Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in postcardiotomy cardiac shock (PCS). The factors that affect mortality in patients who receive ECMO for PCS remain unclear. In this study, we analyzed the outcomes, predictive factors and complications of ECMO use for PCS.A total of 152 adult subjects who received VA-ECMO for PCS in Fuwai Hospital were consecutively included. We retrospectively collected the baseline characteristics, outcomes and complications. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictive factors for in-hospital mortality.p = 0.004), secondary thoracotomy before ECMO initiation , pre-ECMO cardiac arrest/ventricular fibrillation , bedside implantation of ECMO , and more transplant procedure , concurrent IABP initiation with ECMO . Multivariate logistic regression indicated concurrent IABP initiation with ECMO was the only independent protective factor for in-hospital mortality . Concurrent IABP initiation with ECMO had less need for continuous renal replacement therapy  and less neurological complications , but more thrombosis complications .The mean age of the subjects was 49.5 ± 14.1 years, with a male dominancy of 73.7%. The main surgical procedures were heart transplantation (32.2%), coronary artery bypass graft (17%) and valvular surgery (11.8%). Intra-aortic balloon pumping (IABP) was initiated concurrently with ECMO in 32.2% subjects and sequentially in 18.4% subjects. The ECMO weaning rate was 56.6%, and the in-hospital mortality was 52.0%. When compared with non-survivors, survivors had less hypertension (15.1% vs. 35.4%, Concurrent initiation of IABP with ECMO provides better short-term survival for PCS, with reduced peripheral perfusion complications. The incidence of postcardiotomy heart dysfunction is about 3–5% , and neaWe consecutively included 152 adult subjects ( ≥ 18 years) who received veno-arterial VA-ECMO for refractory PCS in Fuwai Hospital from January 1, 2005 to December 31, 2017 in the study. We retrospectively collected clinical variables for all the subjects from their clinical records. Our study complies with the Declaration of Helsinki. The Ethical Committee of the Fuwai Hospital approved this study. As this was a retrospective chart review study, requirement of informed consent was waived.2 and pulmonary capillary wedge pressure ≥ 20 mmHg.Primary indication for VA-ECMO was intra-operative circulatory instability during or immediately after weaning from cardiopulmonary bypass when the primary surgery procedure was finished. Secondary indications included delayed PCS for progressive heart failure, post-operative cardiac arrest. The decision and the optimum time to initiate VA-ECMO and IABP support was made by the surgical team, which was independent of the study. The clinical criteria of VA-ECMO institution for PCS were defined as follows: hypotension with systolic arterial pressure < 80 mm Hg and mean arterial pressure (MAP) < 60 mm Hg; signs of renal failure (urinary volume < 20 mL/h), anaerobic metabolism and metabolic acidosis , despite optimized supportive measures such as IABP, inotropes, nitric oxide and phosphodiesterase inhibitors. Hemodynamic criteria were cardiac index (CI) < 30 mL/s/mIn our center, the surgical team evaluated the patient to decide when the ECMO was indicated according to inclusion criteria mentioned above. The ECMO circuit consisted of a centrifugal pump console  in conjunction with a microporous membrane oxygenator  or a polymethylpentene oxygenator with a plasma-tight diffusion membrane  with integrated heat exchanger and adapted tube. All components were heparin bonded and connected by the shortest possible tubing system. All patients had peripheral ECMO via the cannulae of the femoral vein and artery. An additional 16Fr intravenous needle casing was inserted distally into the femoral artery to prevent leg ischemia.2, with an aim to keep mixed venous oxygen saturation (SvO2) around 70%, and mean artery pressure of 60–65 mmHg. The oxygenator was examined twice a day for early detection of thrombus formations. After 48 h, cardiopulmonary recovery was daily assessed by hemodynamic, clinical and echocardiographic measurements to define the optimal time of weaning. Weaning was cautiously begun when SvO2 ≥ 70%, hematocrit of 30–35%, absence of bleeding, tamponade or left heart distension, left ventricular ejection fraction (LVEF) ≥ 35% and normal blood lactate levels. Flow rate was reduced stepwise to approximately 1 L/min under continuous monitoring of hemodynamic and respiratory variables. When signs of insufficient perfusion occurred during ECMO weaning, the flow was increased again to full, allowing prolonged ECMO support. When the patients were hemodynamically stable on the minimal ECMO flow with satisfactory recovery of myocardial function evaluated by echocardiograph, patients were weaned off of ECMO support and IABP was retained for further evaluation.The ECMO system was implanted under full heparinization, and activated clotting time (ACT) was kept longer than 300 s. Half of the heparin was antagonized with protamine when full ECMO flow was established, aiming for an ACT of 140–180 s unless there was ongoing coagulopathy with hemorrhage. During the first 24–48 h, ECMO blood flow was adequately adjusted to maintain cardiac index of 40 mL/s/mThe primary care surgeon made the decision of IABP initiation. IABP  was inserted through a femoral sheath and with the tip located near the second rib with a 30 or 40 mL IABP balloon, which was judged according to the patient’s height. The support was initiated at a 1:1 inflation–deflation to cardiac cycle ratio, triggering by the R wave of the electrocardiogram. The weaning criteria of IABP were the systolic blood pressure above 100 mmHg without inotropic agent after removal of ECMO. The support was decreased at a 1:3 inflation–deflation to cardiac cycle ratio when weaning program was initiated, and the patients were weaned off of IABP if the hemodynamic condition was stable.t test, while those that were not normally distributed were reported as medians (first and third interquartile range) and compared by Mann–Whitney U test. Categorical variables were expressed as percentages and compared by Chi-square test. Logistic regressions were used to analyze the predictors for in-hospital mortality. The multivariate logistic regression was performed to identify independent factors using an “Enter” method. P values were two sided, and values < 0.05 were considered statistically significant. SPSS statistical software  was used for the analyses.The normality was tested by Shapiro–Wilk test. Continuous variables with normal distribution were expressed as mean ± standard deviation and compared by Student’s Baseline characteristics of all subjects in our study are shown in Table p = 0.004), more heart transplantation procedures , lower rate of secondary thoracotomy before ECMO initiation  and pre-ECMO cardiac arrest/ventricular fibrillation . However, we found subjects in survivor group had a lower LVEF  and a larger left ventricular end-diastolic diameter  than those in non-survivor group. Interestingly, we detected much less subjects initiated VA-ECMO by bedside  among survivors than that among non-survivors. Although both groups had a similar rate of IABP implantation, concurrent initiation of IABP with ECMO was significantly higher in survivors . Multivariate logistic regression analysis was performed to analyze relevant factors that might affect in-hospital mortality .There were 86 (56.6%) subjects successfully weaned from VA-ECMO, among which 73 (48.0%) survived to discharge. Mean VA-ECMO and IABP support time was 4.8 ± 2.7 days and 6.6 ± 4.2 days, respectively. Characteristics of the survivors and non-survivors were compared as listed in Table p = 0.039) and neurological complications , but more thrombosis complications .Complications are shown in Table We reported a total of 152 subjects received VA-ECMO for PCS, which was the largest group of subjects in mainland China. The weaning rate and in-hospital mortality were 56.6% and 