients with PH of various origins, most importantly a decline in systolic blood pressure, PAPm and cardiac output. ASV was safe and well tolerated during this short-term study, but the observed drop in blood pressure and cardiac output may be of concern if ASV is applied in patients with advanced PH and severely impaired right ventricular function. Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure (PAPm) ≥25 mmHg at rest. Depending on the level of the pulmonary artery wedge pressure (PAWP), PH is divided into pre-capillary and post-capillary forms, the former encountered in patients with pulmonary arterial hypertension (PAH), chronic thromboembolic pulmonary hypertension (CTEPH), or PH due to lung disease; the latter in patients with left heart disease such as heart failure with preserved ejection fraction (HFpEF) , 2.Although some forms of PH may occur in young patients, the majority of patients with PH is in an advanced age and often presents with co-morbidities such lung disease, left heart disease, obesity and sleep-related breathing disorders. Obstructive or central sleep apnea has been found in about one fourth of patients with pre-capillary PH . In addiIn patients with chronic left heart failure application of continuous positive airway pressure (CPAP) or NIV reduced pulmonary congestion and left ventricular preload by increasing intrathoracic pressure and by reducing afterload via reduction of transmural wall pressure. Cardiac index remained stable or increased –8. One fPatients admitted to our hospital for diagnostic work-up or follow-up assessment of pulmonary hypertension were invited to participate in this study. Patients with PAH, CTEPH and PH-HFpEF according to current diagnostic criteria were eligible. Patients with PH due to lung disease were excluded as were patients already receiving noninvasive ventilation for other reasons.All patients provided written informed consent and the study was approved by the local ethics committee of Hannover Medical School institutional review board (Ethikkommission Medizinische Hochschule Hannover).Right heart catheterizations were performed via a jugular approach following a standardized protocol. The pressure transducer was zeroed at the mid-thoracic level and pressure readings were done at end-expiration . MeasureExperienced technicians obtained arterialized capillary blood gases from earlobes. Mixed-venous blood was obtained from the pulmonary arteries during right heart catheterization. The blood samples were analyzed without delay using a standard device .2O, the minimum end-expiratory pressure (EPAP) was increased every 5 min by 4 cm H2O up to a maximum of 12 cm H2O, while maximum EPAP (14 cm H2O), maximum pressure support (10 cm H2O), and minimum pressure support (4 cm H2O) were kept stable. Individual maximum tolerable pressure support levels were then applied during right heart catheterization. In patients receiving oxygen therapy, the flow of oxygen was kept constant throughout the procedure.After individual mask fitting, ASV was initiated during a 15 min period using PaceWave™ modus with a standardized protocol of pressure support level titration under continuous blood pressure monitoring (Carescape V100). Starting at 4 cm Ht-test were used as appropriate. Comparisons between baseline and intervention were made with two-sided paired t-test. Pearson correlation analysis was performed to assess changes in right and left sided filling pressures and changes in cardiac output. P-values <0.05 were considered statistically significant.Data are shown as mean ± standard deviation (SD). For comparison of the two patient populations, Fisher’s exact test, Chi-square test and two-sided paired n = 8; CTEPH, n = 13) and 12 with post-capillary PH associated with HFpEF. The demographics and baseline characteristics of the patients are shown in Table The study enrolled 33 patients, 21 with pre-capillary PH  while diastolic blood pressure  and mean arterial blood pressure  remained unchanged. Clinically, therapy initiation was uneventful and all patients tolerated the procedure without any side effects.Familiarization with ASV on the day before right heart catheterization was associated with a significant drop of systolic blood pressure . Hemodynamic effects have been summarized in Table p = 0.01; Fig. p = 0.40). The cardiac filling pressures increased . PAPm decreased by 5 mmHg (p < 0.0001), PVR decreased by 10 %  and cardiac output decreased by 0.4 L/min (p < 0.0001). The individual changes in cardiac output are depicted in Fig. p = 0.41), while the heart rate declined by 7 beats per minute (p < 0.0001). There was no correlation between the change in PAWP and the change in cardiac output . In contrast, the change in cardiac output was inversely related to the change in right atrial pressure .The individual maximum tolerable pressure settings were then applied the next day during right heart catheterization without causing adverse events. Twenty-nine patients (88 %) were ventilated at the highest-pressure settings (maximum EPAP 14 cmHp < 0.0001), as did the mixed venous oxygen saturation . The mixed-venous pCO2 dropped by an average of 4 mmHg (p < 0.0001). After 15 min of recovery, all values had returned to baseline  were probably caused directly by the increased intrathoracic pressure during ASV, and would not be expected to be clinically relevant. However, our data also show that right heart catheterization performed during noninvasive ventilation may result in over interpretation of the PAWP and could therefore lead to a misclassification of pre-capillary as post-capillary PH, at least in some patients.2, and it is possible that these effects resulted in some pulmonary vasodilation.There was a considerable decline in PAPm and PVR. The latter was caused by a drop in PAPm (−5 mmHg) and an increase in PAWP (+4 mmHg). The drop in PAPm was substantial and cannot be directly explained by increased intrathoracic pressures during ASV, as this would have caused the PAPm to increase as well. The drop in cardiac output can explain part of the observed effect on PAPm to some extent, although not entirely. Our data show that ASV was associated with slight improvements in peripheral and mixed venous oxygenation as well as a fall in the mixed venous pCO. These effects may be explained, at least partly, by reduced cardiac sympathetic nerve activity or increased parasympathetic nerve activity, which may result from stimulation of pulmonary stretch receptors due to lung inflation [Perhaps the potentially most relevant effects seen in our study were the declines in systolic blood pressure and cardiac output. It is not entirely clear why only the systolic blood pressure decreased while the diastolic blood pressure remained unchanged, especially as the drop in cardiac output was not caused by a decline in stroke volume but almost entirely by a drop in heart rate. However, the observed effects on blood pressure and heart rate were consistent with previous studies on continuous positive airway pressure or NIV in patients with left heart disease –15. Thesnflation .Nevertheless, the decline in cardiac output was a somewhat unexpected finding, which has been described with the administration of high pressure during NIV in healthy individuals , 18 and ASV was well tolerated in all of our patients, both at the familiarization day as well as during right heart catheterization. There were no side effects and none of the patients reported any discomfort, except for what was caused by the facemask. Of note, all of our patients were clinically and hemodynamically stable. We cannot conclude from our data that ASV would also be safe if applied to patients with severe PH, right-sided heart failure and a low blood pressure. On the first glimpse, the drop in PAPm seems re-assuring. However, our data raise some concerns as any drop in blood pressure, cardiac output, or both in unstable PH patients could lead to hemodynamic decompensation and even death due to right heart failure. Such patients need to be studied further but our results at least raise the possibility that non-invasive ventilation may have deleterious hemodynamic consequences in patients with advanced right heart failure.Recently a multicenter, randomized controlled trial on ASV therapy in patients with heart failure with reduced left ventricular ejection fraction failed to show a statistically significant difference between patients randomized to ASV therapy and those in the control group in the primary endpoint of time to all-cause mortality or unplanned hospitalization for worsening heart failure. There was, however, a statistically significant increased risk in all-cause and cardiovascular mortality in patients receiving ASV therapy . WhetherOur study has several strengths and limitations. Strengths include the inclusion of well-characterized patients with severe pre-capillary and post-capillary PH, the familiarization with ASV prior to right heart catheterization and the fact that all patients had invasive hemodynamic measurements. Limitations included the single-center setting, the relatively small number of patients, the application of only one form of NIV, i.e. ASV, and the limited duration of NIV. Different modes and longer applications of NIV may result in different results but we aimed to study the acute effects on NIV in these patients and we wanted to make sure not to extend the invasive procedure any longer than necessary. The pressure support used in our study was relatively high compared to other studies , 18 and In conclusion, our data showed that administration of NIV in stable patients with pre-capillary or post-capillary PH resulted in small but consistent declines in heart rate, systolic blood pressure, PAPm, PVR and cardiac output. These hemodynamic effects were clinically unapparent in the patients under study, but our findings suggest that NIV should be used with caution in PH patients presenting with hypotension and low cardiac output failure.


