Since a 2017 update, there have been important advances in stroke prevention. These include new evidence about nutrition, antiplatelet therapy, anticoagulation, lipid-lowering therapy, hypertension control, pioglitazone, and carotid endarterectomy and stenting. Evidence regarding toxic metabolites produced by the intestinal microbiome from egg yolk and red meat has important dietary implications, particularly for patients with impaired renal function, including the elderly. They should avoid egg yolk and red meat and limit the intake of animal flesh. Higher doses of folic acid may be needed for patients with the T allele of MTHFR, so it may not be sufficient to give vitamin B12  alone, even in countries with folate fortification. There is now good evidence that lipid-lowering therapy is even more beneficial in the elderly than in younger patients; we should be using lipid-lowering therapy more intensively, often/usually combining statins with ezetimibe. There is new evidence that lower systolic blood pressure targets are better for most patients, but a subgroup with stiff arteries, a wide pulse pressure, and a diastolic pressure of <60 would be more likely to be harmed than helped by aiming for a systolic target of <120 mmHg. There is a better understanding of how the pharmacological properties of direct-acting oral anticoagulants and the metabolism of antiplatelet agents should inform decisions about the use of these agents. Pioglitazone markedly reduces the risk of stroke, both in diabetics and prediabetics; it should be used more widely. It is now clear that carotid endarterectomy is safer than stenting and that the difference is strongly affected by age. Most patients, and in particular older patients, would be better served by endarterectomy than stenting. Readers are invited to study that review. In this update, I discuss more recent developments in nutrition, hypertension, antiplatelet therapy, anticoagulation, lipid-lowering therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). Exercise, smoking cessation, and adherence are also important, but there have been few recent advances in those topics. A report from the Insulin Resistance Intervention in Stroke (IRIS) trial reported a 34% reduction of stroke within 5 years among participants who quit smoking2. A Swedish study reported important improvements in risk scores, presumed to be a result of improved adherence, among patients with one or more risk factors attending a prevention program who were shown images of their carotid plaque3.In a 2017 updateIn 2017, I discussed the important advantages of the Mediterranean diet for stroke prevention. Since then, there have been developments regarding the consumption of cholesterol, meat, and eggs and the dietary implications of the interaction between renal function and the intestinal microbiome.4, so it seems obvious that, as egg yolk is very high in cholesterol content, the consumption of eggs would increase cardiovascular risk. Similarly, the consumption of meat, which is high in cholesterol and saturated fat, should also increase cardiovascular risk. This has been difficult to demonstrate, and indeed some observational studies suggest that egg and meat consumption are not harmful. Such findings are very likely based on indication bias and both measured and unmeasured confounders5 and are not biologically plausible. The reason it has been hard to demonstrate harm from eggs and meat is that the US diet is so bad that the AHA reported in 2015 that only 0.1% of Americans consume a healthy diet6. On that background, it is hard to show thatanything makes it worse. On the other hand, in Greece, where the Mediterranean diet is the norm, the harm from egg consumption was more obvious. Among Greek diabetics, an egg a day increased coronary risk fivefold, and even 10 grams/day of egg (a sixth of a large egg) increased coronary risk by 54%7.Dietary cholesterol increases cardiovascular risk8. We reported in 2018 that plasma levels of TMAO and three other toxic metabolites produced by the intestinal microbiome were significantly higher in patients with severe atherosclerosis not predicted by risk factors (“unexplained atherosclerosis”) than in patients with a protected phenotype (little or no carotid plaque despite high levels of coronary risk factors)9. Hazen’s group recently reported that phenylacetylglutamine increases cardiovascular risk via effects on adrenergic receptors10.Furthermore, besides cholesterol, egg yolk and red meat also contain high levels of dietary precursors of trimethylamine N-oxide (TMAO). High levels of TMAO strongly predicted the 3-year risk of stroke/myocardial infarction/vascular death among >4,000 patients referred to the Cleveland Clinic for coronary angiographyet al.11, who reported that, in the US, on the basis of data from 29,615 participants during a median follow-up of 17.5 years, both cholesterol consumption and egg consumption increased cardiovascular risk in a dose-dependent manner.I recently reviewed evidence that vegetarian diets reduce cardiovascular risk. Perhaps the best evidence about this issue is presented by Zhong212. Such levels of eGFR are the norm for patients aged over 7513. This means that patients with impaired renal function, including the elderly, should avoid egg yolk and red meat and limit their intake of animal flesh.Plasma levels not only of TMAO but also all of the toxic metabolites of the intestinal microbiome that we measured , were significantly higher among study participants with an estimated glomerular filtration rate (eGFR) of <66 mL/minute/1.73 m1, I summarized evidence showing that B vitamins to lower homocysteine do indeed reduce the risk of stroke. In the early studies, harm from cyanocobalamin among participants with renal failure obscured the benefit. For that reason, we should use methylcobalamin instead of cyanocobalamin14. I had been under the impression that folate fortification of the grain supply in North America meant that we needed to give only B12 supplements to reduce the risk of stroke. However, recent studies indicate that patients with the T allele of methylene tetrahydrofolate reductase (MTHFR) probably need higher doses of folate than would be obtained from fortification of the grain supply15. This means that we will need to reconsider higher doses of folic acid in addition to B12 supplements and perhaps vitamin B6 and riboflavin17 as well. Further study is needed; a trial of methylcobalamin plus folic acid (and perhaps pyridoxine) versus placebo would be important though unlikely to be funded. Subgroups of patients most likely to benefit would be those with metabolic B12 deficiency, which is very common and usually missed, and patients with the T allele of MTHFR.In the previous reviewet al.18 reported that apparent “aspirin resistance” was due to enteric coating. We should probably be using chewable or uncoated aspirin, not coated aspirin.There are a couple of important developments in antiplatelet therapy. Grosser19. That loss-of-function variant is present in ~30% of European and >50% of Chinese patients. We probably should stop using clopidogrel and switch to prasugrel or ticlopidine. A recent study indicated that prasugrel was superior to ticlopidine20.The other major issue is that clopidogrel, a prodrug, requires activation by CYP2C19. Patients with a loss-of-function variant of CYP2C19 have reduced benefit of clopidogrelThere have been a number of other advances in antiplatelet therapy, including combination of aspirin with rivaroxaban, as well as dual antiplatelet therapy for the prevention of recurrent stroke, which are not discussed here owing to word count limits.21.Although there are not randomized controlled trial (RCT) head-to-head comparisons across the class of direct-acting oral anticoagulants (DOACs), there are important differences in their pharmacokinetic properties that should be considered in choosing which one to use. These are summarized in213, this means that dabigatran is probably not a good choice for elderly patients. Dabigatran also has by far the lowest bioavailability, which makes it subject to large changes in blood levels with small changes in absorption or with drug interactions. It has a narrow therapeutic range, so it has been suggested that blood levels of dabigatran should probably be monitored22, thus negating one of the major advantages over warfarin. Rivaroxaban is not longer acting than the other DOACs, so it probably should not be administered once daily. Tellingly, recent studies with rivaroxaban have used twice-daily dosing23. As edoxaban also does not have a half-life longer than that of other DOACs, it too should probably not be taken once daily.Dabigatran is the most renally excreted of the DOACs, so it is unsuitable for patients with impaired renal function. Since the mean eGFR in patients older than 80 is <60 mL/minute/1.73 m24  but do not prevent “red thrombus”, which forms in the setting of stasis, with fibrin polymerization and entrapped red blood cells31, the paradigm should change. There are good reasons to think that in patients in whom a cardioembolic source is strongly suspected, it would be more prudent to prescribe a DOAC than an antiplatelet agent32.In the past, when vitamin K antagonists such as warfarin were the only drugs available for anticoagulation, it was understandable that the paradigm would essentially be that one would never prescribe an anticoagulant without proving the presence of a cardioembolic source such as atrial fibrillation. However, since DOACs are not significantly more likely than aspirin to cause severe bleeding33. Since antiplatelet therapy is more efficacious in LAA, failing to exclude such patients may be why anticoagulation was not superior in ESUS. Importantly, a meta-analysis that was included in a substudy of one of those trials showed that anticoagulation was superior to antiplatelet therapy for patients with patent foramen ovale34.Several trials to test that hypothesis failed to show a benefit of anticoagulation in patients with embolic stroke of unknown source (ESUS); however, it is very likely that misclassification of large artery disease may have accounted for that. When large artery atherosclerosis (LAA) is defined as a 50% carotid stenosis, it will miss 79% of patients classified as LAA by a high carotid plaque burden35, discussed in the 2017 review, have become more apparent. The physiology of salt and water retention was reviewed in 201836. A study of hypertension in foreign-born vs. US-born blacks revealed that African-Americans have nearly twice the rate of hypertension37, supporting the African Diaspora theory proposed by Grim38 and others: the very high mortality rate during the Atlantic crossing in slave ships, from diarrhea, vomiting, and sweating in the heat below decks, created a selective advantage for genetic causes of salt and water retention. It is now apparent that at least six genetic variants predispose to a primary aldosteronism/inappropriate aldosterone secretion phenotype , best treated with an aldosterone antagonist such as spironolactone or eplerenone, and at least six predispose to a Liddle phenotype , best treated with amiloride39. An important cause of resistant hypertension is “Diagnostic Inertia” – failure to ask the question “What is the physiological driver of the hypertension in this patient?”