52.0%, respectively. Multivariate logistic regression indicated concurrent initiation of IABP with VA-ECMO was an independent protective factor for in-hospital mortality. Concurrent initiation of IABP reduced the need for continuous renal replacement therapy and the rate of neurological complications, but increased thrombotic risk.In such a critical situation as PCS, VA-ECMO is widely used to facilitate myocardial recovery. VA-ECMO supporting in PCS has favorable long-term outcomes, but a high risk of in-hospital mortality . TherefoThe general survival rate of discharge was comparable to previous studies . DiffereIt has been controversial for a long time whether additional use of IABP could improve survival or not –17. As pAs pulsatile flow provides better peripheral perfusion, concurrent initiation of IABP with ECMO would improve the blood supply for the kidney and the brain. Therefore, it would be the mechanism for concurrent initiation could reduce the need for continuous renal replacement therapy and decrease neurological complications. However, as additional implantation of IABP increased extracorporeal circuit, which brought extra strike on coagulation system, it put the subjects under more risk of thrombosis. Thus, it would be cautious to monitor blood coagulation and thrombosis in this group of subjects.In summary, in order to improve the short-term survival and reduce complications related to peripheral perfusion, we suggest concurrent initiation of IABP with VA-ECMO in subjects with PCS if there are no contraindications. Meanwhile, an additional attention should be paid on monitoring coagulation function and potential thrombosis complications.As a single-center retrospective study, this study is subject to all limitations of a non-randomized study. Our findings need to be further confirmed in a larger multicenter cohort or a randomized controlled trial.Concurrent initiation of IABP with VA-ECMO provides a better survival rate to discharge for subjects with PCS and concurrent initiation reduced peripheral perfusion complications.


Although 5-aminolevulinic acid (5-ALA) is used for the photodynamic diagnosis of bladder tumors, hypotension is the most commonly observed adverse effect. We present a case of 5-ALA-induced severe hypotension during transurethral resection of a bladder tumor.A 68-year-old man underwent transurethral resection of a bladder tumor using 5-ALA under general anesthesia. Three hours before anesthesia induction, ALA 20 mg/kg was administered orally. After anesthesia induction, his blood pressure decreased to 47/32 mmHg. Although we used phenylephrine and ephedrine, hypotension persisted at 50/33 mmHg. Bolus administration of noradrenaline slightly increased his blood pressure to 65/39 mmHg. Following this, bolus administration of adrenaline elevated his blood pressure. We decided to perform surgery under continuous administration of adrenaline.Our case report suggests that anesthesiologists should consider 5-ALA-induced hypotension as a differential diagnosis for hypotension occurring after anesthesia induction. Moreover, ephedrine and phenylephrine might be less effective in treating this condition. ExogenoA 68-year-old man  was scheduled for transurethral resection of a bladder tumor using 5-ALA. He had been receiving amlodipine 5 mg and azilsartan 20 mg every morning orally for hypertension. His blood pressure was maintained around 130/70 mmHg. Since he had been diagnosed with pyogenic spondylodiscitis in the fourth/fifth lumber disk region in his forties, general anesthesia was preferred. During the pre-operative examination, chest X-ray, electrocardiogram, and laboratory test findings were normal.3− concentration, 23.2 mmol/L; base excess, 2.3 mmol/L; and lactate concentration, 1.7 mmol/L. Following this, bolus administration of adrenaline at a total dose of 30 μg over 9 min elevated the blood pressure from 53/26 to 127/49 mmHg. We decided to perform surgery under continuous administration of adrenaline. Anesthesia was maintained with sevoflurane and remifentanil. The patient’s blood pressure and heart rate ranged from 72/31 to 94/40 mmHg and from 70 to 85 beats/min, respectively, under the administration of adrenaline at 0.01–0.07 μg/kg/min. On completion of the surgery, he was transferred to the intensive care unit under intubation. Twelve minutes after admission to the intensive care unit, he was extubated as his blood pressure had stabilized at 142/56 mmHg under the administration of adrenaline at 0.03 μg/kg/min. Ten minutes after extubation, adrenaline infusion was discontinued. Although his lactate concentration was 5.3 mmol/L at this time, it decreased to 2.7 mmol/L after 3 h. His blood pressure and heart rate were stable during his intensive care unit stay. The patient was then transferred to the general ward on day 1 postoperatively. He was discharged without any complications 6 days postoperatively. Three months later, dermatologists performed a skin-prick test on him for propofol, rocuronium, and 5-ALA, the results of which were negative. Five months later, he received TUR-Bt under general anesthesia without 5-ALA for recurrence of tumor. Although we used propofol and rocuronium, severe hypotension did not occur.The patient took only amlodipine besylate on the morning of the surgery. Three hours before anesthesia induction, 5-ALA 20 mg/kg  was administrated orally. Just before anesthesia induction, the patient’s blood pressure was 98/61 mmHg and his heart rate 82 beats/min. Anesthesia was induced with propofol 100 mg, rocuronium 50 mg, fentanyl 100 μg, and remifentanil 0.4 μg/kg/min. After 5 min, just before tracheal intubation, his blood pressure decreased to 47/32 mmHg. There were no observed changes in his electrocardiogram, such as ST-T changes or arrhythmia. Although we used phenylephrine at a total dose of 0.2 mg and ephedrine at a total dose of 10 mg over 10 min, hypotension persisted at 50/33 mmHg. Wheezing and erythema were not observed. Administration of 100 mL hydroxyethyl starch bolus for a few minutes was unsuccessful in increasing blood pressure. Transthoracic cardiac ultrasonography revealed normal systolic function, no asynergy, and normal size of the inferior vena cava. Bolus administration of noradrenaline at a total dose of 30 μg over 6 min slightly increased blood pressure to 65/39 mmHg. Arterial blood gas analysis revealed the following: pH, 7.350; HCOp < 0.01) [A previous systematic review reported that hypotension was the most common adverse effect of 5-ALA, since hypotension comprised 60% of these events [ < 0.01) . Another < 0.01) . This st < 0.01) . Fluid r < 0.01) . A previ < 0.01) . The aut < 0.01) . Our patA recent review reported that it is important to consider anaphylaxis as a differential diagnosis when perioperative hypotension or bronchospasm do not respond to conventional therapy during general anesthesia . We alsoWe believe that our case raises two important inferences. First, some patients with 5-ALA-induced hypotension might not respond to conventional therapy, akin to anaphylaxis. As mentioned above, fluid resuscitation and noradrenaline were shown to be effective in previous studies. Bolus administration of 100 mL hydroxyethyl starch and noradrenaline could not recover our patient’s blood pressure, despite the lack of systolic dysfunction and asynergy. Adrenaline should probably be considered in such situations. Second, the use of antihypertensive agents on the morning of the surgery should be reconsidered. Previous studies and our case suggest that a history of hypertension and the use of antihypertensive agents are risk factors of 5-ALA-induced hypotension. From the perspective of balancing the risks and benefits, further detailed studies are required to identify the risk factors of 5-ALA-induced hypotension.In conclusion, our case report suggests that anesthesiologists should consider 5-ALA-induced hypotension as a differential diagnosis for hypotension occurring after anesthesia induction. Moreover, ephedrine and phenylephrine might be less effective in treating this condition.