Patient- and procedure-related factors associated with postoperative pulmonary complications (PPCs) have changed over the last decade. Therefore, we sought to identify independent risk factors of PPCs and to develop a clinically applicable scoring system. We retrospectively analyzed clinical data from 2,059 patients who received preoperative evaluations from respiratory physicians between June 2011 and October 2012. A new scoring system for estimating PPCs was developed using beta coefficients of the final multiple regression models. Of the 2,059 patients studied, 140 (6.8%) had PPCs. A multiple logistic regression model revealed seven independent risk factors (with scores in parentheses): age ≥70 years (2 points), current smoker (1 point), the presence of airflow limitation (1 point), American Society of Anesthesiologists class ≥2 (1 point), serum albumin <4 g/dL (1 point), emergency surgery (2 points), and non-laparoscopic abdominal/cardiac/aortic aneurysm repair surgery (4 points). The area under the curve was 0.79  with the newly developed model. The new risk stratification including laparoscopic surgery has a good discriminative ability for estimating PPCs in our study cohort. Further research is needed to validate this new prediction rule. Postoperative pulmonary complications (PPCs) are one of the most common perioperative adverse events in patients undergoing surgery and contribute to significant increases in morbidity, mortality, and length of postoperative hospital stay Based on the American College of Physicians (ACP) guidelines for preventing PPCs in patients undergoing non-cardiothoracic surgery This retrospective, single-center, observational study with prospectively collected data was conducted at Samsung Medical Center  between June 2011 and October 2012. The study was approved by the Institutional Review Board of Samsung Medical Center to review and publish information obtained from patient records. Informed consent was waived because of the retrospective nature of the study and patient data was deidentified prior to data access and analysis.Over the study period, all consecutive patients consulting respiratory physicians to evaluate the risk of PPCs before surgery were included, and the PPC-related variables of each patient were registered prospectively. The patients were not included in this study with 1) aged younger than 18 years; 2) pulmonary related surgery; and 3) obstetric surgery or any procedure during pregnancy and the patients with organ transplantation were excluded.1/FVC) <0.7 and FEV1 <80% of predicted value.Data collection was performed prospectively by respiratory physicians at the time of consultation about the risk of PPCs. The following information was collected: data related to the patient , smoking status, alcohol habits, airflow limitation, comorbidities such as congestive heart failure (CHF), mental status, American Society of Anesthesiologists (ASA) physical status classification, serum albumin, serum hemoglobin, and chest radiograph findings) and the surgical operation , which are identified in the ACP guidelines as PPC-related variables in patients undergoing non-cardiothoracic surgery. The presence of airflow limitation was defined as the ratio of forced expiratory volume in 1 s to forced vital capacity  for continuous variables and as numbers (percentages) for categorical variables. Some continuous variables, such as age, ASA physical status, and serum albumin, were coded as dummy variables using cut-off points based on the highest Youden's index ([sensitivity + specificity] – 1) From the multiple logistic regression model findings, a score-based predictive scoring system was developed. We assigned scores according to dividing beta coefficients by the absolute value of the smallest coefficient in the final model and rounding up to the nearest integer to generate a simple integer-based point score for each predictor variable All tests were two-sided, and a p-value of less than 0.05 was considered to indicate statistical significance. Statistical analyses were performed using the SPSS software  and STATA 12  for ROC analysis.During the study period, 2,338 consecutive patients had respirology consultations to evaluate the risk of PPCs . Of thesTheir baseline characteristics are presented in The prevalence and number of PPCs according to each type of surgery is presented in A multivariable logistic regression model for evaluating risk factors of the occurrence of PPCs is shown in Of these seven predictors, the lowest logistic coefficient was 0.398 for serum albumin <4.0 g/dL. On the basis of this value, we developed a new scoring system to predict the occurrence of PPCs, composed of age ≥70 years (2 points), current smoker within 2 months (1 point), ASA class ≥2 (1 point), the presence of airflow limitation (1 point), serum albumin <4.0 g/dL (1 point), emergency surgery (2 points), and cardiac/aortic aneurysm repair/abdominal open surgery (non-laparoscopic) surgery (4 points), resulting in a maximum of 12 possible points. The new predictive scoring system had a high discriminatory power to predict the occurrence of PPCs with an area under the curve (AUC) of 0.79 (95% CI 0.75–0.83), which was similar to 0.79 (95% CI 0.75–0.82) for the average AUC obtained from an internal validation. Moreover, the AUC of this scoring system was significantly higher than the AUC of 0.65 (0.61–0.69) from predictive scoring summed simply as 1 point for each variable (maximum of 7 possible points) (p<0.001).This study evaluated risk factors for the occurrence of PPCs among more than 2,000 patients who underwent surgery with general or neuraxial anesthesia and the overall incidence of PPCs was 6.8%. Using multivariable logistic regression models, we found seven independent predictors of PPCs: age ≥70 years, current smoker within 2 months, ASA class ≥2, the presence of airflow limitation, serum albumin <4.0 g/dL, emergency surgery, and cardiac/aortic aneurysm repair/abdominal open surgery. When each independent variable was endowed with a weighted score based on logistic coefficients, cardiac/aortic aneurysm repair/abdominal open surgery was the most predictive variable with 4 points, followed by age ≥70 years and emergency surgery with 2 points each. Compared with the predictive scoring system based on simply scoring 1 point for each variable, this weighted risk score strategy had a significantly better discriminative power for estimating PPCs.Using the variables listed in the ACP guidelines, we derived new cut-off values for each variable using our cohort. The newly determined cut-off values from our cohort were 70 years of age, class 2 of ASA physical status, and 4.0 mg/dL for albumin. While advanced age and limited physical status were similar to the findings of previous studies, the cut-off value for albumin was considerably higher than that suggested in previous studies  The incisions for chest and abdominal operations frequently damage the diaphragm and respiratory muscles, and postoperative pain provokes hypoventilation Contrary to previous studies In our study, all variables were registered prospectively by specialists in respiratory medicine after examining the patients. In addition, all patients scheduled for surgery were advised to undergo perioperative strategies to prevent PPCs. Particularly, as incentive spirometry has been shown to correlate with a reduction in the incidence of respiratory infection, respiratory failure, and atelectasis and with lung function improvement There were several limitations to this study. First, there was its retrospective nature for evaluating the main outcome of PPCs. Second, there were 38,225 cases with non-pulmonary/non obstetric surgical operations during the period of this study. Since the consultations with respiratory physicians were at the discretion of the treating surgeons, 2,059 patients (5.4%) were included in our cohort. Thus, selection bias might have influenced our findings despite the use of prospectively registered data. Given that more than 75% of cohort patients were older than age of 60 years and 30% had the presence of airflow limitation, our cohort would reflect real world practice. Third, this study was from a single institution, a tertiary referral center, which might limit the generalizability of our findings. Finally, our scheme needs to be validated by prospective studies.In conclusion, a new risk stratification system that comprises seven factors with weighted scores had good discriminative ability for predicting PPCs in our study cohort. Our findings raise the possibility of using new cut-off values for albumin and inclusion of laparoscopic procedures as a separate variable. Additional studies are required to validate this new prediction rule.Table S1Cut points of the continuous variables in the logistic regression.(DOCX)Click here for additional data file.