. Plasma renin and aldosterone should be measured in a stimulated condition , and the results should be interpreted in light of the class(es) of medication being taken at the time of blood sampling40.Reasons why physiologically individualized therapy based on renin/aldosterone phenotyping significantly improves blood pressure control41, lower blood pressure targets (a systolic pressure of <120 mmHg) are being recommended for blood pressure control. This approach may be well suited to most hypertensive patients, but there is an important exception. Patients with stiff arteries are at risk from systolic targets that are too low. The reasons include 1. stiff arteries widen pulse pressure, 2. stiff arteries increase the likelihood that the blood pressure measured by a cuff is actually much higher than the true  pressure42, and 3. most of coronary perfusion43, and more than half of cerebral perfusion44, occurs during diastole. For that reason, patients with a diastolic pressure of <60 mmHg with a pulse pressure of >60 mmHg have a doubling of subclinical myocardial ischemia43 and a 5.85-fold increase in the risk of stroke45. Frail elderly patients with stiff arteries (a pulse pressure of >60 mmHg) should not be treated to a target systolic pressure of <120 mmHg. A 2019 meta-analysis of standard vs. intensive blood pressure control for secondary stroke prevention supported a blood pressure target of less than 130/80 mmHg46.In the wake of the Standard Trial of Intensive versus Blood-Pressure Control (SPRINT) trial, among participants with increased cardiovascular risk but without diabeteset al. recently reported that lower target LDL-C significantly reduced the risk of recurrent stroke47. Participants randomized to a lower target LDL-C of <70 mg/dL (1.8 mmol/L) vs. a target range of 90 mg to 110 mg/dL (2.3 to 2.8 mmol/L) had a significantly lower risk of the primary endpoint . A frequently missed opportunity is in adding ezetimibe to statins; ezetimibe more than doubles the effect of statins, with fewer adverse effects than the use of high-dose statins48. The recent European guidelines recommend the addition of ezetimibe in high-risk patients who do not achieve a target LDL-C of 140 mmol/L (53 mg/dL)49. In the guideline, high risk was defined as having a previous cardiovascular event, but patients with asymptomatic carotid stenosis50, a high coronary calcium score51, or a high carotid plaque burden52 are also at very high risk52. A number of new lipid-lowering therapies are in development53.A key part of stroke prevention is lipid-lowering therapy; this is particularly important in patients with LAA. AmarencoTwo other recent developments are from the 2019 European guideline on the management of dyslipidemia, with consensus guidelines recommending a lower target LDL-C of 1.4 mmol/L (53 mg/dL) and the use of ezetimibe in patients who do not achieve target levels with statin alone. Using ezetimibe with statins is an important measure. Because statins and ezetimibe work by different mechanisms, the combination is synergistic. Ezetimibe more than doubles the lowering of LDL-C by statins. In patients who do not tolerate full doses of statins, adding ezetimibe will achieve the effect of high-dose statins with fewer adverse effects .et al.47. Patients with ischemic stroke and atherosclerosis were randomized to a lower target LDL-C of less than 1.8 mmol/L (70 mg/dL) vs. a target of 2.3 to 2.8 mmol/L (90 mg to 110 mg/dL). At sites where patients were in the target range for >50% of the time, major cardiovascular events were reduced by 36% ; at sites where participants were at target <50% of the time, there was no reduction in major cardiovascular events . There is a major problem with patients stopping statins for the wrong reasons (often influenced by internet nonsense). A review in 201648 discussed approaches to helping patients stay on statins; adding ezetimibe is a cornerstone of that effort.The importance of keeping patients on their lipid-lowering therapy was shown in the 2020 trial by Amarenco54. In the past, there was a tendency to withhold statins in older patients on the basis that since patients over the age of 80 years were not enrolled in randomized trials, there was no direct evidence of benefit; but, then again, there was also no evidence of harm! As discussed by Mortensen and Falk55, because the elderly are at higher risk of cardiovascular events, the benefit of lipid lowering should be even greater in old patients than in younger patients, with a greater absolute risk reduction and a smaller number needed to treat (NNT). This has indeed been shown to be the case in an RCT of adding ezetimibe to simvastatin: the NNT in patients aged over 75 was only 11 vs. 125 in patients younger than 75. In an RCT in Japan, patients with a mean age of 80.6 years at baseline were randomized to diet alone or diet plus ezetimibe. Over a median follow-up of 4.1 years, there was a 34% reduction of composite cardiovascular events and a 40% reduction of combined coronary events56.An important advance is that there is now good evidence that lipid-lowering therapy is even more beneficial in the elderly than in younger patients. I recently reviewed this issue57. Collinet al. point out that most such putative adverse effects based on observational studies are the result of indication bias or confounders, and they are refuted by meta-analysis of randomized trials of statins in very large numbers of patients58. The GREACE trial established that patients with elevated liver enzymes actually do better if they continue statins; “transaminitis” is probably due to fatty liver59. The European Guideline49 now recommends against monitoring of liver function in patients on statins and against stopping statins on account of “transaminitis”. I recently reviewed the issue of intracerebral hemorrhage (ICH). The widespread belief that statins cause ICH was an artefact of an inappropriate intention-to-treat analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) RCT, in which ~25% of patients randomized to placebo crossed over to statin, and many patients randomized to statin stopped taking it. The proof that atorvastatin could not have caused ICH is that there was a greater reduction of ischemic stroke, but no increase in ICH, among SPARCL participants who achieved a 50% reduction of LDL-C (i.e. they were taking the medication)60. Even if there were a slight increase in ICH with statins, there would be far greater harm from withholding or stopping statins than continuing them61.A scientific statement from the American Heart Association in 2019 reviewed the evidence that statins do not cause most of the adverse effects that have been attributed to themLipid-lowering therapy should be intensive, should frequently  be combined with ezetimibe, and should not be withheld on account of age or misplaced fear of ICH. In some patients, if the very high cost is not an issue, therapies directed at proprotein convertase subtilisin/kexin type 9 (PCSK9) might be considered.62. In 2016, the IRIS trial reported a 23% reduction in recurrent stroke with pioglitazone over 5 years in the intention-to-treat analysis, but adherence was suboptimal in many patients, mainly because of fluid retention and weight gain.Diabetes and insulin resistance are risk factors for stroke. Pioglitazone, a weak agonist of peroxisome proliferator-activated receptor-α (PPAR-α) and a potent agonist of PPAR-γ, reduces insulin resistance and has anti-atherosclerotic effects63. In 2019, a substudy of the IRIS trial was conducted among participants with insulin resistance defined by a glycosylated hemoglobin (A1C) level of 5.7 to 6.4% or fasting plasma glucose level of 5.55 to 6.94 mmol/L (100mg/dL to 125mg/dL). Among those with good adherence (taking >80% of the protocol dose), stroke or myocardial infarction was reduced by 43% in 5 years, recurrent stroke was reduced by 36%, and new-onset diabetes was reduced by 82%62  to cause one serious fracture is 12562. Pioglitazone should be used more widely for stroke prevention, both in diabetes and in prediabetes/metabolic syndrome.Pantoni, in an accompanying editorialet al.65 reported from a pooled analysis of individual data from 4,754 participants in symptomatic carotid stenosis that CEA was superior to CAS; the risk of stroke or death or subsequent ipsilateral stroke with CEA was 2.8% (95% CI 1.1–4.4) vs. 4.1% (2.0–6.3) with CAS at follow-up times up to 10 years. These outcomes were dominated by periprocedural events66. It is now clear from a meta-analysis by Howardet al.67 that CEA is preferable for most older patients (66.Recent advances include two important meta-analyses. Brottatients . “CAS shWhat does the future hold? Probably advances in transcarotid stenting will show the benefit of this approach over transfemoral or transradial stenting. New therapies for cholesterol-lowering will probably also improve stroke prevention, as well as improvements in antiplatelet therapy. What questions remain? Ongoing RCTs of stenting vs. endarterectomy vs. intensive medical therapy will likely provide answers about asymptomatic stenosis that may be applicable to symptomatic carotid stenosis; also, we need further evidence about anticoagulation in ESUS when the misclassification of LAA has been addressed. There have been many recent advances in stroke prevention; no doubt more are to come.