Patients with Phenylketonuria (PKU) are exposed to multiple cardiovascular risk factors, but the clinical significance of these abnormalities is yet unknown. The purpose of this study was to characterize the cardiovascular phenotype in adult patients with PKU by clinical and dietary data, measurements of biochemical markers, and non-invasive examination of vascular functions.Twenty-three adult patients with PKU  and 28 healthy controls  were included in this study. PKU patients had significantly higher systolic and diastolic blood pressure, increased resting heart rate and a higher body mass index. Total cholesterol and non-HDL cholesterol levels were significantly increased in PKU patients, whereas plasma levels of HDL cholesterol and its subfraction HDL2 (but not HDL3) were significantly decreased. The inflammatory markers C-reactive protein and serum amyloid A protein and the serum oxidative stress marker malondialdehyde were significantly higher in patients with PKU. Venous occlusion plethysmography showed marked reduction in post-ischemic blood flow and the carotid to femoral pulse wave velocity was significantly increased demonstrating endothelial dysfunction and increased vascular stiffness.This study shows that the cardiovascular phenotype of adult PKU patients is characterized by an accumulation of traditional cardiovascular risk factors, high levels of inflammatory and oxidative stress markers, endothelial dysfunction and vascular stiffness. These data indicate the need for early cardiovascular risk reduction in patients with PKU. Phenylketonuria (PKU) is an autosomal-recessive inborn error of phenylalanine (Phe) metabolism, caused by the deficiency of the enzyme phenylalanine hydroxylase (PAH). In untreated patients, the accumulation of Phe and its metabolites leads to mental retardation and other neurological symptoms . The objPrevious studies have shown a high prevalence of cardiovascular risk factors in young patients with PKU. Among the traditional risk factors, dyslipidemia, obesity, and hypertension are the most prevalent –7. MoreoThe purpose of this study was to further characterize the cardiovascular phenotype in adult patients with PKU by clinical and dietary data, measurements of biochemical markers, and non-invasive examination of vascular functions. Venous occlusion plethysmography (VOP) was used to evaluate endothelial function, and the carotid to femoral pulse wave velocity (PWV) to assess the arterial stiffness.We hypothesized that these measurements might detect distinct vascular alterations already in early adulthood and, together with clinical data and selected biochemical markers, improve the cardiovascular risk assessment of PKU patients.Early diagnosed patients with PKU aged 18 years and older who were on a lifelong Phe-restricted diet with synthetic amino acid supplementation were eligible for the study. Exclusion criteria were inability to cooperate with study requirements, acute infections, smoking and pregnancy. All examinations were performed on the same day and consisted of a standardized interview, measurements of weight, height, resting heart rate, blood pressure, blood drawing (after an overnight fast), measurement of vascular stiffness by PWV and endothelial function by VOP.The patient’s daily natural protein intake was estimated by review of the regularly conducted three-day-dietary-protocols. Total daily protein intake was defined as the sum of synthetic protein and natural protein intake.All analyses were performed on venous blood samples taken under fasting conditions. Phe and tyrosine concentrations in plasma were determined by amino acid analyzer. Renal function was assessed by the estimated glomerular filtration rate (eGFR) based on the CKD-EPI equation .For all other parameters, serum aliquots were frozen at − 80 °C until analysis. Serum concentrations of total cholesterol, HDL cholesterol (HDLc) and LDL cholesterol (LDLc) were measured using commercially available assay kits , a microtiter plate and a spectral photometer device . To obtain the HDL2c/3c ratio, the HDL3c fraction of the serum was precipitated using the Quantolip reagent B  and HDL2c was calculated. Serum amyloid A (SAA), C-reactive protein (CRP), apolipoprotein A1 (apoA1) and myeloperoxidase (MPO) were determined using the Luminex™ technique with commercially available assay kits  and measurements were performed on a Bio-Plex® device with Bio-Plex® software (version 6.1) . Malondialdehyde (MDA) and 3-nitrotyrosine (3-NT) were determined in serum by colorimetric-based enzyme-linked immunosorbent assay (ELISA) according to the manufacturer’s protocol .The urine protein-to-creatinine ratio was measured in all patients by immunoturbidimetry.Blood pressure and resting heart rate were measured with a Dinamap® Pro 100 V2 patient monitor after 10 min of rest in supine position. The mean values of two measurements were used.Venous occlusion plethysmography was performed with the Compactus device  as previously described . PatientArterial stiffness was assessed by measuring the carotid to femoral PWV, which is considered the gold standard for this purpose and recommended by current guidelines , 15. Patn = 21 for PKU patients and n = 28 for healthy controls. We used Tukey’s method to exclude outliers [A priori sample size estimates were calculated with a power analysis based on the results of a previous clinical study, which showed that the PWV was significantly higher in patients after renal transplantation compared to controls , assuminoutliers .p < 0.05 was considered significant.Statistical analyses were performed using IBM SPSS . For non-parametric distribution, data are expressed as median and interquartile range. In these cases, the Mann-Whitney-U-test was used for statistical comparison between the groups and the Spearman-Rho correlation coefficient to explore associations with other variables. For parametric distribution, data are expressed as mean ± standard deviation, and the independent t-test and Pearson correlation coefficient were used for statistical analysis. Multiple linear regression analysis was used to evaluate the influence of measured variables to the outcome variable of interest. A value of Of 123 patients regularly attending the outpatient clinic for metabolic disorders at the Charité-Universitätsmedizin Berlin, 29 patients who met the inclusion criteria and gave informed consent were enrolled in the study. 3 patients were excluded after review of their clinical history (patients were smokers) and 3 patients did not complete the study as they had to leave before completion of the investigation. Thus, a total of 23 patients with PKU and 28 healthy controls were included in the final analysis. 