Hypertension is an important health problem in China and raised blood pressure in children may lead to future hypertension. Accordingly we aimed to provide a reference blood pressure table for age, gender and height in Chinese children.A reference sample of subjects was drawn from the Chinese Health and National Survey 1999–2009 aged 7–17 years after excluding overweight and obese children, the 50th, 90th and 95th percentiles of systolic and diastolic blood pressure (SBP and DBP)are presented corrected for height and age by gender. These values are compared with existing Chinese and US recommendations.Results for the 50th, 90th and 95th percentile of SBP and DBP for 6245 boys and 5707 girls were presented by age and height percentiles. These observations were lower than existing Chinese recommendations before 13 years of age at median heightbut went higher in those >13 years old. At same age and height, SBP levels of American children were overall higher than Chinese counterparts from this study by average 9–10 mm Hg, but DBP did not show overall or significant difference.The first height-specific blood pressure reference values are proposed for Chinese children and adolescents aged 7–17 years. These are lower than existing US reference values and current Chinese cutoffs. High blood pressure in children and adolescents is more common and is associated with increasing childhood obesity in western countries -3 as welNational blood pressure cutoffs by age groups for Chinese children were first published in 1992, and updated in 2010 , howeverhttp://www.cpc.unc.edu/projects/china) [We used data from the China Health and Nutrition Survey (CHNS) -17. Genes/china) -17. Bries/china) ,17. Aftes/china) , boys anBlood pressure was measured using mercury sphygmomanometer according to the standard protocol by trained and qualified observers, which was described elsewhere . Korotkohttp://www.cran.r-project.org/). GAMLSS is a generalization of the LMS method where Y has a specified frequency distribution D , the 4 parameters define the location, scale and shape of the blood pressure distribution with age and height. Linear effect and additive effect of age and height (two covariates) on SBP and DBP were modeled simultaneously to obtain the optimal models by minimizing the Schwarz Bayesian Criterion (SBC). The all possible functions of age and height as well as the interactions of which were considered in the modeling, the most fitted model were achieved. The reference values of 50th, 90th, and 95th percentiles of SBP and DBP were computed by age and height  for boys and girls respectively.Percentiles of height as a function of age were obtained by smoothed centile curves modeled using LMS method  with theTo make comparisons with the existing Chinese blood pressure recommendations for children , heightsDifferences in proposed SBP and DBP cutoff values  for Chinese boys and girls were compared with the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents of the US  at givenIndependent software called “Blood Pressure Calculator “has been developed based on the fitted models of blood pressure from this study.Based on Chinese national BMI cutoff points, a total of 620 boys and 445 girls (8.2%) were excluded from the original study sample n = 13014) because of being overweight or obese. The remaining reference sample consists of children and adolescents aged 7–17 years (including 6245 boys and 5704 girls) with complete data on age, gender, height and three SBP and DBP readings. The characteristics of subjects were given in Table 3014 becaThe optimal models for the 4 parameters of SBP and DBP distribution for boys and girls were fitted. It showed that BCPE model was the best fitted model for SBP for boys and DBP for both genders, BCT model was the best fitted model for SBP of girls. Reference values of the 50th, 90th, and 95th percentiles of SBP and DBP, were computed by age and exact heights according to the 5th, 25th, 50th, 75th and 95th percentiles ) for boys and girls respectively and presented as Table Figure Height is not taken into account in the earlier national recommendation. The 50th, 90th and 95th centile curves of SBP proposed by the current study were lower than the existing national non-height specific reference, the differences tended to decrease after 14 years old. However, the three centile curves of the current study were lower than then existing national reference curves before age of 11–12 years but exceeded it up to 17 years old to the similar extent with the age of 7. This trend remained similar in boys and girls.Compared with the international blood pressure table recommended by the Fourth report  Figure , the 50tWe present the first height percentile specific-blood pressure references in China and compare these with the earlier ones also international values. These new cutoffs will be more accurate for evaluating blood pressure levels for children and adolescents with extreme heights. The proposed 90th and 95th percentiles of blood pressure may be used to detect prehypertension and hypertension in Chinese pediatric population. The using of non-overweight reference sample may makes the proposed blood pressure cutoff points more sensitive to identify children with elevated blood pressure because of with risk factors such as being overweight or obese. The 99th percentiles are not proposed based on the thinking that children with blood pressure measurements over it will not be directly diagnosed as hypertension, instead, additional blood pressure measurements will be suggested.Height is a key covariate associated with blood pressure levels. The ignoring of height of the blood pressure references may result in inaccurate blood pressure evaluation in pediatric practice especially for children who are very short or tall. Since there may be significant difference in height distribution between the current study sample and others, the blood pressure cutoffs for exact height values instead of height percentile categories are proposed to make it more practical and accurate for individual blood pressure assessment.Compared with the existing national age-specific blood pressure recommendations , the bloIn overall, the blood pressure percentiles we proposed are lower than the international one for American children , which aGiven the complex calculations for individual assessment of blood pressure in practice, a Blood Pressure Calculator has been developed based on the fitted models of blood pressure from this study. After inputting age, gender, height, SBP and DBP levels, it will return SBP and DBP percentiles and blood pressure status . This calculator may greatly help individual clinical evaluation of blood pressure in hospitals and public health settings.Our study has some limitations. The sample size of boys and girls aged 7–17 years are relatively small compared with the total population of China, and survey fields cover only 7 east coast provinces. However, we choose to use CHNS data is based on the considerations that the CHNS study are jointly funded by Chinese government and American organizations, the methodology of blood pressure measurement, quality control and data management follow international criteria, the international comparisons will be more convincing. Second, no external validation was made to assess the performance of the newly proposed blood pressure tables. A second validation study would be helpful to compare the accuracy of age- and height-specific blood pressure percentiles from nonoverweight reference sample proposed by the current study with the existing age-specific percentiles but without excluding overweight subjects  in childIn summary, the current study proposes the first age and height corrected blood pressure percentiles for Chinese children and adolescents aged 7–17 years with potential for more accurate blood pressure evaluation for children with extreme height, and in identifying obesity-related high blood pressure. It is expected that the proposed new references will be used in clinical individual blood pressure evaluation and government-supported annual national regular school-based fitness and physical survey in China.The authors declare no financial or non-financial competing interests.AB carried out the molecular genetic studies, participated in the sequence alignment and drafted the manuscript. JY carried out the immunoassays. MT participated in the sequence alignment. ES participated in the design of the study and performed the statistical analysis. FG conceived of the study and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript. WY conceptualized and designed the study, supervised the gamlss modeling and all the statistical analyses, drafted the manuscript, and approved the final manuscript as submitted. FL, XL, LW, YZ and YC carried out the conventional statistical analyses, made the tables, reviewed and revised the manuscript, and approved the final manuscript as submitted. WZ and GH participated design, data interpretation, discussion and approved the final manuscript as submitted.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/13/195/prepub


Treatment of end stage renal disease patients with short daily hemodialysis has been associated with an improvement in blood pressure. It is unclear from these studies if anti-hypertensive management had been optimized prior to starting short daily hemodialysis. Also, the potential mechanism(s) of blood pressure improvement remain to be fully elucidated.We undertook a randomized cross-over trial in adult hypertensive patients with ESRD treated with conventional hemodialysis to determine: 1) if short-daily hemodialysis is associated with a reduction in systolic blood pressure after a 3-month blood pressure optimization period and; 2) the potential mechanism(s) of blood pressure reduction. Blood pressure was measured using Canadian Hypertension Education Program guidelines. Extracellular fluid volume (ECFV) was assessed with bioimpedance. Serum catecholamines were used to assess the sympathetic nervous system. Interleukin-6 (IL-6) and thiobarbituric acid reactive substances (T-BARS) were used as markers of inflammation and oxidative stress respectively.After a 3-month run-in phase in which systolic blood pressure improved, there was no significant difference in pre-dialysis systolic pressure between short-daily and conventional hemodialysis (p = 0.39). However, similar blood pressures were achieved on fewer anti-hypertensive medications with short daily hemodialysis compared to conventional hemodialysis (p = 0.01). Short daily hemodialysis, compared to conventional hemodialysis, was not associated with a difference in dry weight or ECFV (p = 0.77). Sympathetic nervous system activity as assessed by plasma epinephrine (p = 1.0) and norepinephrine (p = 0.52) was also not different. Markers of inflammation (p = 0.42) and oxidative stress (p = 0.83) were also similar between the two treatment arms.Patients treated with short daily, compared to conventional hemodialysis, have similar blood pressure control on fewer anti-hypertensive medications. The mechanism(s) by which short daily hemodialysis allows for decreased anti-hypertensive medication use remains unclear but effects on sodium balance and changes in peripheral vascular resistance require further study.NCT00759967ClinicalTrials.gov  More than 50% of the patients with end stage renal disease (ESRD) die from cardiovascular disease, a risk 10–20 times greater than the general population The intermittent nature of conventional hemodialysis treatments  results in the majority of patients having a fluctuating ECFV that likely contributes to the activation of neurohormonal pathways In the majority of reported studies it is unclear if the patient's antihypertensive management, including achievement of the appropriate dry weight, had been optimized prior to the introduction of more intensive hemodialysis. A limited number of investigations have been undertaken to determine the mechanisms of blood pressure reduction. For this reason, we undertook a randomized cross-over trial in patients with ESRD treated with hemodialysis. Our primary objective was to determine if short-daily hemodialysis, compared to conventional hemodialysis, is associated with a reduction in systolic blood pressure pre-dialysis after an optimization period. Our secondary objective was to determine the potential mechanism(s) of blood pressure reduction by assessing extracellular fluid volume and the sympathetic nervous system. The potential role of inflammation and oxidative stress were added to the study design because of the increasing evidence suggesting that these mediators may have an etiologic role in hypertension We undertook a 9-month randomized, crossover trial of adult prevalent hypertensive ESRD patients. Paperwork for the trial was submitted to the Ottawa Hospital Research Institute in June 2007 for registration at clinicaltrials.gov as per protocol at the time but due to administrative delays was not released until September 24, 2008 (NCT00759967). The protocol for this trial and supporting CONSORT checklist is available; see Inclusion criteria included: 1) on hemodialysis for >3 months, 2) any patient on 1 or 2 antihypertensive medications with a pre-dialysis systolic blood pressure of >140 on average over 1 month, 3) any patient on 3 or more antihypertensive medications regardless of pre-dialysis systolic pressure, 4) able to make the time commitment to daily therapy, and 5) able to give informed consent. Patients were excluded if they were expected to switch treatment modality or die within one year or have known dilated cardiomyopathy with an ejection fraction <0.3. Eligible patients provided written informed consent to the study coordinator and then underwent a 3-month run-in phase. All patients were dialyzed with a Fresenius K machine, Optiflux 160 dialyzer, blood pump speed 300–400 mls/min and a dialysate flow of 500 mls/minute. A protocolized blood pressure algorithm was followed to