Globally, diabetes mellitus is a leading cause of kidney disease, with a critical percent of patients approaching end-stage kidney disease. In the current era, sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as phenomenal agents in halting the progression of kidney disease. Positive effects of SGLT2i are centered on multiple mechanisms, including glycosuric effects, tubule—glomerular feedback, antioxidant, anti-fibrotic, natriuretic, and reduction in cortical hypoxia, alteration in energy metabolism. Concurrently, multiple kidney and cardiovascular outcome studies have reported remarkable advantages of SGLT2i including mortality benefits. Additionally, the superiority of combination therapies  in treatment-naïve diabetic patients is further looked into with potential signal towards glycemic and blood pressure control. Reported promising results initiate a gateway for future research targeting kidney outcomes with combination therapies as an initial approach. In the current paper, we summarize leading cardiovascular and kidney outcome trials in patients with type 2 diabetes, the role of SGLT2i in non-diabetic proteinuric kidney disease, and the potential mechanisms of action of SGLT2i with special focus on combination therapy as an initial therapeutic approach in treatment-naïve diabetic patients. Diabetes mellitus and associated conditions including hypertension, obesity, and atherosclerosis significantly contribute to progression of chronic kidney disease (CKD), cardiovascular health, and overall mortality ,5,6,7,8.Over the past 20 years, angiotensin receptor blockers (ACE) have been used in attenuating neuro-humoral activation and reducing intra-glomerular hypertension. ACE inhibitors reduce doubling of serum creatinine and progression to ESKD by about 20% ,14. EvenSGLT2i have been increasingly recognized for their remarkable renoprotective and cardioprotective benefits ,22,23,24The seminal study by Milder et al. reviewed efficacy and safety of a combination approach of SGLT2i and metformin in treatment-naïve type 2 diabetic patients . Four raSignificant benefits of SGLT2i in type 2 diabetic patients outweigh minor side effect profile mentioned in the literature. Furthermore, appropriate preventive steps can be undertaken to help mitigate potential adverse effects. For example, SGLT2i has been associated with increased risk of mycotic genital infections, necessitating frequent monitoring and good hygiene. It has been proposed that prophylactic antifungals could be considered in patients with high risk of fungal infections. Additionally, SGLT2i has demonstrated significant natriuretic effects, which necessitates holding the doses in patients with nausea and vomiting or other conditions that would make them more prone to dehydration. Avoiding SGLT2i with early signs of DKA is also recommended due to concerns of worsening acidosis. Careful consideration should be given to the risk of urinary tract infections associated with SGLT2i. Lastly, patients with open foot wounds or skin ulcers should also be cautious due to some existing reports of lower limb amputations linked to SGLT2i ,38,39,40Based on recognized health benefits of SGLT2i, multicenter, randomized controlled studies were conducted evaluating renal and cardiovascular outcomes. As a pioneer agent, empagliflozin was compared to placebo in patients with type 2 diabetes mellitus at high risk of cardiovascular events . Among 72 of body-surface area and albuminuria of greater than 300 mg/g. Due to the apparent benefit of the drug observed in the study, CREDENCE trial was stopped earlier. Around 34% relative risk reduction in doubling of serum creatinine, progression to ESKD, and death from renal causes have been reported. Besides renal specific advantage, cardiovascular benefits were also observed.Some of the renal specific outcomes were studied in multicentric, double-blind, randomized trial, CREDENCE. This study looked at the effects of canagliflozin in patients with type 2 diabetes and albuminuric CKD . This haRecently, another multicentric, double-blind, randomized trial, DAPA-CKD, compared dapagliflozin to placebo. This trial specifically included late-stage CKD patients with GFR above 25 and below 75 mL/min, albuminuric patients with urine albumin-to-creatinine ratio of equal or above 200 and equal or below 5000 mg/g in patients with or without diabetes. Similar to CREDENCE, this trial was also stopped early given demonstrated superior efficacy of dapagliflozin. Primary endpoint was defined as a composite of an eGFR decline of at least 50%, onset of ESKD, and death from cardiovascular or renal cause in patients with CKD regardless of presence of diabetes.2  ,69. Theyong-term ,74. The ong-term . Furtherong-term ,43,76,77SGLT2i exhibits antioxidant properties by reducing free radical generation. Phlorizin was initially studied by Osorio et al. and was found to reduce oxidative stress in diabetic rats by its effect on catalase and glutathione peroxidase and decrease in nitrogen-free radicles . Tang etVarious inflammatory cytokines are upregulated in hyperglycemic milieu ,82. IndeSGLT2i modulate alterations in oxygen consumption and, therefore, are able to reduce renal cortical hypoxia. It has been noticed that decreased activity of Na-K-ATPase and reduced accumulation of intracellular glucose and sodium contribute to decreased oxygen utility. Fibroblasts might recover erythropoietin production as cortical hypoxia improves . Recent As discussed above, SGLT2i can cause natriuresis, and account for 7% of plasma volume reduction, leading to a decrease in preload . In a meSGLT2i also inhibits NHE1 in the myocardium and lower intracellular sodium and calcium content leading to reduced pro-oxidant and pro-thrombotic state as reported in empagliflozin experimental models . SGLT2i SGLT2i has revolutionized treatment approach in patients with type 2 diabetes mellitus. Although primarily glucosuric agents, their renoprotective property appears to be independent of its glucose-lowering effects. Even though multiple randomized controlled studies have illustrated beneficial effects of SGLT2i regarding renal outcomes, a certain degree of hesitation still exists in prescribing combination therapy with SGLT2i in insulin naive diabetic patients. Randomized controlled studies to evaluate therapeutic benefits and renal outcomes of combination therapies as initial approach in patients with type 2 diabetes might further guide the process of establishing more organized treatment approach. Additionally, further controlled studies are required in evaluating the potential role of SGLT2i in reducing proteinuria in non-diabetic CKD patients.


Although nondiabetic subjects with plaques had lower sCD36 levels than those without (p = 0.023), the multivariate models revealed no association of sCD36 with CAP in any of the three study groups. No differences were found in surface CD36 or CD36 mRNA expression between the patients with and without CAP. sCD36 is not associated with SCA in type 1 or type 2 diabetic or in nondiabetic subjects.This study aimed to determine the association of fatty acid transporter plasma soluble cluster of differentiation 36 (sCD36) with subclinical carotid atherosclerosis (SCA). A cross-sectional study was conducted in 1023 subjects, 225 with type 1 diabetes (T1D), 276 with type 2 diabetes (T2D) and 522 who were nondiabetic. Carotid atherosclerotic plaque (CAP) presence was determined using B-mode carotid ultrasound imaging. sCD36 were analysed by ELISA, and CD36 surface receptor and mRNA expression were measured by flow cytometry and real-time PCR. Logistic regression models were used to evaluate sCD36 as a biomarker of SCA. Up to 376 (36.75%) participants had at least one CAP, 76 T1D, 164 T2D and 136 without diabetes, while the remaining 647 (63.25%) did not have any CAP. There were no differences in sCD36 between patients with and without CAP in T1D ( Accelerated atherosclerosis is the primary cause of the increased cardiovascular morbidity and mortality associated with type 1 (T1D) and type 2 diabetes (T2D). Apart from other important cardiovascular risk factors, and although it has not been clearly established, there is some evidence that points to hyperglycemia as a contributing factor to the diabetes-associated macrovascular burden [There are several factors that have been described to be involved in the pathogenesis of atherosclerosis in patients with diabetes. Among these, we find hyperglycemia, dyslipidemia and chronic inflammation . In thisFor these reasons, CD36 has been proposed as a biomarker of future cardiovascular disease in diabetes with potential clinical applicability . The cirIn this study, we aimed to assess whether the circulating concentrations of sCD36 are associated with presence of carotid plaques in subjects with T1D, T2D, and without diabetes, all of them with normal kidney function and free of previous cardiovascular disease.1c < 6.5% and glucose < 126 mg/dL) [This cross-sectional study included 1023 participants recruited from the University Hospitals Germans Trias i Pujol  and Arnau de Vilanova . Among them, 225 with T1D and 276 with T2D were selected from two previous studies ,21; 522 6 mg/dL) ,21. BlooCarotid B-mode ultrasound imaging was performed using a Sequoia 512  or LOGIQ E9  with 15-MHz linear-array probes. The presence of atherosclerotic plaques was identified using B-mode and colour Doppler examinations. The presence of atherosclerotic plaques at different carotid artery sites was defined as a cIMT ≥ 1.5 mm protruding into the lumen, according to the criterion given in the ASE Consensus Statement  and the n = 64/522; T1D, n = 41/225 and T2D, n = 24/276). The intra-assay and inter-assay precision coefficients provided by the ELISA manufacturer were 4–6% and 8–12%, respectively.To assess the concentration of plasma sCD36, we used a commercial ELISA kit  following the instructions of the manufacturer. In brief, standards and samples, in appropriate dilutions, were incubated in duplicate for 2 h on the plate shaker at room temperature (RT). After washing four times, a detection antibody was added and incubated for 2 h on the plate shaker at RT. After four washes, a solution of streptavidin conjugated with horseradish peroxidase was incubated for 50 min again on the plate shaker protected from light at RT. After washing four times, a 50 μL substrate solution (TMB (tetramethylbenzidine)) was added, and this solution was incubated and protected from light for 20 min at RT. Then, 50 μL of stop solution was used to stop the colour development. Absorbance was read at 450 nm using SpectraMax 340PC384 . A log-log curve fit was used to analyse the results. The calibration was performed with recombinant human CD36 in a concentration range of 1.95–250 ng/mL. A value of 0.05 ng/mL was assigned to values of sCD36 lower than the detection limit  for 10 min to lyse erythrocytes. The cells were washed with PBS and then incubated with monoclonal antibodies against CD36 , CD3 and CD14 . Flow-cytometric analysis was performed on a Fortessa SORP flow cytometer  using the sample acquisition and analysis software FACSDiva v6.2 .