19 patients were classified as classical PKU and 4 patients mild PKU. 5 patients were regularly taking anti-hypertensive medication  and one patient was on statin therapy.The demographic and clinical characteristics of both groups are shown in Table n = 22) as assessed by the serum creatinine (0.78 ± 0.13 mg/dl), urea levels (22.5 ± 5.2 mg/dl), eGFR (113.9 ± 13.2 ml/min/1.73 m2) and the urine protein-to-creatinine ratio .Renal function was normal in PKU patients .PKU patients had a mean BMI of 27.6 ± 5.4 kg/mcriteria ; 48% of p = 0.047), indicating an association of these metabolic syndrome components.The presence of a higher BMI and higher blood pressure raised the question whether these were components of a metabolic syndrome, which is known to be associated with increased arterial stiffness and higher inflammation , 21. We . We calculated total protein and current synthetic protein intake  and the mean of the synthetic and total protein intake of the last 5 years per kilogram body weight . There were no significant associations between dietary intake parameters , tyrosine plasma concentrations and protein intake of the PKU patients are shown in Table 2p = 0.001) and the concentration of non-HDLc , triglyceride , and the LDLc/HDLc-Ratio , respectively and negatively with the HDL2c concentration  and the HDL2c/3c-ratio .Phe plasma levels significantly and positively correlated with the BMI , but no other blood lipid levels were significantly associated with the BMI. Table p = 0.031, n = 21), Phe plasma concentrations  and MDA  and positively with SAA  in PKU patients. This suggests associations of the altered cholesterol content within the HDL fractions with dietary adherence, inflammation and oxidative stress.The HDL2c levels were negatively correlated with the systolic blood pressure , suggesting an influence of the increased weight on the patient’s inflammatory status.As further atherogenic risk factors, we investigated serum biomarkers for inflammation, SAA and CRP, and oxidative stress, MDA, MPO, 3-NT Table , Fig. 1.Similarly, MDA levels were significantly higher in PKU patients, but there were no significant differences of MPO and 3-NT levels between the groups.We further analyzed serum selenium concentrations as part of the antioxidatively acting glutathione peroxidase, which were found to be negatively correlated with elevated MDA levels in other studies , 27. HowTaken together, these data indicate the presence of inflammation and oxidative stress in the PKU patients.p = 0.005; Fig. p = 0.028), but not with systolic or diastolic blood pressure in the PKU patients. A multiple regression analysis was performed to test whether the observed differences in endothelial function between the groups were independently affected by the BMI. Only the BMI (but not the diagnosis of PKU) was a significant predictor of PIFR , suggesting that endothelial dysfunction in the PKU patients was mediated by their increased BMI. In some patients and controls, no reliable vascular measurements could be performed.Endothelial dysfunction was evident in the PKU patients, who had a significantly lower PIFR than the healthy controls , but there was no correlation with the systolic blood pressure or the BMI. A multiple regression analysis (R2 = 0.49) showed that both, age , and the diagnosis of PKU  were independent predictors of the PWV.Arterial stiffness was significantly increased in PKU patients compared to controls, as indicated by the PWV  were in part modified by dietary adherence as indicated by the current plasma Phe concentrations. These data further define the cardiovascular phenotype of adult PKU patients and suggest an important pathophysiological role for dietary adherence.Phe plasma concentrations than recommended in the European guidelines [The patients in this study had higher idelines  and alsoidelines , 6. Indeidelines . In a reidelines . The majidelines . Thus, tBMI [2) were almost identical to adult PKU patients included in a recent study of body composition of PKU patients in the US [2) was reported, which increased with age and was significantly correlated with the Phe level [Our patient’s characteristics were comparable with other studies of adult PKU patients, not only including increased Phe plasma concentrations but also concerning dietary data and a high BMI , 29, 31.he level . In our he level . Furtherhe level .obesity in the adult PKU population [2) and no evidence of obesity in their study of body composition of 89 patients [Our study confirms several previous reports of a high prevalence of pulation , 11, 33,patients ; howeverblood pressure compared to controls [We found significantly higher systolic and diastolic blood pressure as well as a significantly increased resting heart rate. While some studies in children and young adults with PKU found normal or even lower controls , 35, a scontrols  and in acontrols , has notlipoprotein profile in PKU patients was significantly different from the control group. Patients had higher levels of total cholesterol and non-HDLc and a higher LDLc/HDLc ratio, while HDLc levels were lower. This pattern is widely used for the definition of dyslipidemia and generally indicates a higher risk for cardiovascular disease [The  disease . Importa disease . Insteadtotal cholesterol levels in PKU patients have shown inconsistent results. While in some studies lower cholesterol levels were measured [Previous studies of measured , 39, we measured . Lower Hmeasured , 41.PKU diet in adults is similar to a vegetarian diet, avoiding protein mainly of animal origin, and supplemented by a synthetic Phe-free amino acid mixture [The  mixture . Patient mixture . A veget mixture  and asso mixture . Therefo mixture . HoweverHDL is a lipoprotein which has been shown to be inversely correlated to the risk of cardiovascular disease [ disease . Its ant disease .HDL subtypes have not been studied previously in PKU patients. We found that the decrease in HDLc was due to low cholesterol levels in the HDL2, but not the HDL3 fraction. Studies analyzing the HDL subtypes in vegetarian populations also found a decrease in the HDL2 fraction, probably due to lower cholesterol intake and a higher polyunsaturated-to-saturated fat ratio [HDL ameliorates endothelial functions and has anti-inflammatory properties. It can be classified into subtypes differing in density . HDL2c hat ratio . Thus, lat ratio .Oxidative stress as well as high SAA can alter the antiatherogenic properties of HDL , 50. Impoxidative stress and inflammation in PKU patients as possible mediators of endothelial dysfunction and vascular stiffness. Biomarkers included MDA, a marker of lipid peroxidation, the peroxidase MPO, and 3-NT, reflecting tyrosine oxidation by reactive nitrogen species. We found that MDA-levels, but not MPO or 3-NT, were increased in patients with PKU. This supports the results of Ercal et al. [Beside the traditional cardiovascular risk markers, we further analyzed l et al. , who foul et al.  found hil et al. . Howeverl et al. , 41. Thel et al. , 53. Posl et al. , 54.inflammation have been rarely studied thus far. Deon et al., could demonstrate increased serum levels of IL-1b, IL-6 and IL-10 in a study of 7 well-controlled adolescent patients with PKU compared to controls [While oxidative stress is well documented in PKU patients, suggesting a high pro-inflammatory potential, markers of controls . In addiWe further analyzed the vascular status and found alterations in its function and structure.endothelial function has not been studied previously in patients with PKU. We here show a significant reduction of post-ischemic blood flow in these patients as measured by venous occlusion plethysmography, a long established and validated method [To our knowledge, d method . The posd method .A decline of the elastic properties of the aorta is a result of vascular ageing and leads to an acceleration of the pulse wave. Thus, a high PWV can be interpreted as a sign of relevant arterial damage. The development of vascular stiffness in the general population is strongly promoted by hypertension, inflammation and oxidative stress , but it Taken together, these data indicate endothelial dysfunction and premature vascular ageing in PKU patients. Increased oxidative stress and a decrease in antioxidative activity has been demonstrated in PKU patients , which aIn summary, this study provides evidence for an increased cardiovascular risk in PKU patients. An accumulation of traditional cardiovascular risk factors, high inflammatory and oxidative stress markers, endothelial dysfunction and vascular stiffness characterize the cardiovascular phenotype of adult PKU patients. These findings indicate the need for cardiovascular monitoring and early preventive measures against cardiovascular disease in patients with PKU.Recent guidelines by the American Heart Association provide detailed recommendations for risk calculation and treatment of atherosclerotic cardiovascular disease (ASCVD) for the general population . For adu