optimize blood pressure control . BrieflyAfter the 3 month run-in phase, patients were randomized using a computer generated randomization sequence. Each patient completed 3 months of conventional 3 times per week hemodialysis or 6 times per week short daily hemodialysis and then crossed-over to the other treatment arm . The onlPost treatment extracellular fluid volume was measured with the Xitron Hydra  using standard techniques. The Hydra is a multifrequency bioimpedance analyzer that allows for differentiation of ECFV and intracellular fluid volume by detecting differences in the conductive properties of cells by measuring resistance (impedance) to electrical current. The technique is reliable in tracking sequential changes in ECFV with a reported coefficient of variation and intra-observer error of 2.5% Blood samples were taken post dialysis with the patient in a quiet dark room prior to the removal of the hemodialysis needles. The plasma samples were prepared immediately and stored at −80C and analyzed within 6 months by high performance liquid chromatography at a commercial laboratory.Plasma interleukin-6 (IL-6) and plasma thiobarbituric acid reactive substances (T-BARS) were used as markers of inflammation and oxidative stress respectively. Plasma was prepared from blood collected in EDTA vacutainer tubes pre-dialysis and stored at −80°C. Plasma levels of IL-6 were measured using a solid-phase sandwich ELISA kit from Biosource International according to manufacturer's instructions. Plasma TBARS levels were measured colorimetrically and values were expressed in nmol/ml malondialdehyde (MDA) equivalents as we previously reported Based on our previous experience with daily hemofiltration, we calculated that 20 patients would be required to detect a difference of 11 mmHg in systolic blood pressure assuming a standard deviation of 11, a two-sided alpha = 0.05, and a power of 80% A paired t-test was also used for weight, ECFV, total ultrafiltration and ultrafiltration rate. Due to the non-normal distribution of the hypertension medication intensity score, serum catecholamines, IL-6 and TBARs, these were compared using the Wilcoxin sign rank test. Linear regression analysis was undertaken to explore the predictors of the intensity of anti-hypertensive medication use after conventional and daily hemodialysis (post-hoc).Twenty-two patients consented to participate in the study; 3 patients withdrew prior to randomization, 2 patients did not complete the short daily hemodialysis . TherefoThere was a statistically significant decrease in systolic blood pressure from study entry to the end of the run in phase  without an overall change in dry weight  or intensity of antihypertensive medications . Although we did not demonstrate a reduction in average post dialysis body weight at the end of the run-in phase compared to baseline, there was tremendous variability with the weights of some participants being decreased (maximum 8.7 kgs) and the weights of other participants being increased (maximum 5.4 kgs). Similar changes were seen in the anti-hypertensive medication use from baseline to the end of the run-in phase with some patients requiring increased medication while other patients had decreased medication. Overall, there was a decline in the amount of ultrafiltration per treatment from the first month of the run-in phase to the last month of the run-in phase .Of the standard biochemical tests throughout the study, serum sodium was 138 mmol/L at baseline and 137 mmol/L at the end of the run-in phase. This change was maintained throughout the study. Serum phosphate declined from 1.86 mmol/L at baseline to 1.61 mmol/L at the end of the run-in phase (p = 0.04). During conventional hemodialysis and short daily hemodialysis after randomization, serum phosphate was 1.82 mmol/L and 1.58 mmol/L respectively (p = 0.25). Weekly Kt/V was similar at the end of the run in phase and 3 months of conventional HD (5.4) but increased (6.6) during short daily HD. No changes were observed in serum potassium, calcium, bicarbonate or albumin throughout the study.Changes in the antihypertensive medication classes are shown in Serious adverse events were rare during the trial. One patient was hospitalized during the study during the short daily hemodialysis phase with volume overload.Short daily hemodialysis achieves a similar degree of systolic blood pressure control compared to conventional 3 times per week hemodialysis after a blood pressure optimization phase. However, this control is associated with a decreased requirement for antihypertensive medications. Our results highlight the importance of a run-in phase using a protocolized blood pressure algorithm when treatment modalities cannot be blinded.The decline in blood pressure at the end of the 3 month run-in phase, compared to baseline, was likely multifactorial. Although we did not demonstrate a reduction in average post dialysis weight, there was tremendous variability with some participant's weight being decreased and other participant's weight being increased. Similar changes were seen in the anti-hypertensive medication use. A reduction in dialysate sodium has been associated with a reduction in blood pressure in hypertensive patients without a change in pre-dialysis serum sodium concentration in some The mechanism for the decrease in antihypertensive requirements on short daily hemodialysis, compared to conventional hemodialysis, is unclear. A reduction in ECFV has been demonstrated in some The activity of the sympathetic nervous system was found to be important in a study that included 11 patients treated with short daily hemodialysis 2O2) was higher in granulocytes of patients with CKD treated with hemodialysis compared to controls 2O2 levels increased after hemodialysis with a cellulose acetate dialyzer highlighting the potential deleterious effects associated with the dialysis treatment itself In that last decade there has been an emerging evidence to support importance of oxidative stress in the development of hypertension A generalized increase in inflammatory markers including IL-6 may occur via a number of mechanisms including volume overload and oxidative stress. We were unable to show a difference in IL-6 or albumin with short daily compared to conventional hemodialysis. In a prospective cohort study of 26 patients treated with short daily HD in-centre, Ayus et al reported significant improvements in hs-CRP values after 12 months Our study has a number of limitations including the inability to blind the patients and investigators to the treatment group. We did not measure residual renal function and therefore could not assess the importance of this variable. However, the dialysis vintage of the patients suggests that many of them may have been anuric. Lastly, we did not measure ECFV at baseline and again at the end of the run-in phase; we are therefore unable to comment on the role changes in ECFV in the blood pressure improvement that was seen in the BP optimization phase. Strengths of our study over others that have been published to date include the run-in phase and use of standardized blood pressure algorithm.In summary after a 3-month run-in phase in which blood pressure was optimized by decreasing dialysate sodium, adjusting dry weight and anti-hypertensive medications,patients treated with short daily HD compared to conventional HD require fewer anti-hypertensive medications to achieve the same blood pressure. This effect on blood pressure control was not related to a reduction in ECFV, sympathetic nervous system activity, oxidative stress or inflammation. The mechanism(s) by which short daily HD allows for decreased use of anti-hypertensive medication remains unclear but may be related to effects on sodium balance and changes in peripheral vascular resistance that require further study.Checklist S1CONSORT Checklist.(DOCX)Click here for additional data file.Protocol S1Trial Protocol.(DOC)Click here for additional data file.


Semen hyperviscosity (SHV) is one of the factors involved in deficiency in sperm function. This research aimed to evaluate seminal plasma total antioxidant capacity (TAC)and malondialdehyde (MDA) levels in infertile patients with hyperviscous and non-hyperviscous semen samples to understand whether hyperviscous semen is associated withoxidative damage in infertile subjects. In this cross sectional study, 59 semen sampleswere provided by fertile (n=12) individuals as control, infertile patients with normal viscosity (n=25) and infertile patients with hyperviscosity (n=22). After semen parameters examination, semen viscosity was studied by glass pipettes. Seminal plasma TAC and MDAlevels were measured by ferric reducing of antioxidant power (FRAP) and thiobarbituricacid reaction (TBAR) methods, respectively. A probability less than 0.05 was consideredstatistically significant throughout the article. The mean of sperm parameters including:counts, motility and normal morphology in patients with hyperviscosity were significantlylower than those in non-hyperviscosity patients . The mean of seminal plasma TAC value in seminal plasma of non-hyperviscositypatients (1710.31 ± 458.67 µmol/l) was significantly (p<0.01) higher than that of hyperviscosity group (1230.25 ± 352 µmol/l). A trend toward a higher mean of seminal plasmaMDA value was estimated for hyperviscous group compared with non-hyperviscous (1.01± 0.41 nmol/ml vs. 0.94 ± 0.28 nmol/l); however, it was nonsignificant. Hyperviscous semen impairs seminal plasma TAC which is eventually associated with sperm membranelipid peroxidation. Sperm deficiency induced by oxidative stress(OX) is one of the main idiopathic factors thataffect male fertility , 2. It oIn Vitro Fertilization (IVF) Center, Babol, Iran. Aninformed consent form was obtained from all participantsprior to any involvement. Semen sampleswere obtained by masturbation into a sterile containerafter sexual abstinence for 2-3 days. Beforesemen analysis, a questionnaire was distributed toobtain information on age and lifestyle including:smoking habits, alcohol use, use or abuse of othersubstances and drugs, history of orchitis, testiculartrauma, sexually transmitted disease, varicocele,inguinal hernia operation, cryptorchism, etc.In this cross sectional study, 59 semen sampleswere collected from fertile (n=12) individualsas control, infertile patients with hyperviscosity(n=22), infertile patients without hyperviscosity(n=25) who were referred to the Fatemeh ZahraAfter collection, semen specimens were allowedto liquefy at room temperature for 30 minutes, andthen used for analysis. A single sample providedby each subject was examined according to theWorld Health Organization (WHO) criteria, whichis summarized in our previous study and analyzedfor the appearance, volume and consistency .On micr4) and samples wereestimated by spectrophotometer at 593 nm.Five hundred μl of semen sample were centrifugedat 1400 xg for 7 minutes at 4˚C. Thesupernatants were removed from pellets and diluted10-fold with distilled water , thenimmediately used for TAC assay. TAC wasmeasured by ferric reducing of antioxidantpower (FRAP) method described by Benize. BrieflySeminal malondialdehyde (MDA) levels wereanalyzed according to methods described byRao et al. . MDA wasAll data are reported as means ± standard deviation(SD). An independent t test was considered tocompare the scores of each of the measures andsome of the parameters between the two groups.ANOVA model was utilized for statistical analysesof TAC and MDA concentrations among allgroups. A probability less than 0.05 was consideredstatistically significant. Data were analyzedusing the statistical package for the social sciences(SPSS)  version 16.The mean values of examined sperm parametersin the fertile and infertile men are shown inComparison of TAC and MDA levels in the seminalplasma groups are shown in figures The mean of seminal MDA levels amonggroups was significantly different p<0.01, . The meain vitro and also considered hardto obtain the spermatozoa of good quality  becausehyperviscous semen is always difficult tobe manipulated  quality .Hypervi quality , 18-22.  quality .Some research showed reduced levels of fructosein SHV, and hypothesized inadequate functioningof the seminal vesicles as the explanation , 24.OthUreaplasma urealyticum infections were associatedwith SHV. In a study by La Vignera etal. (The other interest is the possible correlation betweenSHV and infections or inflammation of thegenital tract. There are conflicting conclusionsabout this area of study. According to Munuceet al. , there ia etal. , they eva etal.  also proAnother area of particular interest is the possiblecorrelation between SHV and impaired semen antioxidants system that leads to an increase inoxidative stress and DNA damage. Siciliano et al. have demAccording to our study and other researches, asevere impairment of seminal antioxidative systemsand an increased sperm membrane lipid peroxidationare considered as indications for lowquality of sperm in patients with hyperviscous semen.But the mechanism in which the depletionof antioxidants in the seminal plasma of patientsoccurs has not been fully elucidated. Furthermoreone consequence of antioxidants deficiency inhyperviscous semen can be an increase in oxidativedamage induced by ROS. Leukocytes andmorphologically abnormal spermatozoa are themain sources of ROS in human semen . PatientAccording to our study and other research, a severeimpairment of seminal antioxidative systemsand an increased sperm membrane lipid peroxidationare considered as indications for low qualityof sperm in patients with hyperviscous semen. Butthe mechanism in which antioxidants in the seminalplasma of patients with hyperviscous semenoccurs has not been fully elucidated. It can also saythat treatment with antioxidants may be useful inpatients showing abnormal semen consistency toprotect sperm cells by peroxidative damage and toimprove their functional properties which is meritedfuture studies.