® 480 PCR system using SYBR Green I Master . The CD36 primer pairs used in the reaction were forward primer 5′–›3′ (GAGAACTGTTATGGGGCTAT) and reverse primer 5′–›3′ (TTCAACTGGAGAGGCAAAGG). The expression level of glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was used to normalise gene expression values before analysing the results.In the 50 patients mentioned above, an analysis of CD36 mRNA expression was carried out to find differences between subjects with and without atherosclerotic plaque. After lysing, the erythrocytes with ammonium chloride , the cells were washed with PBS and disrupted with QUIzol Lysis Reagent . The mRNA Mini Kit  was used to extract total mRNA. Total RNA (1 µg) was reverse-transcribed using the Transcriptor First Strand cDNA Synthesis Kit . Each reaction was then amplified in a LightCyclerThe R statistical software, version 3.3.1, and SPSS software  was used for all handling of data, statistical analysis and figure construction. The results of the quantitative measurements are expressed as mean (standard deviation) or median (interquartile range), while for qualitative variables, absolute and relative frequencies are used.p-value < 0.1 and clinical relevance were used. The Hosmer–Lemeshow test evaluated in all models tested the goodness-of-fit assumption. Receiver operating characteristic (ROC) curves and DeLong’s test for correlated ROC curves were used to check the logistic regression models. Furthermore, multinomial logistic regression models were performed to determine the variables associated with the burden of carotid atherosclerotic plaque, one plaque or multiple plaques; patients without plaque were used as the reference. A p value < 0.05 was established as statistically significant.Analysis of variance (ANOVA), the Mann–Whitney test, or the Kruskal–Wallis test was used to determine the differences between patients with and without carotid atherosclerotic plaque in the T1D, T2D and control groups. The chi-squared test or Fisher’s exact test was used to evaluate the differences in qualitative variables. Tukey’s correction and Spearman’s rank correlation coefficient were used to account for multiple tests and correlations, respectively. A logistic regression model was used to determine the associations of variables with the presence of atherosclerotic plaque in every study group. In all these models, the variables of the bivariate analysis with a n = 225), 33.8% had atherosclerotic plaques; of 276 subjects with type 2 diabetes, 59.4% had plaques, and 26.1% of nondiabetic subjects (n = 522) had plaques. In the overall study population, the mean age was 51 ± 12.5 years, and up to 45.4% were men. In T1D, patients with at least one atherosclerotic plaque were older and had a higher proportion of tobacco exposure, hypertension, dyslipidaemia and antiplatelet treatment. Moreover, they had higher BMI (body mass index), SBP (systolic blood pressure) and ALT  than those without plaque. On the other hand, in the T2D group, patients with at least one atherosclerotic plaque were older and had a higher proportion of alcohol consumption, tobacco exposure and hypertension. Further, they had increased SBP and mean platelet volume (MPV)  with and 647 (63.25%) without a carotid atherosclerotic plaque, were included in the study. In the T1D group (me (MPV) . Finallyme (MPV) .p = 0.009). In head-to-head comparisons, the concentration of sCD36 was different between nondiabetic subjects with and without atherosclerotic plaques . Conversely, there was no difference between T1D patients with and without plaques  or between T2D patients with and without atherosclerotic plaques  (p = 0.043). Although in the T2D and nondiabetic groups, sCD36 concentrations were higher in echolucent compared to echogenic/mixed plaques, no significant differences were found. In T1D, echogenic/mixed plaques showed non-significantly higher levels of sCD36  . Furtherof sCD36 .p < 0.001), higher systolic blood pressure , tobacco exposure , higher BMI , T1D  and T2D  (p < 0.001), male sex , tobacco exposure , and higher LDL cholesterol   . In the = 0.019) . Circulap < 0.001), hypertension , dyslipidaemia , and tobacco exposure   a. sCD36 th sCD36 .p < 0.001), hypertension , and tobacco exposure , but not sCD36 , tobacco exposure, BMI, lipid profile , haematocrit, haemoglobin, platelets, serum creatinine, blood glucose, HbA1c and medication use. However, the associations observed were between atherosclerotic plaque and classical cardiovascular risk factors, i.e., hypertension, dyslipidaemia, tobacco exposure and age, but not with sCD36.The fatty acid transporter CD36 is believed to play a role in the development of atherosclerosis through its ability to bind and internalize modified lipids, such as ox-LDL. This action facilitates the formation of macrophage foam cells and their localisation to the subendothelial space, promoting endothelial dysfunction, CV disease and associated metabolic disorders ,29. NeveConcerning the potential role of sCD36 as a biomarker of cardiovascular disease, we found no association between increased concentration of sCD36 and the presence or burden of carotid atherosclerosis. On the contrary, we found higher sCD36 concentration in nondiabetic subjects without plaque compared with those with plaque. This could suggest a possible protective role of higher sCD36 concentration against subclinical carotid atherosclerosis in nondiabetic subjects. A recent study reported a possible protective effect of sCD36 concentration against metabolic syndrome components in patients with early coronary artery disease . SeveralTherefore, there is a lack of clear answers as to the relationship between plasma sCD36 concentration and carotid atherosclerosis in subjects with T1D or T2D or nondiabetic controls. Many studies agree that there is a lack of reliable, well-characterized or standardized methods to evaluate its concentration ,35. MoreOur study has some limitations that merit consideration. First, the cross-sectional study design excludes any conclusions about causality. Thus, a large prospective study is necessary to establish the usefulness of the sCD36 plasma concentration as a predictive factor for cardiovascular disease. Second, we adjusted for risk factors known to be related to atherosclerosis; however, the possibility that some other confounding factors can influence may have been incompletely accounted for. Third, in the flow-cytometric analysis of CD36 and in CD36 mRNA expression few samples were included. Finally, CD36 was not assessed in platelets, which are an important source of this molecule.Circulating plasma sCD36 concentration does not appear to be a biomarker of the presence or burden of subclinical nonstenotic carotid atherosclerosis. The possibility that other markers related to the CD36 protein such as CD36-associated MP as well as its main cellular source could be a biomarker of subclinical carotid atherosclerosis should be further explored. In addition, the measurement of sCD36 concentrations must be improved through the use of methodologies that allow for evaluating all circulating sources of this molecule. The use of assays with a higher sensitivity to detect sCD36 could contribute to assess more accurately the role that sCD36 actually plays as a marker of subclinical atherosclerosis. Thus, our study does not eliminate the potential of sCD36 as a biomarker of future atherosclerotic cardiovascular events. Prospective studies that include subjects with and without carotid atherosclerosis may help in clarifying this question.


Aneurysmatic Subarachnoid Haemorrhage (aSAH) is typically caused by extravasated blood in the subarachnoid space due to a ruptured aneurysm. aSAH is often life-threatening in the acute stage, but may also cause secondary brain damage due to delayed cerebral ischaemia (DCI) and other complications in the days and weeks after the initial bleeding. Rapid onset of a most severe headache is a typical sign of a non-traumatic aSAH besides a reduced level of consciousness and neurologic deficits.Immediate diagnostic steps in case of a suspected SAH are cerebral imaging  and lumbar puncture. If a SAH is confirmed, a digital subtraction angiography should be performed to detect an aneurysm. If an aneurysm is detected it should be occluded immediately after interdisciplinary consultation with neurosurgeons and neuroradiologists.If endovascular coiling and surgical clipping are both available and equally suitable, coiling should be preferred due to a better long-time outcome. Often the age of the patient, the location of the aneurysm, and the configuration of the aneurysm result in favouring one or the other technique. Special care aims at avoiding stress, increased intracranial pressure, pain, fever, emesis, and at keeping glucose levels and electrolytes in the normal range. As nimodipine is associated with a better outcome, it should be administered from the beginning. To detect vasospasm, serial transcranial doppler should be performed at least once a day for at least 14 days. If vasospasms are detected, this procedure needs to be continued until flow velocity returns to the normal range. To detect an increased intracranial pressure, external ventricular drainage or intraparenchymal probes are recommended. Regarding haemodynamics, euvolaemia and normotension should be achieved. If vasospasms and/or an increased intracranial pressure occur, mean arterial pressure needs to be adjusted to ensure an adequate cerebral perfusion pressure.If immediate actions are taken to treat the aneurysm and complications in the following weeks are handled with care, a favourable outcome is possible for this otherwise often devastating disease. An aneurysmatic Subarachnoid Haemorrhage (aSAH) is a life-threatening disease with a mortality rate of 25–50%  in whichTypically, patients report a most severe headache  with a sudden onset. This is often accompanied by neck stiffness, nausea, vomiting, decreased level of consciousness, vegetative disturbances , neurologic deficits , and epileptic seizures . An aSAHIn 10 to 43% of the patients, a warning leak  can occur up to eight weeks before the aSAH [For grading, various scores are used . Accordingly, evidence-based recommendations are often difficult to make. However, decisions need to be taken in handling patients with aSAH, therefore this SOP is based on guidelines and, where available, on clinical trials.bloody cerebrospinal fluid xanthochromiavisual inspectionerythrocytes in the cerebrospinal fluidxanthochromiaferritine levelsiderophageslaboratory work-upIf clinical signs and symptoms are suggestive for an aSAH immediate cerebral imaging is essential, preferably CT (sensitivity 95%) including CT angiography. If cerebral imaging shows no signs of bleeding, lumbar puncture must be performed , 10 to cSensitivity is higher if the lumbar puncture is performed 8–12 h after the first symptoms , 11.If the patient’s condition is unstable concerning the cardiopulmonary system, sedation and intubation have to be initiated first (preferably with Midazolam/Ketamine). Patients should be treated on neurological or neurosurgical intensive care units . Mild caDigital subtraction angiography (DSA) should be performed within 24 h after the initial bleeding (gold standard). If logistically possible and suitable, aneurysm occlusion by coiling can be performed in the same session. If no aneurysm is detected, a re-angiography after the period of (possible) vasospasm is recommended , 11.The highest incidence of re-bleeding is during the first 72 h . Accordingly, an immediate interdisciplinary diagnostic work-up and planning of interventional procedures together with neuroradiologists and neurosurgeons is recommended , 11. If Location: middle cerebral and pericallosal arteryConfiguration of the aneurysm: wide neck of the aneurysm, arterial branches stemming from the aneurysmRelevant intracranial haemorrhageFindings and features favouring clipping , 10:LocaLocation: posterior circulationConfiguration of aneurysm: small neck of aneurysmPatient age above 70 yearspoor-grade aSAH based on WFNS-scoringFindings and features favouring coiling , 10:LocaOcclusion of the aneurysm via endovascular coiling or surgical clipping  should bIf a hydrocephalus is present, external ventricular drainage should be applied prior to aneurysm occlusion (avoid aggressive drainage) .Patients should rest in bed  in sittiSerial neurological assessment and neurologic monitoring should be performed regularly. Headaches should be treated  using analgesics , e.g., NFever (temperature above 37.4 °C) should be treated medically and physically , 10, 11;Regarding blood glucose, volume, and electrolyte management, euvolaemia , 11 and For deep venous thrombosis prophylaxis, sequential compression stockings should be used before occlusion of the aneurysm , 10. ImmThe treatment depends on the intracranial pressure (ICP) and the presence of vasospasm. The recently published HIMALAIA-trial showed no favorable outcome for induced hypertonia up to 130 mmHg mean arterial pressure [The following recommendations can be made:systolic blood pressure < 140 mmHgmean arterial pressure 60–90 mmHgcerebral perfusion pressure > 60 mmHg Untreated aneurysm, normal ICP:normotension, CAVE: systolic blood pressure should always be above 120 mmHg, light hypertension is tolerable.Treated aneurysm, normal ICP, no vasospasm:A cerebral perfusion pressure above 60 mmHg  and striTreated aneurysm, increased ICP, no vasospasm:Mean arterial pressure should be increased up to > 90 mmHg stepwise (CPP > 70 mmHg), in cases of severe vasospasm even higher. Light hypercarbia should be considered to make use of vasodilatation effects, acidosis (pH < 7.2) should be avoided.Treated aneurysm, normal ICP, vasospasm:Cerebral perfusion pressure should be above 70 mmHg. If cerebral blood flow is diminished, an even higher cerebral perfusion pressure should be considered. Strict normocarbia (PaCO2 35 mmHg) is recommended. Invasive neuromonitoring should be considered.Treated aneurysm, increased ICP, vasospasm:Catecholamines should be used to increase blood pressure and cerebral perfusion pressure. Severe hypervolaemia and haemodilution should be avoided, light hypervolaemia is tolerable. Under unstable conditions and the urge for increasing the catecholamines, monitoring should be extended , e.g., aAs myocardial injury may occur in the course of an aSAH, cardiac assessment by electrocardiography, serial enzymes, and echocardiography is recommended. Cardiac output should be monitored if signs of dysfunction are detected , 11.A narrowing of cerebral arteries  is a common complication after aSAH. Vasospasms occur most frequently seven to ten days after the haemorrhage and can last up to 21 days. Vasospasm can result in delayed cerebral ischaemia (DCI), however, not all cases of vasospasm lead to DCI, and DCI can occur without the presence of vasospasm [To detect vasospasm, serial transcranial doppler / transcranial color-coded duplex ultrasonography (TCD) at least once a day is recommended . If no vAlthough its mechanism of action remains debated, nimodipine has been shown to improve neurological outcome after an aSAH . TherefoIn case of a symptomatic vasospasm and relevant hypoperfusion shown by CT perfusion, consider administration of nimodipine intraarterially or angioplasty , 11. Fur2 not less than 30 mmHg).In case of increased intracranial pressure, hypertonic saline continuously (145–150 mmol/L) or mannitol (10%) should be considered. If further action is needed, consider thiopental (single use or continuously). Hyperventilation is only recommended for a short period of time . An external ventricular drainage can be used to drain cerebrospinal fluid to decease intracranial pressure  and to apply fibrinolytic drugs.In poor-grade SAH consider intensive and invasive neuromonitoring measuring brain tissue oxygen and applying cerebral microdialysis , 11. AltContinuous EEG may help to detect epileptic seizures or DCI .Extended neuromonitoring is recommended in poor-grade SAH with increased intracranial pressure and mechanical ventilation :Serial nTo detect a hydrocephalus malresorptivus , frequent monitoring using clinical features, ultrasound, and CT-imaging is recommended. In the case of an occlusive hydrocephalus, disturbed cerebrospinal fluid circulation and/or global cerebral edema, an external ventricular drainage should be applied immediately , 10, 11.Approximately 10% of the patients develop epileptic seizures and/or a status epilepticus. To detect epileptic activity (mainly non-convulsive) serial EEG or continuous EEG is recommended. Prophylactic anticonvulsive treatment is not recommended [ventricular and supraventricular extrasystoles or tachycardiaatrial fibrillationST segment elevation or depressionmyocardial infarction type ECGelevation of troponinneurogenic or cardiac pulmonary oedemacardiac failurecardiogenic shockCardiopulmonary complications are common after aSAH :ventricuIf neurologic and/or cognitive deficits persist, rehabilitation is warranted.For follow-up after successful occlusion of the aneurysm without complications, MR angiography is preferred rather than digital subtraction angiography . RepetitPatients with symptomatic chronic hydrocephalus require a ventriculoperitoneal or ventriculoatrial shunt , 10, 11.In case of a familial preponderance (≥2 first-degree relatives with SAH or aneurysm), screening with MR angiography can be considered. A general screening for aneurysms cannot be recommended , 11.Modifiable risk factors of aneurysm rupture are smoking, high systolic blood pressure, alcohol abuse, and drugs , 10, 11.Immediate action concerning diagnostic and therapeutic steps are essential in the management of aSAH. After establishing the diagnosis via cerebral imaging and lumbar puncture (if imaging is inconclusive), the detected aneurysm should be occluded by surgical clipping or radiological coiling. As relevant as the acute management is the detection and treatment of complications following aSAH including vasospasm, increased intracranial pressure, disturbed cerebrospinal fluid circulation, delayed cerebral ischaemia, cardiopulmonary complications, and neurological deficits including cognitive deficits, all of which affect the clinical outcome to a great extent.


Different physical activities are widely recommended as non-pharmacological therapies to reduce blood pressure. However, the effectiveness of exercise programs is associated with its continuity and regularity, and the long-term adherence to traditional exercise interventions is often low. Recreational sports emerge as an alternative, being more captivating and able to retain individuals for longer periods. Besides, sport interventions have demonstrated improvements in physical fitness components that are associated with a lower incidence of hypertension. However, no studies have investigated the effects of recreational sports on 24 h ambulatory blood pressure. The aim of the present study is to evaluate the effect of beach tennis training on ambulatory blood pressure and physical fitness in individuals with hypertension.This study will be a randomized, single-blinded, two-arm, parallel, and superiority trial. Forty-two participants aged 35–65 years with previous diagnosis of hypertension will be randomized to 12 weeks of beach tennis training group (two sessions per week lasting 45–60 min) or a non-exercising control group. Ambulatory (primary outcome) and office blood pressures, cardiorespiratory fitness, muscle strength/power and quality of life will be assessed at baseline and after the intervention period.Our conceptual hypothesis is that beach tennis training will reduce ambulatory blood pressure and improve fitness parameters in middle-aged individuals with hypertension. The results of this trial are expected to provide evidences of efficacy of recreational beach tennis practice on blood pressure management and to support sport recommendations for clinical scenario in higher risk populations.NCT03909321. Registered on April 10, 2019.ClinicalTrials.gov,  Hypertension is considered the most important modifiable risk factor for cardiovascular disease , 2 affecThe effectiveness of physical exercise programs seems to be directly associated with its continuity and regularity, and the long-term adherence to traditional exercise interventions  is often low . One of The age-related decline in physical fitness components   and physreserve) of 59–68% and there were no reported adverse events, confirming the potential of this sport to improve the cardiovascular profile in individuals with hypertension .Although participation in recreational sports can be enjoyable, it may also face some difficulties to obtain high adherence, particularly due to musculoskeletal injuries . InvasioTo the best of our knowledge, no studies have investigated the chronic effects of team sports on 24 h ambulatory blood pressure and have assessed the effects of a beach tennis intervention in cardiovascular profile and physical fitness. Based on that, we designed this parallel randomized controlled trial to evaluate the effect of beach tennis training on 24 h ambulatory blood pressure and different physical fitness parameters in individuals with hypertension. The difference between the intervention arms in mean change from baseline in 24 h, daytime and nighttime systolic and diastolic ambulatory blood pressure at 12-weeks is the primary outcome; secondary outcomes are the difference between mean change in office blood pressure as well as cardiorespiratory fitness, muscular strength and power. We anticipate that 12 weeks of beach tennis training will reduce blood pressure when compared to a non-exercising control group. Additionally, our recreational beach tennis intervention will improve all physical fitness components in comparison to the baseline values.This is a single-center, two-arms, parallel randomized controlled trial with concealed allocation, blinded measurers, with 12 weeks of follow-up analyzed using an intention-to-treat approach. The recruitment will take place between December 2020 and December 2021 through social media and banners. The protocol followed the recommendations for interventional trials (SPIRIT) 2013 guidelines .The primary site of this study is the Center of Clinical Research at Hospital de Clínicas de Porto Alegre . The intervention center takes place at indoor and outdoor beach tennis courts , located outside to the hospital.Men and women (aged 35–65 years) with previous diagnosis of hypertension and using up to 3 of any class or type of anti-hypertensive drugsNot engaged in structured exercise programs in the 3 months prior to the start of the studyAble to be enrolled, based on resting electrocardiogram  and questionnaire about the participant’s clinical and osteoarticular symptomsSigned a written consent form for participation in the studyInclusion criteria:Cardiovascular disease detected by acute myocardial infarction, angina, stroke or heart failure diagnosed in the last 24 months, as well as other chronic diseases Current smokers or non-smokers for less than 6 months2Body mass index over than 39.9 kg/mDiabetic proliferative retinopathyExclusion criteria:Participants will be randomly allocated to the beach tennis training intervention (BTT) or to the control group (Con), which will not be submitted to intervention and will be instructed not to engage in any kind of structured physical exercise training and to keep the life activities identified at baseline. The International Physical Activity Questionnaire (IPAQ) will be applied before and after the intervention in order to assess the level of physical activity.versus1). As an objective measure of exercise intensity, heart rate (HR) will be continuously recorded with a Polar HR monitor  during the beach tennis sessions, and data related to the average HRreserve and maximal HR will be used to characterize the intensity throughout the sessions. We previously tested the physiological demand of beach tennis practice using the same methods and found an average HR of 59–68% HRreserve during the beach tennis session lasting 45 min in participants with hypertension .In BTT, supervised beach tennis sessions will be performed two times per week. Each session will be composed of an initial period of 10 min of warm up and technical exercises . After that, 3 games of 10–15 min each  with an interval of 2 min between each game will be played in pairs . In case of less than 4 participants are able to play at the same time, the games can also be played individually , intermediate (more agile and coordinated movements), or advanced , in order to organize the schedule of beach tennis sessions by matching players of the same performance level. We believe that ensuring high motivation and adequate intensity during any sport practice is important and to organize the games using participants at a similar performance level will help to get it. Outcomes will be assessed for all randomized participants before and after the intervention sessions, irrespective of attendance or completion status. For participants who drop-out of the study at any time after the randomization, researchers will use contact information to invite such participants to undergo the end-study outcome assessments (12 weeks after the beginning of intervention).The primary outcome is the change from baseline in 24 h, daytime and nighttime systolic and diastolic blood pressure measured by ambulatory blood pressure monitoring at 12 weeks.Secondary outcomes include the average change in office systolic and diastolic blood pressure as well as cardiorespiratory fitness, muscular strength and power and quality of life evaluated at baseline and after 12-week intervention in both arms. Additional measures of office blood pressure and enjoyment level during beach tennis sessions will be assessed at weeks 1, 4, 5, 8, 9 and 12.Participants will be recruited from electronic medical records, phone calls, e-flyers in social media, word of mouth, and personal references. Patients potentially eligible for the study will be contacted by telephone by the trial investigator, who will explain the study and ascertain the patient’s interest to participate. Those who accept to participate will attend the Center for Clinical Research of Hospital de Clínicas de Porto Alegre, where the study consultations will be performed, to sign a consent form. The schedule of enrollment, interventions, and assessments