Renal transplantation can significantly improve the quality of life of patients with end stage renal disease (ESRD) who would otherwise require dialysis. Renal transplant (RT) recipients have higher risks of cardiovascular disease compared with general population. The carotid intima-media thickness (CIMT) and pulse wave velocity (PWV) have been used as the important predicting factor of vascular arteriosclerosis. Therefore, this study was to investigate the improvement of carotid intima-media thickness and pulse wave velocity in renal transplant recipients.Thirty-one patients with chronic kidney disease being treated with hemodialysis, 31 renal transplant recipients and 84 healthy control subjects were included to have the clinical evaluations and ultrasonography of bilateral carotid arteries. CIMT and PWV were independently measured by two ultrasonographers using the technique of ultrasonic radiofrequency tracking and correlated with arteriosclerosis risk factors. The progression of CIMT and PWV with age were analyzed by linear regression models, and the slopes of curves were compared using Z test.Compared with the patients on hemodialysis, the CIMT was significantly lower in renal transplant recipients and healthy control. The PWV were higher in hemodialysis patients and renal transplant recipients than that of the subjects in control group. The progression is CIMT positively corelated with age and cumulative duration in renal transplant recipients and hemodialysis patients. In both hemodialysis patients and renal transplant recipients, age and cumulative time on dialysis were all positively correlated with the increase of PWV as well.Carotid intima-media thickness and pulse wave velocity is the predicting factors of developing arteriosclerosis, which were improved in renal transplant recipients.The online version of this article (10.1186/s12880-018-0263-7) contains supplementary material, which is available to authorized users. Kidney transplantation is the standard treatment for patients with ESRD because it can significantly prolong the life of the patient, mainly by improving renal function to prevent progression of cardiovascular disease . AdvanceThis study involved 112 consecutive adult ESRD patients (age ≥ 18 years) from May 2015 to December 2016. Among the 112 patients, 50 peritoneal dialysis patients were excluded. All the patients who received the renal transplant had been treated with hemodialysis. Considering the effect of arteriovenous fistulas on arterial stiffness in hemodialysis patients, peritoneal dialysis patients without arteriovenous fistulas were excluded from the study. Thus, the final study subjects comprised of 62 ESRD patients, including 31 patients who received a single renal transplant  and 31 patients relied on hemodialysis . All the RT patients received the treatment of immunosuppression, including tacrolimus, steroids and mofetil mycophenolate. The clinical information of the subjects was extracted from our Hospital Renal Transplant database, which had been updated yearly since 1993. 84 sex- and age-matched healthy subjects  were recruited as controls. They have no history of chronic kidney disease, and the results for physical and laboratory examinations,including electrocardiography, echocardiography and blood tests of hepatic and renal function, are normal. The study was approved by the Institutional Review Board of Shanghai General Hospital (2014158). Written informed consents were provided by all participants.Demographic characteristics, including age, gender, comorbidities, actual treatment, smoking status, weight and height, were collected from the electronic database of our hospital. Cardiovascular risk factors, including systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), hemoglobin A1c (HbA1c), total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), were recorded for all subjects. Diabetes was diagnosed as fasting plasma glucose levels ≥126 mg/Dl at the time of entry in this study, or if the individual who was undergoing treatment with a hypoglycemic agent or any long-acting insulin, was diagnosed diabetic patients. Hypertension was defined as systolic pressure ≥ 140 mmHg and/or diastolic pressure ≥ 90 mmHg, or continuous on the antihypertensive medications. Subjects were classified as smokers if they had smoked at least one 20-cigarette pack per day in the year before the study. Body mass index (BMI) was calculated as weight (kg) divided by the square of height (m2). Serum calcium (Ca) and phosphorus (P) were tested. Parathormone (PTH) concentrations were measured with the ELISA method .All ultrasonographic measurements were performed by two ultasonographers who were blinded to the clinical data , as described previously . UltrasoSpecifically, PWV was calculated from the following equation:D = diastolic diameter, ΔD = change of diameter in systole and DC = distensibility coefficient, ΔP = local pulse pressure, ρ = blood density. PWV is a functional parameter directly affected by arterial wall stiffness. In addition to these hemodynamic parameters, the peak systolic velocity (Vmax), end diastolic velocity (Vmin), mean flow velocity (Vmean), velocity time integral (VTI), artery S/D ratio, resistance index (RI) and pulsatility index (PI) of the CCA were also recorded by using vascular ultrasound measurement. RI and S/D ratio were calculated using the following formulas:Where, Z test was used for the comparison of slopes between groups. The statistical analyses were performed using SPSS 13.0  and the statistical significance set at P < 0.05.Continuous data were expressed as mean ± SD. The one-way analysis of variance analysis and least significant difference method were used to compare the differences between the groups. The Chi-square test was used for the comparisons of categorical variables between the groups. Repeatability evaluation between the two observers using linear correlation analysis and Bland-Altman Plots. Subsequently, variables related to the carotid morphological were correlation with stiffness parameters by using the stepwise multiple linear regression models. The slops of the CIMT-to-Age and PWV-to-age were determined using linear regression models. Basic clinical characteristics and laboratory results were described in Table The median CIMT measured by the two observers were 505 μm  and 526 μm IQR, 421–594 μm). The median PWV were 7.2 m/s  and 7.1 m/s , respectively. The ICC for the CIMT and PWV measured by the two observers was 0.93 for PWV  and 0.95 for CIMT . Combining Bland-Altman and linear correlation analysis in intergroup, the results were further confirmed the measurement of CIMT and PWV was a consistent trend. , respectively. In both hemodialysis patients and renal transplant recipients, PWV were all positively correlated with age and cumulative time on dialysis , respectively  and the hemodialysis patient group , respectively. No significant difference was found between the renal transplant recipient group and the hemodialysis patient group   and between the renal transplant recipients and hemodialysis patients   . Age-relPWV is another major parameter being used to assess the development of arteriosclerosis –19. In tThere were some limitations in this study. This is an observational single-center study with relatively small sample size. A longitudinal study with large sample size are needed to evaluate the morphologic changes of carotid arteries and their association with cardiovascular factors .In conclusion, our study demonstrated that the significantly lower PWV and CIMT in transplant recipients than that in the patients with hemodialysis, which indicate that PWV and CIMT may be used as the predictive factor for the improvement of atherosclerosis progression.Additional file 1:Figure S1. Repeatability was analyzed by Bland-Altman Plots in intergroup. Bland-Altman analysis showed a consistent trend in the difference value and the mean value of CIMT by repeated measurement. Figure S2. Repeatability was analyzed by linear correlation analysis in intergroup. The results showed that intergroup comparison had a high degree of consistency. Figure S3. Repeatability was analyzed by Bland-Altman Plots in intergroup. Bland-Altman analysis showed a consistent trend in the difference value and the mean value of PWV by repeated measurement. Figure S4. Repeatability was analyzed by linear correlation analysis in intergroup. The results showed that intergroup comparison had a high degree of consistency. (DOCX 104 kb)