P < 0.001, OR = 0.940), duration of diabetes , hemoglobin A1c , systolic blood pressure , diastolic blood pressure , high density lipoprotein cholesterol , and eGFR . Through stratified analysis and saturation effect analysis, our data suggests that eGFR of 99.4 mL/min or lower might imply the early stage of DR in diabetic patients. Thus, the evaluation of eGFR has clinical significance for the early diagnosis of DR.Diabetic retinopathy (DR) is the leading cause of visual impairment and blindness in working-aged people. Several studies have suggested that glomerular filtration rate (GFR) was correlated with DR. This is a hospital-based study and the aim of it was to examine the relationship between the GFR and DR in patients with type 2 diabetes mellitus (T2DM). We used CKD-EPI equation to estimate GFR and SPSS 19.0 and EmpowerStats software to assess their relationship. Among the 1613 participants (aged 54.75 ± 12.19 years), 550 (34.1%) patients suffered from DR. The multivariate analysis revealed that the risk factors for DR include age ( P = 0.290) [The prevalence of type 2 diabetes mellitus (T2DM) has significantly increased worldwide in the past 25 years , 2. DR i= 0.290) . Because= 0.290) . TherefoDiabetic nephropathy (DN), also known as diabetic kidney disease or diabetic glomerulosclerosis, is another major complication of DM and the leading cause of end-stage renal disease (ESRD). GFR and microalbuminuria are clinically significant markers for the evaluation of renal function. Previous studies have shown that microalbuminuria not only is an important clinical marker for DN, but also is closely associated with the progression of DR . HoweverHence, our researchers are embarking on a series of studies to investigate the relationship between GFR and DR, and this is the baseline study. The aim of this study was to evaluate the prevalence of DR in hospital-based T2DM patients and investigate the correlation between GFR and DR, so that GFR could be used for DR screening, especially in primary hospital of poor areas.We conducted a hospital-based case-control study. DM patients were admitted to the Department of Endocrinology and Ophthalmology of the First Affiliated Hospital in China Medical University from September 2010 to March 2012. A total of 1613 patients, 844 (52.3%) males and 769 (47.7%) females, with T2DM were enrolled in this study after rigorous diagnosis and exclusion criteria. The project was performed in accordance with the principles of the Declaration of Helsinki and approved through the Ethics Committee of China Medical University.Diabetes was diagnosed according to the 2006 World Health Organization (WHO) criteria . The DR μmol/L.” Therefore, we converted SCR according to the formula “1 mg/dL = 17.1 μmol/L” and put it into the formula to obtain eGFR.The clinical data were extracted from the medical records of 1613 T2DM patients. Information, including the age, gender, duration of diabetes, family history of diabetes, and history of hypertension, was collected for each patient. The blood pressure was measured during the medical examination and recorded as the means of two measurements after the patients rested for 5 minutes. Fasting blood was drawn from the cubital vein and used for biochemical assays, including fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), triglycerides (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), serum creatinine (Scr), and blood urea nitrogen (BUN). For the 2-hour postprandial glucose (2hPG) measurement, blood was drawn at 2 hours after ingestion of 75 g glucose powder or bread . All samples were measured using the ARCHITECT c8000 biochemical analyzer . The eGFR was calculated using the CKD-EPI equation . The uniDirect ophthalmoscopy and fundus photography were conducted after the participants were administered mydriatic eye drops to dilate the pupils. The center of the macula and optic disc of both eyes was photographed using a 45-degree digital camera . Two trained ophthalmologists performed the diagnosis of DR. If there were different opinions, they would discuss to make decision or consult the superior. Based on the results of the assessment, the subjects were divided into two groups: a DR group and a non-DR (DM without DR) group. There were 550 patients in DR group  and 1063 patients in NDR group .http://www.empowerstats.com/), and MedCalc software programs. The basic description and logistic regression analyses were performed using SPSS 19.0 software. The stratified analysis, the interaction test, covariate screening, and curve fitting were performed using EmpowerStats statistical software. MedCalc was used to draw the receiver operating characteristic curve (ROC curve), a graphical plot illustrating the performance of a binary classifier system with varying discrimination thresholds. The area under the ROC curve (AUC) ranged from 0.5 to 1. The numerical variables of normal distribution were expressed as the means ± standard deviation (means ± SD) and percentage (%). The independent samples t-test was used to analyze the continuous variables, whereas the odds ratio (OR) and chi-square (χ2) test was used to analyze the categorical variables. P < 0.05 was considered as statistically significant.All statistical analyses were performed using the Statistical Package from the Social Sciences (SPSS) version 19.0, EmpowerStats (P = 0.003), family history of DM (P = 0.036), duration of DM (P < 0.001), FBG and 2hPG (P < 0.001), HbA1c (P = 0.003), TC (P < 0.001), HDL-C (P = 0.013), LDL-C (P = 0.002), SBP (P < 0.001), DBP (P = 0.033), eGFR (P < 0.001), and SCR (P < 0.001)  patients were diagnosed with DR. No differences in TG, DBP, and BUN were detected between the DR and NDR groups. In contrast, statistically significant differences were detected for age (< 0.001) .P < 0.001), DM duration (P < 0.001), HbA1c (P = 0.007), HDL-C (P = 0.024), SBP (P < 0.001), DBP (P = 0.007), and eGFR (P = 0.010). According to the severity of the disease, DR patients were divided into 3 groups: nondiabetic retinopathy (NDR), nonproliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR) groups. The mean value of eGFR was 106.27 ± 23.37, 100.12 ± 30.85, and 83.33 ± 33.77 (mL/min) for the NDR, NPDR, and PDR groups, respectively.To determine the risk factors for DR, a logistic regression model was performed. DR was used as the dependent variable. Different risk factors, identified in the univariable analysis, were used as independent variables . There wP ⩽ 0.05 means interaction exists between that factor and the relationship. The presence of effect modifiers of eGFR and DR was observed. Eligible factors, which as effect modifiers for the relationship between eGFR and DR, include SCR (P = 0.003), SBP (P = 0.043), LDL-C (P = 0.025), TC (P = 0.005), and BUN (P = 0.062) (P = 0.062 means there is certain effect modification).In order to accurately study the relationship between eGFR and DR, we need to excluded the influence factors that have an effect on their relationship through stratified analysis, interaction tests, and covariate screening. First of all, we analyzed the relationship between DR and all risk factors through stratified analysis . Each coCovariate screening was analyzed using computer software. The screening criteria included risk factors producing >10% change in the regression coefficient after introduction into the basic model. The results showed that the SBP, FBG, 2hPG, HbA1c, and the DM duration met the filter criteria .P < 0.001)  . In addi< 0.001) . When thto 0.036 . The resDiabetic retinopathy is one of the most common microvascular complications of DM . With anSimilar to other hospital-based epidemiologic studies in urban China , the preMany studies have described the risk factors for DR, which primarily include the extended duration of DM, old age, hyperglycemia, hyperlipidemia, proteinuria, severe obesity, alcohol consumption, genetic factors, and the expression of a variety of hormones, such as growth hormone –23. SimiThen we successively conducted stratified analysis, interaction test, and covariate screening to get rid of the factors that affect the relationship between DR and eGFR. After the adjustment of these influence factors, the results still suggested that eGFR was significantly associated with DR. The graphical representation of the relationship between them displayed a two-stage pattern and that the value of eGFR less than or equal to 99.4 mL/min was significantly correlated with DR. The AUC was 0.591815, a value between 0.5 and 0.7, indicating that the diagnostic value was not very useful, likely reflecting a bias in this study based on the fact that absence of the related variables with GFR, like urine protein or microalbumin. In addition, recent studies have shown that the incidence of kidney disease in some diabetic patients was independent of DN, referred to as nondiabetic renal disease (NDRD) , 26. TheGFR is an important indicator of kidney function and an important factor in the diagnosis of diabetic nephropathy . AlthougFor DM patients, DR and DN have a common pathological basis and a similar course of evolution. Hyperglycemia causes glomerular hyperperfusion and high filtration, leading to an increase of GFR during the early stages of T2DM . The accThe pathological mechanisms described above are similar to those observed in the retina. As in the kidney, the high blood sugar exerts deleterious effects on the retina, which include the apoptosis of Muller cells, ganglion cells , and perTaken together, these data highlight the use of eGFR as a predictor of DR. However, the results of the present study are important to the primary hospital for DR screening, especially to the ones with limited resources in China. But there are still some limitations. First, this study was a retrospective case-control study, including hospital-based patients with DM. Second, DR was diagnosed using ophthalmoscopy and fundus photography, but not fundus fluorescein angiography (FFA). Third, the GFR values were estimated by formula, and some of the factors associated with GFR, such as urinary protein excretion or microalbuminuria, were not included in this study. Therefore, a long-term follow-up study should be performed in the future. Moreover, more factors should be included in this study to provide an in-depth examination of the relationship and mechanism of GFR and DR.In summary, the results of the present study indicate that GFR may have certain implications for DR, which is important to DR screening in primary hospital of China, especially in poverty-stricken areas. Additional studies are needed to explore the mechanisms that couple GFR and DR.