is presented in Table Those who signed the consent will undergo a clinical screening, resting electrocardiogram, anamnesis with sociodemographic, anthropometric and clinic data assessment, and questionnaire to evaluate quality of life. After that, the participants will perform a familiarization with strength and power muscle tests and with the mask that will be used in the cardiopulmonary test. In the second visit, participants will place the equipment of ambulatory blood pressure monitoring. On the day after, each participant will return at the laboratory to remove the equipment and perform evaluations of the cardiorespiratory fitness, muscular strength and power. All variables are assessed at baseline and at study completion. Participants will be asked to maintain their habitual activity and dietary habits at the time of recruitment.Ambulatory blood pressure will be assessed throughout 24 h in intervals of 15-min in daytime and 20-min in nighttime periods. Daytime period starts at 7 AM and night-time starts at 11 PM. Participants will receive a formulary to note day activities, symptoms, sleep time and wake-up time. Each exam is considered valid when at least 14 measurements during the day and seven measurements at night [at night . If any Office blood pressure will be measured after 10–20 min of rest, with the participant sitting quietly in a chair, according to standardized guidelines [idelines . Three mCardiorespiratory fitness will be assessed using an incremental exercise test on a treadmill in order to determine peak oxygen consumption. The protocol will consist of an initial velocity of 3.5 km/h with 1% inclination for the first 2 min. Thereafter, velocity and grade will be incremented by 0.4–0.6 km/h and 0.5–1.0% inclination, respectively, every 1 min until the participants achieve their volitional exhaustion [haustion . The expCountermovement jump test will be assessed using My Jump2 software for mobile [r mobile . The parMedicine ball throwing test will be assessed using a medicine ball of 1 kg for women and 2 kg for men. Each participant will remain seated at the floor in an upright standing posture, with 90° abduction shoulder position, arms shoulder-aligned and flexed elbows. We will instruct to throw the ball as fast as possible, performing full-speed movement. Three attempts will be performed with a 1-min rest interval.Chair-stand test will be conducted using a folding chair without arms, with a seat height of 43.2 cm. The test will begin with the participant seated in the middle of the chair, back straight, feet approximately shoulder-width apart and placed on the floor at an angle slightly back from the knees. Arms should be crossed at the wrists and held against the chest. At the signal “go”, the participant will stand up (body erect and straight) and then return to the initial seated position. The total number of stands executed correctly within 30-s and time to perform the first five repetitions will be used during the analyses [analyses .Isometric handgrip strength will be measured in both arms with an analogic hand dynamometer . The participant will remain seated with upright posture, placing the forearm parallel to the ground (elbow flexed at 90°). Thereafter, the participants will be instructed to perform a maximal squeezing contraction with sustained (isometric) effort lasting 5-s. Three attempts will be performed in each hand with 30-s rest intervals.Quality of life will be evaluated through WHOQOL-BREF questionnaire [ionnaire . The queEnjoyment can define the level of fun in the different interventions and we will assess this variable through the Physical Activity Enjoyment Scale (PACES). The scale is composed of 18 items in a bipolar affirmations format  punctuated in a range from the minimum value “1” to the maximum value “7” [alue “7” .Data will be collected on standardized paper forms identified by participant number and trial ID and containing instructions for standardized operational procedures. From these forms, we will proceed with double data entry for primary, secondary, and additional outcomes. All data will be stored and managed using the Research Electronic Data Capture (REDCap), an electronic data capture tool hosted at the Hospital de Clínicas de Porto Alegre.n= 28) and  allowing a dropout rate of 10%, will be able to detect a difference of 4 ± 6 mmHg in systolic 24 h blood pressure between groups. Statistical power was set at 90% including a type I error rate of 5%. WinPepi software calculator was used to estimate the sample size [Sample size for the primary outcome was calculated using estimates of effect sizes from randomized clinical trial with similar design . This esple size .www.random.org), with blocks of random sizes that will not be disclosed to ensure concealment. Groups will be generated by stratified randomization per age (35–50 and 51–65 years) and baseline systolic ambulatory blood pressure in order to provide homogeneity on these prognostic factors. The epidemiologist will not participate in the recruitment or assignment to intervention sessions. The outcome assessors and data statistical analyses will be double masking to the endpoints of study. In contrast, participants and the beach tennis instructors will be blinded to the randomization list until the moment of assignment.The randomization list will be generated by an epidemiologist using web software .Data distribution will be analyzed using Shapiro-wilk test with analysis of histogram and Q-Q plots in combination. Data will be expressed as means and standard error for variables with normal distribution or medians and interquartile range for non-normal distributions and 95% confidence intervals (95%CI). Ambulatory blood pressure will be analyzed as daytime, nighttime and 24 h systolic and diastolic blood pressure. Primary and secondary outcomes will be analyzed using generalized estimating equation model (GEE) for correlated measures. Adjustment for multiple comparisons will be accomplished using Sequential Bonferroni test. All analysis will be conducted using SPSS Statistics for Windows, version 18.0 .We intend to disseminate the methods and findings of the BAH study through individual explanation about the main findings and practical application of the study to each participant; press releases written by journalists and using our personal social media to the general public; and submit scientific manuscripts related to our main findings.Although several types, formats, and frequencies of physical activity interventions are available to reduce blood pressure, the optimal exercise training remains controversial. Recreational sports can be effective to reduce blood pressure , 21 and Team sports interventions have also demonstrated improvements in different physical fitness components that are comparable to traditional exercise programs . The inc


TGF-β1 is known to promote cardiac remodeling and fibrosis during Congestive Heart Failure (CHF). In this study, an attempt was made to investigate expression of Transforming Growth Factor beta1 (TGF-β1) and relative expansion or contraction of regulatory T-cell (Tregs) population in peripheral blood of patients with Chronic Heart Failure (CHF).+CD25+FoxP3+ Tregs.Real-time PCR assay was used to investigate expression and post-stimulation levels of TGF-β1 in cell culture supernatant of Peripheral Blood Mononuclear Cells (PBMC) of 42 patients with CHF and 42 controls. Flow cytometry was used to identify relative counts of CD4+ helper T-cells were unchanged. Treg expansion was more significant in NYHA functional class I patients compared to class IV patients.PBMCs in patients with CHF expressed higher levels of TGF-β1 compared to controls. Post-stimulation levels of TGF-β1 expression were significantly higher in New York Heart Association (NYHA) functional class IV patients compared to stage I patients. Tregs were significantly expanded in PBMC in CHF, while the CD4Expansion of Treg population in CHF provides an extrinsic source for TGF-β1 production to induce reactive fibrosis and cardiac remodeling. Relative decrease in Treg population at advanced stages of CHF is indicative of a loss of regulatory characteristics in these cells and unopposed proinflammatory milieu. Patients were excluded if they were in decompensated heart failure phase at the time or within the last 1 month of sampling, or if they had experienced acute coronary syndrome within the last 6 months.A case-control study was designed enrolling 42 patients  with CHF from referrals to the Tehran Heart Center, and another 42 matched, healthy individuals  as the control group. The diagnosis of CHF in case group was made on clinical grounds as well as the patient’s most recent echocardiography in which the Left Ventricular Ejection Fraction (LVEF) had been measured less than 45%. Mean LVEF of the patients was 24.6±1.13% with a mean systolic/diastolic blood pressure of 143±30/103±20 ml whole blood was obtained to isolate PBMC through Ficoll–Paque density gradient centrifugation. Total cellular RNA was isolated from 5–10 ×106 cells from the PBMC solution by 12000 RPM centrifugation, using RNX solution . Next, 1 μg of total RNA from each sample was reverse transcribed to complementary DNA (cDNA) using First Strand High Capacity cDNA Reverse Transcription Kit . TGF-β mRNA expression levels were analyzed using a quantitative real-time Reverse Transcriptase Polymerase Chain Re-action (RT-PCR) method by TaqMan Universal PCR Master Mix . Differences in gene expression were normalized against β Actin as a housekeeping gene, via ABI Prism7900 Sequence Detection System  5 6 cells from each tube of cultured PBMC were stained with anti-cell-surface antibodies, anti-CD4-FITC and anti-CD25-PE antibodies . The resulting cellular cocktail was used to obtain flow cytometry data on a FACS Calibur  using the Flowjo 7.6 software. Statistical analyses were performed using SPSS software version 23.Next, 1×10+ CD25+FoxP3+ T-cells (Regulatory T-cells) was increased in patients with CHF compared to controls (p= 0.01). The percentage of CD4+ helper T-cells was unchanged in patients with CHF , yet the relative count of regulatory over helper T-cells was significantly increased in patients with CHF compared to healthy controls . Interestingly, patients with CHF in NYHA class IV had a significantly lower count of CD4+CD25+FoxP3+ T-cells compared to those in class I (p=0.02) (A significant increase in mRNA expression of TGF-β1 was found in patients with CHF (3.1±2.66) compared to controls (1.75±2.11) (p=0.01) . Higher (p=0.02) .+CD25+FoxP3+ regulatory T-cells over CD4+ helper T-cells in CHF. Paradoxically, this expansion was less prominent in patients with NYHA functional class IV compared to those in class I, and was most prominent in NYHA class II. This could be justified in a two phase model of cytokine expression in CHF. In patients with well-compensated CHF, peripheral cytokines are largely from cardiac origin which later stimulate polarization of T lymphocyte into regulatory phenotype. Expansion of Treg population and relative contraction of helper T-cells are then responsible for excessive amounts of TGF-β produced in later stages of CHF and progressive fibrosis. In line with this, no difference was previously shown in expression of FoxP3, interleukin 10 and Treg transcription factors in early CHF Our results confirm previous findings on peripheral TGF-β1 upregulation in chronic heart failure and the possible benefits in suppressing TGF-β expression to prevent cardiac muscle fibrosis. TGF-β expression did not show any correlation with patient’s functional class at baseline level, but did so following stimulation of cultured PBMC with PHA. Lymphocytes of CHF patients expressed lower TGF-β during early functional stages of disease, compatible with relative expansion of CD4etc. According to Okamoto et al, compensatory increase in IL-6 expression is in favor of naïve T-cells to maturate into Th17 subtype rather than Treg phenotype, counteracting profibrotic function in advanced stages of CHF et al also suggested a prognostic value for Treg, predicting a more rapid decline in ventricular ejection fraction in patients with CHF An expansion in baseline expression of TNF-α and IL-6 as two major proinflammatory cytokines in PBMC of CHF has been previously identified Our results are in line with previous findings that early inhibition of TGF-β is in favor of production of proinflammatory cytokines and neutrophil infiltration, while late TGF-β blockade has anti-fibrotic, anti-remodeling effects.