We hypothesized that cerebral blood flow (CBF) regulation in the posterior circulation differs from that of the anterior circulation during a cold pressor test (CPT) and is accompanied by elevations in arterial blood pressure (ABP) and sympathetic nervous activity (SNA). To test this, dynamic cerebral autoregulation (dCA) in the middle and posterior cerebral arteries (MCA and PCA) were measured at three different conditions: control, early phase of the CPT, and the late phase of the CPT. The dCA was examined using a thigh cuff occlusion and release technique. The MCA and PCA blood velocities were unchanged at CPT compared with the control conditions despite an elevation in the ABP. The dCA in both the MCA and PCA remained unaltered at CPT. These findings suggest that CPT-induced elevations in the ABP and SNA did not cause changes in the CBF regulation in the posterior circulation compared with the anterior circulation. Hyperteculation , 10. It culation . AlthougOn the other hand, some previous studies –14 reporAgainst this background, we hypothesized that the dCA or cerebral vasculature tone of the posterior CBF is lower than that of the anterior CBF during an elevation in the arterial blood pressure (ABP) accompanied with sympathoexcitation. To test this hypothesis, the CBF velocity as an index of CBF, cerebral vascular tone, and the dCA in the middle cerebral artery (MCA) and the posterior cerebral artery (PCA) were measured before and during a cold pressor test (CPT). The CPT is widely used as a physiological tool to evoke temporary increases in the ABP with an elevation in the SNA.The protocol was approved by the Institutional Review Board at Toyo University (TU-2017-004) and each subject provided written informed consent prior to participating in the study. The study was performed in accordance with the principles of the Declaration of Helsinki.A total of 11 young men  participated in this study. They did not have any cerebrovascular or cardiovascular disease and were not taking any medications at the time of enrollment. Prior to each experimental session, the participants were required to abstain from caffeine for 12 h and strenuous exercise and alcohol for 24 h. The experiment was performed at least 3 h after a light meal.Following instrumentation, the subjects were asked to rest in the supine position on a bed for at least 15 min before the commencement of the protocol. Each subject had the thigh cuff occlusion-release protocol at three different conditions: control, early phase of the CPT , and the late phase of the CPT  level [Each subject immersed their left hand into 1–2 °C water starts at the 90th or 30th s after cuff inflation during CPT30 or CPT90, respectively, and continued to immerse until 30 s after cuff deflation. All trials were randomized and separated by a minimum of 15 min for the hemodynamics to return to the baseline. The thigh cuff occlusion-release protocol uses acute hypotension to identify the dCA . Each te2) level .ETCO2, minute ventilation (VE), and RR were sampled from a leak-free mask and measured with a gas analyzer . Cerebral blood velocity in the right MCA (MCAv) and left PCA (PCAv) were measured as an index of anterior and posterior CBF, respectively, using a 2-MHz pulsed transcranial Doppler (TCD) probe . The TCD probe was fixed and held in place using a headband.The heart rate (HR) was measured using a lead II electrocardiogram . The beat-to-beat arterial blood pressure was monitored continuously using finger photoplethysmography  to determine the systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP). The stroke volume (SV) was determined from the BP waveform using the Modelflow software program, which incorporates the sex, age, height, and weight of the subject . The cardiac output (CO) was calculated by the SV multiplied by the HR. The PParticipants were asked to indicate their pain level immediately after a CPT on a 10 cm visual analog scale (VAS). The VAS for pain intensity was anchored with “no pain” at one end and “severe pain” at the other end .The beat-to-beat MAP, MCAv, and PCAv were obtained from each waveform. The cerebrovascular conductance index of the MCA (MCA CVCi) or PCA (PCA CVCi) was calculated by dividing the MCAv or PCAv, respectively, by the MAP. The hemodynamic data were averaged using 30 s data points before cuff deflation and 30 s data point before end of cuff deflation at each condition. The dCA was the average of values in two trials at each condition.x-axis, mmHg) and MCAv or PCAv  waveforms determines the CrCP [As previously reported, the CrCP of the cerebral circulation was estimated as the index of cerebral vascular tone . Pairs othe CrCP , 27.T) is the slope of the linear regression between MCA CVCi or PCA CVCi and time (T), and ΔMAP, the magnitude of the step, was calculated by subtracting control MAP from the averaged MAP during the interval from 1.0 to 3.5 s [We have calculated dCA in both MCA and PCA at each condition according as previous study . The preto 3.5 s .ηp2). P values of < 0.05 were regarded as statistically significant.All data are expressed as mean ± SD. One-way analysis of variance (ANOVA) with repeated measures was used to compare for hemodynamics each condition . Two-way ANOVA with repeated measures  was performed with Bonferroni’s post hoc test  where appropriate. Effect sizes for ANOVA are reported as partial eta squared (P > 0.238), suggesting that the 15-min interval between the test conditions was enough for the recovery of hemodynamics to the baseline value.Any differences in hemodynamics during the resting baseline between the different conditions were not observed (P = 0.347). At the CPT30, DBP, SV, and CO were unchanged (P > 0.234), but the HR, SBP, and MAP increased compared with the control conditions (P < 0.025) (Table P < 0.008), but the HR did not change (P = 1.00). Because the subjects maintained their voluntary RR during the experiment (P = 0.883), VE and PETCO2 were unchanged compared with the control throughout the CPT (P > 0.065).There was no significant difference in the subjective pain sensation between the CPT30 (6.94 ± 2.24) and CPT90 7.45 ± 2.13)  compared with the control . The nadir of the MCAv and PCAv responses to cuff release was not different among the three conditions  via the dCA despite CPT-induced high blood pressure accompanied with a high SNA.Unexpectedly, the posterior CBF response to the CPT was not different from that of the anterior CBF Table . In addi2 and neural activities), transmural pressure , and the SNA [P = 0.019, Fig. P = 0.012, Fig. P = 0.075; Fig. The CrCP is a well-established index of cerebral vascular tone, influenced by changes in metabolism . Therefore, the effect of cuff inflation on hemodynamics response to CPT may be minimal. Finally, the participants