Free-ranging brown bears exhibit highly contrasting physiological states throughout the year. They hibernate 6 months of the year, experiencing a decrease in body temperature, heart rate, respiratory rate and metabolism. An increase in food consumption and the resulting weight gain (mostly through fat storage) prior to hibernation are also part of the brown bear’s annual cycle. Due to these physiological changes, haematological and biochemical variables vary dramatically throughout the year. Seasonal changes in 12 haematological and 34 biochemical variables were evaluated in blood samples collected from 40 free-ranging subadult brown bears  immobilised in Sweden in winter (February-March), spring (April-May), and summer (June).Higher levels of haemoglobin, haematocrit and red blood cell count, and a lower white blood cell count and mean cell volume was found during hibernation than in spring and summer. Lower values of the enzymes; aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (AP), γ-glutamyl transpeptidase (GGT), glutamate dehydrogenase (GD) and amylase, and increased values of β-hydroxybutyrate (β-HBA) and blood lipids; triglycerides, cholesterol and free fatty acids, were present during hibernation compared to spring and summer.This study documents significant shifts in haematological and biochemical variables in samples collected from brown bears anaesthetised in winter (February-March) compared to in spring and summer (April-June), reflecting the lowered metabolic, renal and hepatic activity during hibernation. Lower values of enzymes and higher values of blood lipids during hibernation, likely reflect a lipid-based metabolism. Ursus arctos). Brown bears spend about half of the year in a den and survives extreme winter conditions without eating. Brown bears in Sweden enter their dens in October-November and emerge during March-April. The precise mechanisms determining den entry and exit are still unknown [Hibernation is an important feature of the biology of the brown bear , spring (immobilised from April 12th to May 3rd) and summer (immobilised between the 8th to the 23rd of June). The grouping was based on the seasonal changes in the bears’ life during the year, with winter being the hibernation period, spring the transition period and summer the active period. There was at least one month gap between each season group.This study included 40 free-ranging subadult (2-4 years old) brown bears , which were immobilised in the period of 2006 through 2013. Mean age at the time of immobilisation for females and males were 2.9 and 2.7 years old, respectively. Season was assigned to three categories according to the date the bear was immobilised; winter (immobilised from the 4Blood samples from bears captured during spring (April-May) were included in a previous study . The stuDuring spring and summer (April–June), bears were immobilised by remote darting from a helicopter using medetomidine-zolazepam-tiletamine, as previously described . In FebrBlood was sampled as reported previously  within 6Blood for biochemistry was collected in 9 mL tubes with gel and clot activating factor . The samples were kept at room temperature for 1-2 h to ensure complete clotting, and then centrifuged at 1500 g for 10 min to separate the serum. The serum was stored in 2 mL cryogenic vials  and kept at -20 °C until shipment to the Central Laboratory, Norwegian School of Veterinary Science, Oslo, Norway. The samples were kept cool during shipment.The haematological analyses and complete blood cell counts were carried out upon arrival at the laboratory. For haematological analyses in 2006 and 2007, a Cell-Dyn 3500 Hematology Analyser  was used. In 2008, the Cell-Dyn 3500 was replaced by an ADVIA®2120 Hematology System . Cell differentiation was carried out by manual examination of a blood smear, by the same technician at the laboratory.The haematology profile included red blood cell (RBC) count, white blood cell (WBC) count, haemoglobin, haematocrit, mean corpuscular volume (MCV) and mean corpuscular haemoglobin concentration (MCHC). In addition, a white blood cell differential count  for band shaped neutrophils, segmented neutrophils, eosinophils, basophils, lymphocytes and monocytes was included.All clinical chemistry analyses, except cortisol analysis, were carried out using an ADVIA®1650 Chemistry System  from 2006 to October 2011. Thereafter it was replaced with an ADVIA®1800 Chemistry System . The methods were the same for both analysers. Upon arrival at the Central Laboratory, samples were kept at -80 °C until analysis. Cortisol was measured with an Immulite system . The protein fractions were measured by Paragon CZE TM 2000 Capillary Electrophoresis System  from 2006 to September 2008, thereafter it was replaced with a Capillarys TM 2 .1-globulin, α2-globulin, β-globulin, γ-globulin, albumin-globulin ratio, total protein, β-hydroxybutyrate (β-HBA), bile acid, total bilirubin, cholesterol, creatinine, free fatty acids (FFA), glucose, triglycerides, urea, uric acid, calcium, chloride, iron, magnesium, inorganic phosphorous, potassium, sodium, and cortisol. Not all analyses were performed on each bear.The biochemical profile included aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (AP), γ-glutamyl transpeptidase (GGT), glutamate dehydrogenase (GD), creatinine kinase (CK), amylase, lipase, lactate dehydrogenase (LD), albumin, αp-value of <0.05 was considered significant. Eight bears were resampled in the same season during multiple years; in these cases, one sample from each bear in each season was randomly selected using a random number generator. The population was characterised based on sex  and the season during which the blood was collected.JMP®10.0.0 statistical software , was used to perform statistical analysis, and a The distributions of the haematological and biochemical variables were tested for normality. Those with an approximate Normal distribution were kept on the direct scale, whereas non-normal variables were transformed to normality with a Box-Cox transformation.The formula for the Box-Cox transformation, where ric mean ;\documenth, 97.5th and 100th percentiles. For variables including observed values of 0, a factor of 0.05 or 0.5 was added to all values before transformation.When >90 % of the values for a given variable was 0, transformation was considered non-sensible, therefore the reference values for these variables were presented as 90F-test was followed by a simultaneous comparison of paired means using the Tukey-Kramer test. After calculating the 95 % confidence intervals in the significantly different seasons, the transformed data were reconverted to the original data scale and corrections were made for any added values. For variables for which significant differences were not detected, sex and season cohorts were grouped together for presentation. Data is presented as 95 % confidence intervals.Comparisons between sex and seasons were performed on the transformed variables using analysis of variance. A significant Results for haematological and biochemical variables for subadult bears in different seasons are presented in Tables th, 97.5th and 100th percentiles. The percentiles for band-shaped neutrophils and basophils were 2.5; 11.3 and 12.4 and 0.0; 1.3 and 1.4, respectively.For the variables band-shaped neutrophils and basophils >90 % of the values were 0, they were presented as 901-globulin, γ-globulins, lipase and cortisol. Haemoglobin, haematocrit, albumin, β-hydroxybutyrate, creatinine and triglycerides were significantly higher during winter compared to spring, and significantly higher during spring compared to summer. For the serum enzymes alanine transaminase, aspartate transaminase, alkaline phosphatase and lactate dehydrogenase the values during summer were significantly higher than during spring, and the values during spring were significantly higher than during winter. The values of red blood cell count, eosinophils, lymphocytes, total protein and cholesterol were significantly higher during winter compared to spring and summer, while the values of mean corpuscular volume, white blood cell count, segmented neutrophils, amylase, γ-glutamyl transpeptidase and bile acids were significantly lower during winter compared to spring and summer.Seasonal changes were found in eight out of twelve haematological variables and in all biochemical variables except creatinine kinase, calcium, potassium, αUniquely, this study documents seasonal differences in blood variables in free-ranging brown bears. Bears were captured in their natural habitat and, when hibernating, inside their dens. Previous studies have used limited numbers of captive bears or non-hibernating bears. The seasonal changes in blood variables demonstrated here reflect the drastic physiological