Intraabdominal hypertension is a common clinical condition with high mortality and morbidity in pediatric intensive care units. The aim of this study was to test the feasibility of regional tissue oxygenation (rSO2) measurement using near-infrared spectroscopy and to assess the correlation between rSO2 and perfusion markers of intraabdominal hypertension in high-risk pediatric patients. In this prospective observational cohort study in a tertiary pediatric intensive care unit in Çukurova University Faculty of Medicine, a total of 31 patients who were admitted between May 2017 and May 2018 with a risk of intraabdominal hypertension were included. Mesenteric and renal rSO2 measurements were taken and correlations with other tissue perfusion markers including mean arterial pressure, pH, lactate, intraabdominal pressure, abdominal perfusion pressure, mixed venous oxygen saturation, vasoactive inotropic score were assessed. Intraabdominal pressure was measured as ≥10 mmHg in 15 patients (48.3%) and these patients were defined as the group with intraabdominal hypertension.In the group with intraabdominal hypertension, mixed venous oxygen saturation was lower (P = 0.024), vasoactive inotropic score was higher (P = 0.024) and the mean abdominal perfusion pressure value was lower (P = 0.014). In the ROC analysis, the mesenteric rSO2 measurement was the best parameter to predict intraabdominal hypertension with area under the curve of 0.812 (P = 0.003) 95% CI [0.652–0.973].Monitoring of mesenteric rSO2 is feasible in patients at risk for intraabdominal hypertension. Moreover, both mesenteric regional oxygen and perfusion markers may be used to identify pediatric patients at risk for intraabdominal hypertension.  Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with high mortality and morbidity rates in children. The World Society of the Abdominal Compartment defines pediatric IAH as having intraabdominal pressure (IAP) > 10 mmHg in continuous or repeated measures with new or worsening organ dysfunction that can be attributed to elevated IAP [1]. Elevated IAP affects both abdominal and extraabdominal organs. It can cause a variety of effects on the functions of the gastrointestinal, renal, respiratory, cardiovascular, and central nervous systems [2]. The vicious cycle of poor perfusion starts and increasing IAP leads to ischemic cellular necrosis [3]. The incidence of IAH is 12.6% and the prevalence is 43.9% in critically ill children in pediatric intensive care units . The mortality of ACS in critically ill children ranges from 16% to 100% in various studies . Abdominal perfusion pressure (APP) is the difference between the mean arterial pressure (MAP) and the IAP and can be thought of as an abdominal analog of cerebral perfusion pressure. Optimum APP level in children is not yet defined. Children have lower MAP levels than adults and therefore have an increased risk of developing multiple organ failure in lower IAP levels than adults . Risk factors for IAH were defined by the consensus published by WSACS [2]. Near-infrared spectroscopy (NIRS) is a technique that evaluates regional tissue oxygenation (rSO2) by noninvasive methods [10]. It measures cerebral or somatic rSO2 and can be used as a marker of hypoperfusion. There is no absolute value reported in the literature yet, though cerebral rSO2 < 50% indicates severe brain injury. Both cerebral and somatic measurements <30%, or a 20% decrease from baseline, are considered urgent and it points to ischemia [11]. In this study, we aimed to determine the relationship of rSO2 measurements with NIRS to other perfusion markers in terms of detecting intraabdominal hypertension in patients in the risk groups.Patients who were admitted to the Çukurova University Faculty of Medicine, Balcalı Hospital Pediatric Intensive Care Unit between May 2017 and May 2018 were evaluated prospectively. Patients with risk factors for IAH, defined using the WSACS consensus decision, were included the study (1). Table 1 shows the risk factors for IAH. Mesenteric and renal rSO2 measurements were performed. Other tissue perfusion markers such as MAP, APP, lactate, IAP, capillary refilling time, central mixed venous oxygen saturation (ScvO2), acidosis, hypothermia, sepsis, coagulopathy, mechanical ventilation status, pediatric logistic organ dysfunction (PELOD) score and pediatric risk of mortality score (PIM) II score, pediatric risk of mortality (PRISM) III score were recorded. Ejection fraction (EF) was measured and vasoactive inotropic score (VIS) was calculated. The VIS was calculated as follows: [dopamine (µg/kg/min)] + [dobutamine (µg/kg/min)] +  + [10 × milrinone (µg/kg/min)] + [100 × epinephrine (µg/kg/min)] + [100 × norepinephrine (µg/kg/min)] [12]. Mesenteric and renal rSO2 measurements were performed using the NIRS  Pediatric NIRS sensors were placed on two locations: just below the umbilicus on the anterior abdominal wall for mesenteric rSO2 and the T10-L1 dorsal lateral region for renal rSO2. In children aged 6 years and over 25 kg, tomographic abdominal wall thickness was measured for the sensitivity of NIRS sensors . To avoid the effect of sampling depth on the NIRS measurement, we excluded patients over 25 kg as abdominal wall thicknesses correlated better with the weight of the subjects than age [13].Capillary refilling time was measured by the same pediatrician on sternum or forehead by applying pressure with soft pad of index finger for 5 s to blanch the area and then releasing finger to note the return of circulation with the help of wall clock.Mesenteric rSO2, renal rSO2 and MAP measurements were performed continuously but recorded 4 times at 6-h intervals and the mean value was calculated. The indirect measurement method was used for IAP measurement as recommended by WSACS. Intraabdominal pressure was measured 4 times at 6-h intervals. One milliliter per kilogram  saline was administered to the bladder with a foley catheter. After waiting for 30–60 s, IAP measurement was made at end-expiration in the supine position. Abdominal perfusion pressure was calculated using the formula (MAP-IAP).Çukurova University Faculty of Medicine clinical research ethics committee approved the study. Written informed consent was obtained from the families of the patients.All analyses were performed using IBM SPSS Statistics Version 19.0 statistical software package. Categorical variables were expressed as numbers and percentages, whereas continuous variables were summarized as mean and standard deviation and as median and minimum–maximum where appropriate. For comparison of continuous variables between two groups, Mann–Whitney U test was used. A receiver operator characteristic (ROC) curve analysis was performed in order to identify the optimal cut-off point of IAH. The statistical level of significance for all tests was considered to be 0.05.Thirty-one patients were included in this study, 11 patients (35.4%) were female. The mean age was 60.8 ± 47.9 months (Range: 2–126 months). The admission diagnoses of the patients in study are shown in Table 2. Intraabdominal pressure was measured ≥10 mmHg in 15 patients (48.3%) and these patients were defined as the group with IAH. There were no significant differences in terms of age, sex, body weight, PIM 2, PRISM III, urinary output, BUN, creatinine level, hypothermia, coagulopathy, MAP between with IAH and without IAH groups. There was a significant difference between the two groups in terms of capillary refilling time, mean APP, mean lactate and mean rSO2 mesenteric, mean rSO2 renal values, ScvO2, VIS, and EF (Table 3). Acidosis was detected in 73.3% (P = 0.183), and sepsis was detected in 73.3% of the group with IAH (P = 0.063). Fourteen patients in the with IAH group (93.3%) were mechanically ventilated (P = 0.018) and 92.8% of them were receiving sedation and analgesia. In patients with IAH, PELOD score was higher than that in the without IAH group (P = 0.086). The mean capillary refilling time was 3.8 ± 1.1 s in the group with IAH, and was statistically significant (P = 0.003). In the group with IAH, the mean lactate was higher and the mean APP value was lower, with P values of 0.007 and 0.014, respectively. Mortality rate was 60% in the group with IAH and 31.2% in the group without IAH and there was no significant difference between the two groups (P = 0.156). The mean mesenteric rSO2 measurement was 44.9 ± 11.8% in the IAH group and 57.9 ± 8.8% in the without IAH group (P = 0.002). In the group with IAH, the mean ScvO2 was 59.6 ± 11.2% (P = 0.024) , the VIS was 40.4 ± 25.9 (P = 0.024) . The mean renal rSO2 value was 50.6 ± 12 (P = 0.004) in the IAH group. The comparison of mean mesenteric and renal rSO2 value in two groups is shown in Figure 4. In the group with IAH, 13 patients were receiving sedation–analgesia. The mean mesenteric rSO2 measurement was 42.8 ± 11.3% in patients with sedation–analgesia and 58.3 ± 1.59% in patients without sedation–analgesia (P = 0.076). In the correlation analysis there was a statistically significant, negative correlation between IAH and, renal rSO2 and mesenteric rSO2 parameters . We detected a statistically significant, positive correlation between IAH and mean lactate levels. ROC analysis was done with mean lactate, EF, ScvO2, renal rSO2, and mesenteric rSO2 parameters for IAH (Table 4). We observed that mesenteric rSO2 has the highest area under curve (AUC) to