in the present study were young healthy subjects. Therefore, the results may differ in older aged individuals with a greater risk of hypertension or stroke. Indeed, a previous study reported that the CBF response to cold stimulation is different between older and young individuals [Some potential limitations of the present study should be considered. First, the TCD-determined MCAv and PCAv can be used as indices of the anterior and posterior CBF, with the assumption of a constant diameter of the insonated artery. In this regard, several studies have reported no change in the MCA diameter in response to physiological stimulations such as orthostatic stress , 42. In ividuals . Thus, aContrary to our hypothesis, there was no difference in CBF and its regulation between the anterior and posterior cerebral circulation during an elevation in ABP and SNA. This finding suggests that CPT-induced acute elevations in blood pressure and SNA did not affect the regulation of posterior cerebral vasculature, and the posterior CBF and the anterior cerebral circulation was well-regulated. However, the effects of a chronic elevation in ABP (hypertension) on the posterior cerebral circulation may be different from that of an acute elevation in ABP.


Hypertension in children and adolescents is on the rise worldwide, especially in China. The prevalence of hypertension is related to many factors, such as obesity. In the era of smart phones, it is important to study the negative health effects of mobile phones on blood pressure. The purpose of this study was to investigate the prevalence of hypertension and its association with smartphone addiction among junior school students in China.A school-based cross-sectional study was conducted, including total 2639 junior school students (1218 boys and 1421 girls), aged 12–15 years old (13.18 ± 0.93 years), enrolled in the study by random cluster sampling. Height, weight, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured following standard protocols, and the body mass index (BMI) was calculated. Overweight/obesity and hypertension were defined according to sex- and age-specific Chinese children reference data. The Smartphone Addiction Scale short version (SAS-SV) and the Pittsburgh Sleep Quality Index (PSQI) were used to assess smartphone addiction and sleep quality among the students, respectively. Multivariate logistic regression models were used to seek associations between smartphone addiction and hypertension.The prevalence of hypertension and smartphone addiction among participants were 16.2%  and 22.8% , respectively. Obesity , poor sleep quality , smartphone addiction  were significantly and independently associated with hypertension.Among the junior school students surveyed in China, the prevalence of hypertension was high, which was related to obesity, poor sleep quality and smartphone addiction. These results suggested that smartphone addiction may be a new risk factor for high blood pressure in adolescents. It is well known that hypertension, or high blood pressure, is a major public health issue, also is one of the primary risk factors for cardiovascular diseases, including cerebrovascular stroke, atherosclerosis –3. In ChFrom a public health point of view, the prevention and control of hypertension are essential to maintain and promote human health, particularly in childhood, because many studies have provided ample evidence that hypertension in adults has its onset in childhood, that is, children and adolescents with elevated blood pressure (BP) could ultimately become recognizable hypertension in adults. Childhood BP is associated with BP in later life , 6. BaseSmartphone can provide a variety of functions such as phone, camera, multimedia player, internet browser, navigation system, and e-mail service as well as facilitate social networking and game playing. Because of these powerful and attractive advantages, many adolescents overuse mobile phones, resulting in similar addiction symptoms .Smartphone addiction is also called “mobile phone dependence”, “compulsive mobile phone overuse” or “mobile phone overuse”. These terms mainly describe the phenomenon of problematic mobile phone use. “Smartphone addiction” is the term typically used in the literature . SmartphThe prevalence of hypertension among young people in China is on the rise. Many factors affect the occurrence of hypertension. The relationship between psychosocial factors and blood pressure has attracted more and more attention. Some studies have shown that smartphone addiction is associated with anxiety, depression and sleep disorders among adolescents . To a ceThe aim of this study was to investigate the risk factors associated with hypertension in Chinese adolescents, especially the relationship with smartphone addiction.A cross-sectional survey was performed during September and December 2014. A total of 2639 junior school students (1218 boys and 1421 girls) in grades 7 to 9, aged 12–15 years old (13.18 ± 0.93 years), were enrolled in this study by random cluster sampling. In our study, 1 district was randomly selected from 4 districts of Wuhu city, which is an important economic development center city of the Yangtze River Basin in China, and then randomly selected 4 middle schools in the area as the research subjects, of the selected schools, two classes in each grade were selected, and all students of the selected classes were invited to participate the survey. The study design and procedure was approved by the ethics committee of Wannan Medical College, Wuhu, China, and informed consent was obtained from all participants and their guardians before the survey.All subjects had a thorough medical examination before the measurements were taken. They were free from cardiovascular or kidney disease and were not taking sleep, cardiovascular, or psychiatric medications. All measurements were conducted by a team of trained senior medical students in a standardized way.Weight status was defined with body mass index . Obesity was defined as a BMI at or above the 95th percentile of the Working Group on Obesity in China (WGOC) definitions for overweight and obesity, overweight was defined as a BMI between the 85th and 95th percentiles , 21.Height (cm) and weight (kg) were measured using the same type of apparatus and followed the standard protocols. Height was measured using metal column height-measuring stands to the nearest 0.5 cm with the participant’s no shoes, heels together, and head touching the ruler with line of aligned horizontally. Weight was measured, using lever scales to the nearest 0.1 kg with the participant’s bare foot and wearing a light cloth.Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in the sitting position by a mercury sphygmomanometer after each subject had rested for at least 5 min with the appropriate cuff using the standard protocol in a quiet room. Three readings were recorded at 5-min intervals with complete deflation of the cuff between each reading. The average of the three readings was calculated.DBP was defined via Korotkoff Sound 4 . The refSmartphone addiction was measured using the Smartphone Addiction Scale short version (SAS-SV) . The SASSleep quality was measured by using the Pittsburgh Sleep Quality Index (PSQI) , which iAll questionnaires were in the self-report format. The basic sociodemographic data was collected in this survey, such as gender, age, grade.Descriptive results of categorical variables are described as frequency (%), and continuous variables are described as mean ± standard deviation (SD). Group differences were evaluated by Pearson’s chi-square test or t tests for category variable and continuous variable, respectively. The logistic regression model was performed to explore the factors associated with adolescent hypertension. P-values of < 0.05 were considered statistically significant. All data were analyzed using the SPSS version 20.0 . To avoid typing errors, we entered information into all questionnaires using a double-entry strategy in EpiData, version 3.1 .Of the 2639 participants, as shown in Tables There was obvious difference in the rate of smartphone addiction among students of different grades. With the increase of body weight, addiction rate was also on the rise. Of the 518 students with poor sleep quality, 98.1% were addicted to smartphones. 