changes that bears undergo during the year. From the hibernation period in winter with decreased metabolism and reduced renal, liver and pancreas function, to the active state during summer where bears increase their food consumption to prepare for hibernation.During the capture event there are several factors that potentially can affect the blood variables; both the immobilising drugs, and the capture method chosen to enable darting may affect the animals’ physiology , 19. In High amounts of haemoglobin, red blood cells and haematocrit in winter have also been reported in other bear studies , 20–22 aSeveral reports, including this present study, have shown lower white blood cell counts in bears during hibernation , 20, 24.Lower enzyme levels during winter, as demonstrated in this study, have been reported in black bears , 25, 26.Creatinine and urea are good indicators of renal function, with high values indicating impaired function . During Increased values of blood lipids; triglycerides, cholesterol and free fatty acids, during hibernation found in this study, have been reported earlier in bears , 34–36. β-hydroxybutyrate (β-HBA) was also significantly higher in the winter compared to the spring and summer; as previously reported for denning bears , 32. EveThe changes reported here represent the many aspects of altered physiology seen during winter. The increased haemoglobin, red blood cells, haematocrit, total protein and albumin can be attributed to hypovolemia from the lack of liquid intake. The shift from carbohydrate and protein metabolism to fat metabolism results in decreased urea production and reduced demand for the enzymes important for protein breakdown . Fat catabolism also resulted in increased blood lipids, triglycerides, cholesterol and free fatty acids and fasting resulted in increased β-HBA, lower bile acids, enzyme and urea levels. The general depression of metabolic rate is also represented by the decreased organ function including decreased kidney (increased creatinine and magnesium), liver (increased ALP), and pancreas (decreased amylase) function and suppression of the innate immune system in winter (neutropenia).Significant seasonal differences in hematological and biochemical variables were documented in free-ranging subadult bears. The changes show the shifts in activity of the liver, kidneys, pancreas and overall metabolic processes that characterizes long term fasting and hypometabolism.


Introduction. Patients with Parkinson's disease (PD) showed reduced myocardial 123I-MIBG uptake, which may affect autonomic regulation. We investigated correlation between MIBC accumulation and cardiovascular autonomic function in PD. Methods. We performed myocardial MIBG scintigraphy, heart rate variability (HRV) analysis, and the head-up tilt test (HUT) in 50 PD patients . Autonomic function tests were also performed in 50 healthy controls (66.5 ± 8.9 years). As HRV parameters, a high-frequency power , a low-frequency power , and LF/HF ratio were used. Results. Our PD patients had a significant reduction in LF and HF compared with the controls (P = 0.005 and P = 0.01). In HUT, systolic and diastolic blood pressure falls in the PD group were significantly greater than those in the controls (P = 0.02 and P = 0.02). The washout rate of MIBG was negatively correlated with blood pressure changes during HUT. Conclusion. Our PD patients showed reduced HRV, blood pressure dysregulation, and reduced MIBG accumulation, which was correlated with blood pressure dysregulation. Orthostatic hypotension in PD may be mainly caused by sympathetic postganglionic degeneration. In addige of PD . SpectraWe studied 50 patients with PD . All patients with PD met the United Kingdom Brain Bank criteria for PD [MIBG myocardial scintigraphy was performed in all patients with PD. Planar scintigraphic images in the anterior view were captured by a single-head gamma camera  15 min (early) and 3 h (delayed) after intravenous injection of MIBG (111 MBq). To measure MIBG uptake, heart (left ventricle) and mediastinal regions of interest were drawn manually. The heart to mediastinum ratio (H/M) for both early and delayed images and the myocardial washout rate for delayed images were calculated. The normal ranges of MIBG parameters are >2.09 for H/M in delay phase and <33% washout rate in our institution (data not shown). For all participants, scintigraphy was performed within 1 month (before or after) of HRV analyses.R-R) was calculated as the standard deviation divided by the mean of 100 R-R intervals. The average of three CVR-R values was used. An abnormal CVR-R value was judged according to age-matched data from our laboratory (not shown). The power spectrum analysis of 300 R-R intervals was computed using fast Fourier transformation. The power spectrum was quantified into frequency-domain measurements; high-frequency oscillations  and low-frequency oscillations  were estimated from the spectra. In addition, the ratio between LF and HF (LF/HF) was calculated [The head-up tilt test and HRV analysis were performed in patients with PD and healthy control subjects in a quiet room at an ambient temperature of 22–26°C. Each subject was asked to relax, stay awake, and remain in a supine position for at least 15 min before each test. During the head-up tilt test, blood pressure and heart rate were measured using a sphygmomanometer at 1-min intervals. After 5 min of baseline measurement, each subject was passively tilted on an electrically driven tilt table to 70° for 10 min. Orthostatic hypotension was defined as a decrease in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within 3 min of tilting . For HRVU test was used to analyze mean differences between the PD and control groups. Spearman correlation coefficients were used to examine the relationships between disease duration, modified Hoehn and Yahr score, or L-dopa equivalent daily dose and the results of MIBG myocardial scintigraphy and autonomic function tests. Differences were considered statistically significant when P values were <0.05.The Mann-Whitney P = 0.002), and a mean fall in diastolic blood pressure in the PD group (−2.5 ± 9.6 mmHg) was also significantly greater than those in the control group . A mean CVR-R value in the PD group (2.16 ± 1.03%) was significantly lower than that in the control group . A mean LF component in the PD group (99.5 ± 127.5 ms2) was significantly lower than that in the control group . A mean HF component in the PD group (79.3 ± 115.6 ms2) was also significantly lower than that in the control group . No significant difference was observed in the LF/HF ratio between the PD (2.0 ± 1.8) and control groups (2.5 ± 2.4).In MIBG myocardial scintigraphy, 39 patients with PD (78%) showed a decrease in the H/M ratio on delay phase images, and 42 patients (84%) exhibited an increased washout rate. The mean H/M ratios in the early and delayed phases were 2.05 ± 0.68 and 1.84 ± 0.88, respectively, and the mean washout rate was 56.8 ± 18.7% in patients with PD. In the head-up tilt test, 11 patients with PD (22%) had orthostatic hypotension, whereas no control subjects had orthostatic hypotension. There were no significant differences in the means of systolic and diastolic blood pressure in the supine position between the PD (121.8 ± 18.9/66.8 ± 10.0 mmHg) and control (123.8 ± 19.1/72.4 ± 12.6 mmHg) groups. P = 0.02) and diastolic (P = 0.04) blood pressure changes during the head-up tilt test but not with any parameter derived from HRV analysis.Decreased accumulation of MIBG, which indicates sympathetic denervation of the heart, has been reported even in the early stages of PD . In our α-synuclein pathology appeared in the dorsal motor nucleus of the vagus nerve [Postmortem studies of the premotor phase of PD found that us nerve  as well us nerve  and the us nerve , suggestus nerve , 13 and us nerve . Compensus nerve . The comIn our study, patients with PD showed a significant negative correlation between the myocardial washout rate of MIBG and blood pressure changes during the head-up tilt test. One previous study showed a significantly greater decrease in myocardial MIBG uptake in patients with PD with orthostatic hypotension during the head-up tilt test ; howeverIn our present study, 33 out of 50 patients with PD were treated with antiparkinsonian agents, including L-dopa (a dopamine precursor). Since dopamine is structurally related to norepinephrine, competitive MIBG uptake inhibition (depletion of granules) has been suspected . In addiOur patients with PD showed reduced LF and HF, blood pressure dysregulation, and reduced myocardial MIBG accumulation, which was correlated with severity of orthostatic hypotension. Orthostatic hypotension in PD may be mainly caused by sympathetic postganglionic degeneration.