detect IAH with a 0.812 and a 0.652–0.973 95% confidence interval (P = 0.003) , 77.8% negative predictive value (NPV), and 80.6% accuracy) . The cut-off value for mesenteric rSO2 was 50% and the cut-off value for renal rSO2 was 57.5% in our study.Intraabdominal hypertension is associated with increased mortality and morbidity in pediatric intensive care units. Increased IAP causes a rise in the tension on the abdominal wall and causes impairment of perfusion and associated with poor outcomes in pediatric intensive care units [3]. Therefore, splanchnic blood flow may be reduced by the early response to global hypoperfusion and mesenteric rSO2 values rapidly decrease in IAH [14]. The recognition of IAH by pediatric intensive care physicians and taking the necessary precautions is very important to prevent progression to ACS and improve outcomes [15]. In our study we showed that the mesenteric rSO2 is a preferable and noninvasive tool for detecting IAH in critically ill pediatric patients. To the best of our knowledge, this is the first study which assesses the use of mesenteric and renal rSO2 measurements with NIRS in children to identify IAH. Conventional hemodynamic monitoring commonly used parameters are either age-dependent , invasive  or laboratory parameters  [16]. Near-infrared spectroscopy is a noninvasive monitoring tool of local tissue oxygenation, it is a continuous method and provides real-time feedback to clinicians. Near-infrared spectroscopy has become a widely used noninvasive clinical monitor and appears to be a favorable, beneficial hemodynamic monitor which improves the care of critically ill pediatric patients and provides early warning for cerebral or somatic hypoperfusion [17]. Decreased perfusion leads to increased oxygen extraction which results in lower rSO2 measurements. In a retrospective study, Balakrishnan et al. [18] evaluated low somatic NIRS values at pediatric intensive care admission in addition to other hemodynamic monitoring tools for critically ill children  and need for life saving interventions . They found a positive correlation between low somatic NIRS oxygen saturation and need for life saving interventions and a higher mortality rate in low NIRS group compared to normal NIRS group. They suggested that somatic NIRS monitoring may identify children at high risk of medical instability. In our study, mesenteric rSO2, lactate, renal rSO2, EF, and ScvO2 were related to intraabdominal hypertension. However, the highest sensitivity, specificity, positive predictive value, negative predictive value and accuracy values were belong to mesenteric rSO2. Therefore, we believe that mesenteric rSO2 may be preferred to detect intraabdominal hypertension. Another preferred reason is that mesenteric rSO2 is noninvasive. In recent years there has been a noninvasive tendency in intensive care units. The patient population ranges from newborn to adolescent for pediatric intensivist. The thickness of abdominal wall varies with patient size and age. Abdominal wall thickness between the skin and the region of interest is important for the appropriate measurement of NIRS probes. Balaguru et al. [13] found better correlation between abdominal wall thicknesses and body weight than age. In the present study, we excluded patients over 25 kg to prevent inaccurate measurements of NIRS probes and we measured abdominal wall thickness by abdominal computed tomography in patients older than 6 years of age. In children, ultrasonography is used to measure abdominal wall thickness in various conditions [19–21]. We could also measure the abdominal wall thickness of our patients using ultrasonography. However, eight of our patients with diagnoses such as pancreatitis, trauma, ileus, liver hydatidosis, and intraabdominal mass had already undergone abdominal tomography imaging. Therefore, abdominal wall thickness measurements obtained from the abdominal tomography measurements were noted. In a PubMed-based literature review we could not find a study about the correlation between IAH and rSO2 in pediatric age group. Our study is the first to examine the relationship between IAH and perfusion markers. In a study including 19 neonates who underwent abdominal surgery, cerebral and renal rSO2 values were measured during surgery, and a decrease in cerebral rSO2-fixed renal rSO2 levels was found [22]. In the same study, at the postoperative period, an increase of 0.71% per hour was detected in renal rSO2 values. A significant correlation was found between renal rSO2 values and oxygen saturation, showing that a 1% increase in saturation caused a 1.5% increase in renal rSO2. There was no correlation between MAP and heart rate with renal rSO2. Our study results showed a statistically significant, negative correlation between IAH and, renal rSO2 and mesenteric rSO2 parameters, and a positive correlation between IAH and mean lactate levels.Kaufman et al. [23] measured intramucosal gastric pH with gastric tonometer as well as abdominal rSO2 measurements in their study of patients who underwent congenital heart surgery and found a significant positive correlation between rSO2 and gastric pH. In the same study, they found a significant negative correlation between serum lactate levels and mesenteric rSO2 levels. They reported that splanchnic rSO2 has strong correlations with gastric pH, serum lactate, and ScvO2 and may serve as an index for systemic oxygenation and perfusion of patients in the intensive care unit after congenital heart surgery. In our study, we found significantly elevated lactate, significantly lower ScvO2, mesenteric rSO2 and APP levels in the IAH group.Kim et al. [14] compared the abilities of cerebral, renal, and splanchnic rSO2 immediately after weaning from cardiopulmonary bypass to predict early postoperative outcomes. The study includes 73 children undergoing corrective or palliative cardiac surgery. Splanchnic rSO2 may be superior to cerebral and renal rSO2 in predicting an increased requirement for vasoactive inotrops, prolonged mechanical ventilation, and a longer postoperative hospital stay for children [14]. No mortality occurred in their study. Our study showed a significantly higher VIS level in the IAH group. The mortality rate was 60% in our with IAH group but this situation was not statistically significant.Stapleton et al. [24] performed mesenteric rSO2 measurements in a neonatal case with NEC, and found a significant decrease in rSO2 values. A significant increase in mesenteric rSO2 values was detected with intravenous antibiotic treatment and discontinuation of the feeding. However, IAP was not measured in this study. Zabaneh et al. [25] monitored the mesenteric rSO2 measurements in the twelve-day-old twins, one of whom had NEC and the other one was healthy. They found significantly lower mesenteric rSO2 measurements in the NEC twin, compared to the healthy one. Measurements of rSO2 of the NEC twin were elevated to the same level as the healthy twin after surgery. Many studies such as this note the importance of abdominal NIRS monitoring in tissue oxygenation in neonates with NEC . The clinical and laboratory findings of poor perfusion might be affected by other clinical conditions associated with the patient such as renal failure, mechanical ventilation, sedation–analgesia, need for vasoactives or vasopressor agents [28]. When we evaluate for the sedation–analgesia in the group with IAH, there was no significant difference in the mean mesenteric rSO2 measurement between patients with sedation–analgesia and without sedation–analgesia.In conclusion, IAH and ACS are common problems with high morbidity and mortality in critically ill children. Judging by our study results and the other studies in the literature, we can say that IAH is a condition of poor perfusion and decreasing in mesenteric rSO2 levels is important for predicting IAH and poor clinical outcomes in critically ill pediatric patients. We think that, compared to other perfusion markers, rSO2 can be easily used in the detection of IAH in terms of noninvasive and continuous measurement. To the best of our knowledge there is no similar study in the pediatric literature and the study is important in this direction. This study had some limitations. It was a study from a single medical center with a small sample and although mesenteric and renal rSO2 values were continuously monitored, statistical analysis was performed with recorded values at 6-h intervals. Further studies conducted using continuous measurements are needed to determine the association between target mesenteric rSO2 values and clinical outcomes in critically ill children. It may be useful to study with larger patient groups in this regard. We would like to thank the patients’ parents for their permission for using their data in this clinical trial.Dr. Nagehan Aslan designed the data collection instruments, enrolled the patients, collected the data, performed echocardiography, drafted the initial manuscript and approved the final manuscript as submitted.Dr. Özden Özgür Horoz conceptualized and designed the study, coordinated and supervised data collection and approved the final manuscript as submittedDr. Dinçer Yıldızdaş and Dr. Awni AL-SUBU critically reviewed the manuscript and approved the final manuscript as submitted.Dr. Yasemin Çoban coordinated and supervised data collection.Dr. Yaşar Sertdemir performed statistical analyses.