Systolic blood pressure is a key parameter when identifying patients in shock. However, the systolic blood pressure level below which a given patient should be considered hypotensive is subject to debate. Furthermore, recent studies have advocated higher systolic blood pressure thresholds than the traditionally recognized 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department and in the pre-hospital setting.A hospital-based cohort study from Odense University Hospital of all adult patients in the emergency department between 1995 and 2011, all patients transported to the emergency department in non-physician staffed ambulances in the period 2012-2013, and all patients serviced by the physician staffed ambulances in Odense between 2007 and 2013. Exposure was the first recorded systolic blood pressure and the main outcome was 7-day mortality. Best performing thresholds were identified with methods based on receiver operating characteristics and multivariate regression. Performance of systolic blood pressure thresholds was evaluated with standard summary statistics for diagnostic tests.7-day mortality rates varied from 1.8%  of 112,727 patients in the emergency department to 2.2%  of 15,862 patients in the non-physician staffed ambulance and 5.7%  of 12,270 patients in the physician staffed ambulance cohort. Best performing thresholds ranged from 95 to 119 mmHg in the emergency department, 103-120 mmHg in the non-physician staffed ambulance, and 101-115 mmHg in the physician staffed ambulance.A systolic blood pressure threshold of 100-110 mmHg might be a clinically relevant trigger point in the emergency department and the pre-hospital setting.


Hypertension is the main risk factor for cardiovascular diseases and stroke. Blood pressure control is a challenge for healthcare providers and the rate of blood pressure control is not more than 50% worldwide.The present study aimed to determine the effectiveness of a short-term educational program on the level of knowledge, lifestyle changes, and blood pressure control among hypertensive patients.This quasi-experimental study was conducted on the hypertensive patients attending Shiraz Healthy Heart House. In this study, 112 patients were selected via systematic random sampling. The study data were collected using a data gathering form which consisted of baseline characteristics and measurements of blood pressure. Multivariate analyses were used to assess the relationship between education and hypertension.At baseline, the scores of aware, treated, and controlled hypertensive patients were 21%, 20%, and 12%, respectively. However, these measures were increased to 92%, 95%, and 51%, respectively at the end of the study. The mean knowledge scores improved from 2.77 ± 2.7 to 7.99 ± 1.78 after 3 months (P < 0.001). Also, the mean lifestyle scores changed from 3.15 ± 1.52 to 4.53 ± 1.23 (P < 0.001).The results of the current study indicated that the educational programs were effective in increasing knowledge, improving self-management, and controlling detrimental lifestyle habits of the patients with hypertension. Hypertension (HTN) is the main risk factor for cardiovascular diseases and stroke. However, it is not taken seriously and is often deficiently controlled . LowerinA survey of the risk factors of non-communicable diseases in Iran revealed that 25.2% and 45.5% of the adults between 25 and 64 years old had HTN and prehypertension, respectively. However, 66% of the hypertensive patients were unaware of their disorder, 75% were untreated, and 94% were not controlled. These proportions are relatively high compared to those reported in other countries  and detrimental lifestyle behaviors (6 questions). Accordingly, one point was allocated to correct answers or behaviors and no points were considered for incorrect answers or behaviors. The total score was computed by summing up the correct answers or behaviors for each patient, ranging from 0 to 15.2) were measured and cardiovascular examinations were performed for all the patients. Besides, eye examination, including visual acuity, was carried out using Snellen chart and ophtalmoscopy. In addition, ECGs were taken and interpreted by a trained resident to diagnose left ventricular hypertrophy according to Romhilt-Estes criteria. Blood samples were collected after a 12-h fasting for assessment of FBS, TG, total cholesterol, HDL, BUN, Cr, Na, and K. It should be noted that written informed consents were signed by all the participants before beginning the study.Resting BP, height, weight, and BMI . The patients were labeled as hypertensive if on the average of three measurements, Systolic Blood Pressure (SBP) was ≥ 140 mm Hg, Diastolic Blood Pressure (DBP) was ≥ 90 mm Hg, or if s/he reported current use of antihypertensive medication. The patients were considered “aware” if they gave a positive response to the question, “Have you ever been told by a doctor or another health professional that you have hypertension, also called high blood pressure?” Moreover, a patient with HTN was classified as “treated” if s/he reported taking antihypertensive medication at the time of the survey. Furthermore, a treated patient was considered “controlled” if his/her SBP was < 140 mm Hg and his/her DBP was < 90 mm Hg”  was used to compute the frequencies and means of the patients’ demographic characteristics and their responses to the knowledge and lifestyle behaviors test. McNemar’s test was used to analyze the categorical data. In addition, paired sample t-test was employed to analyze any changes in the mean scores of knowledge and behaviors at the end of the study. P value < 0.05 was considered as statistically significant.The present study was conducted on 100 hypertensive patients. A total of 12 patients, who failed to return for follow up, were excluded from the study. Among the study participants, 65% were male. In addition, approximately two third of the patients had below high school degrees. At baseline, 21% of the hypertensive patients were aware of their high BP, 20% of the aware patients were treated, and only 12% of the treated ones were controlled. All these variables significantly improved at the end of the study . MoreoveAccording to At baseline, 11 - 90% of the responses to the questionnaires were correct . AccordiIt has been reported that a fall of 10 - 20 mmHg in systolic pressure maintained for 5 years could reduce the risks of myocardial infarction by 25% and that of stroke by40% . HoweverThe present study was a well-organized educational model which involved the patients in their own health care. This study was conducted in order to determine the status of HTN awareness, treatment, and control in the Iranian population and to evaluate the effect of a short-term educational program on the above-mentioned parameters. According to the study findings, the rate of HTN awareness (21% of those having HTN), treatment (20% of those aware of HTN), and control (12% of the hypertensive patients on treatment) was low in our population. HTN control was even less than that reported in other studies (Patient’s involvement in self-monitoring and management, together with continuous follow up has also been recommended by others , 14. SimIn spite of the increasing emphasis on drug therapy, lifestyle modification is an important part of BP control , 17. It Because few hypertensive patients receive guidance on changing their lifestyles, healthcare professionals should further encourage the hypertensive patients regarding lifestyle habits .Moreover, Wai Chiu et al. demonstrated that follow-up calls after nursing clinic consultation were effective in improvement of the patients’ adherence to a healthy lifestyle and their BP control . In the One of the strong points of this study was a matched-pair analysis before and after the measurements on the same patient, because it helps match the unmeasured variables.The present study had some limitations, with small sample size and short follow-up period being the most important ones. Further studies with larger sample sizes and longer follow-ups are therefore recommended to be conducted on the issue. Another limitation was lack of a special emphasis on smoking cessation in the educational program offered to our patients. The importance of smoking avoidance, as one of the strongest predictors of cardiovascular health and survival, has been shown in several studies , 20. RecIn conclusion, educational interventions have significantly desirable effects on lifestyle modification and BP control. Therefore, they should become an integral part of management of the patients with HTN. On the other hand, HTN control in our hypertensive population was found to be less than that reported in many other countries. Thus, a public educational program for promoting HTN awareness and lifestyle modification is an urgent need.


Both propofol and dexmedetomidine decrease systemic blood pressure, heart rate, and cardiac output in a dose-dependent manner. The aim of this study was to compare their safety and efficacy for intravenous sedation during mechanical ventilation.n = 42), sedation was performed by intravenous propofol infusion at a dose of 4 to 12 mg/kg/hour. In patients of the second group (n = 42), sedation was carried out by intravenous infusion of dexmedetomidine at a dose of 0.2 to 1.4 mg/kg/hour. The level of sedation was assessed with bispectral index monitoring, targeting index 70. For comparison of methods we evaluated heart rate, blood pressure, SpO2 30, 90 and 180 minutes after the start of sedation. Both groups were matched for sex, age and comorbidity.Eighty-four patients with traumatic brain injury  entered the study, mean age 44 ± 13.37 years. All patients underwent mechanical lung ventilation. Patients were divided into two groups depending on the type of intravenous sedation. In the first group (2 was 97 ± 3.01%. In patients of the second group 30 minutes after the beginning of sedation, HR was 87 ± 10.01 beats/minute, blood pressure was 131 ± 11.67/68 ± 8.19 mmHg, SpO2 was 97 ± 2.98%. After 90 minutes in the first group of patients, we observed HR was 81 ± 6.27 beats/minute, blood pressure was 119 ± 11.46/59 ± 4.29 mmHg, SpO2 was 98 ± 2.35%. In the second group, HR was 82 ± 7.31 beats/minute, blood pressure was 94 ± 13.62/55 ± 7.81 mmHg, SpO2 was 97 ± 2.76%. In the first group 180 minutes after the start of sedation, HR was 86 ± 6.19 beats/minute, blood pressure was 105 ± 10.34/54 ± 4.28 mmHg, SpO2 was 98 ± 1.32%. In the second group, HR was 75 ± 6.27 beats/minute, blood pressure was 92 ± 12.54/51 ± 6.91 mmHg, SpO2 was 96 ± 2.91%.Thirty minutes after the start of sedation in patients of the first group, HR was 83 ± 11.31 beats/minute, blood pressure was 127 ± 12.87/64 ± 8.54 mmHg, SpOUsing dexmedetomidine at a dose of 0.2 to 1.4 mg/kg/hour for intravenous sedation is safe in terms of hemodynamic stability and blood oxygenation for sedation during mechanical lung ventilation in traumatic brain injury patients.