264 of the 428 hypertensive students reached the standard of smartphone addiction , lower than the results of the previous study conducted in 1441 undergraduate students in China  . This suggests that adolescents with hypertension are more likely to be attracted to smartphones, but the exact mechanism still needs further study.We found that 48.6% of 518 adolescents with poor sleep quality had hypertension, much higher than those with good sleep quality (8.3%). Previous studies had shown that sleep deprivation was associated with high blood pressure –51. PoorOne limitation of this study was that BP levels were obtained by a single visit. Therefore, the prevalence of hypertension was likely overestimated in the current study. Nevertheless, the BP measurement was performed at school, in the adolescents’ usual environment, which would have helped reduce any ‘white-coat’ effect. The second limitation was that cross-sectional nature of the study limits drawing of inferences about causation. This can be resolved by using longitudinal studies to further determine the causation. The last but not least limitation was that we did not assess other factors associated with high blood pressure, such as daily eating habits , physical activity, genetic factors, usage of stimulants for treating attention deficit hyperactivity disorder which is associated with hypertension in adolescents  and deprThis study demonstrated that, among Chinese junior school students aged 12–15 years, the prevalence of elevated blood pressure was high, and associated with the increasing prevalence of overweight/obesity, poor sleep quality and smartphone addiction, respectively. These results suggest that smartphone addiction may be a new risk factor for high blood pressure in adolescents.


The risk of death after kidney transplant is associated with the age of therecipient, presence of comorbidities, socioeconomic status, localenvironmental characteristics and access to health care.To investigate the causes and risk factors associated with death during thefirst 5 years after kidney transplantation.This was a single-center, retrospective, matched case-control study.st 2007 to December 31st 2009, there were 162deaths (case group), corresponding to 5-year patient survival of 91.4%. Ofthese deaths, 25% occurred during the first 3 months after transplant. Themost prevalent cause of death was infectious (53%) followed bycardiovascular (24%). Risk factors associated with death were history ofdiabetes, dialysis type and time, unemployment, delayed graft function,number of visits to center, number of hospitalizations, and duration ofhospital stay. After multivariate analysis, only time on dialysis, number ofvisits to center, and days in hospital were still associated with death.Patients who died had a non-significant higher number of treated acuterejection episodes , higher mean number of adverse events per patient , and lowermean eGFR at 3 months  and 48 months .Using a consecutive cohort of 1,873 kidney transplant recipients from January1This analysis confirmed that in this population, infection is the leadingcause of mortality over the first 5 years after kidney transplantation.Several demographic and socioeconomic risk factors were associated withdeath, most of which are not readily modifiable. Death with functioning graft is a major cause of graft loss among kidney transplantrecipients worldwide. A recent review of almost ten thousand kidney transplantsrevealed that death with functioning graft accounted for 45% of kidney graftlosses.A previous study revealed several risk factors associated with death within the first6 months after transplantation, including donor age and cause of death, recipientgender, HLA compatibility, changes in electrocardiogram, weight at the time oftransplantation, financial assistance, monthly income, and having children andfamily support.,Other socioeconomic factors have been associated with graft loss and death afterrenal transplant. One of these factors is the human development index (HDI), astatistical measure used as an indicator of health to classify regions consideringlife expectancy, education, and per capita income.This was a single-center, retrospective, case-control study comparingdemographical and clinical outcomes between patients who died and paired matchedliving controls during the first 5 years after kidney transplantation. Thecase-control design hindered several traditional risk factors such as recipientage, diabetes, and cardiovascular disease. However, the aim was to investigatebeyond these traditional risk factors and determine whether local socioeconomicand environmental risk factors would be involved. The data was extracted fromthe electronic database and judged accordingly. The study was approved by thelocal ethics committee.We included only patients who received a kidney transplant from January 1, 2007to December 31, 2009, thus allowing 5 years of follow up by December 31, 2014.During this period 2305 kidney transplants were performed. We excluded 140recipients of retransplants, 126 recipients of combined kidney/pancreastransplants and 166 pediatric recipients. Of the final cohort of 1,873 patients,we identified all deaths within the first 5 years after transplantation to formthe case group. The control group (1:1) was selected from the same cohort bymatching the following variables: date of transplant, recipient age (+/- 5years), gender and race, donor age (+/- 5 years), gender and type (living ordeceased) and use of thymoglobulin induction.The objective of this study was to identify risk factors associated with deathduring the first 5 years after kidney transplantation. We also analyzed thesocioeconomic and demographic characteristics, incidence of hospitalizations,renal function, and specific causes of death.http://www.atlasbrasil.org.br/, assessed on 13 of June,2016)maps.google.com). Professionswere classified in three main categories based on the information obtained atthe time of transplantation: higher occupations , intermediate occupations  and loweroccupations , also including those who had never workedor were unemployed according the National Socio-economic Classification(NS-SEC).Data were collected retrospectively from medical records and included recipient,donor, and transplant-related variables. We also assessed human developmentindex (HDI) of the city of each patient using the Human Atlas of HumanDevelopment  infection. Instead, preemptive treatment was performedin patients deemed as high risk for developing CMV infection: (1) seronegativeCMV kidney transplant recipients from seropositive CMV donors (D+/R-); (2) useof r-ATG for induction and (3) use of MPS for maintenance therapy; (4) aftertreatment of acute rejection episodes.The use of induction therapy, with basiliximab or rabbit anti-thymocyte globulin,and the maintenance immunosuppressive regimens consisted primarily of acalcineurin inhibitor in combination with an anti-proliferative drug or an mTORinhibitor and were based on institutional protocol derived from evaluation ofimmunological risk. All patients received corticosteroids, 1 mg intravenousbolus of methylprednisolone before graft revascularization followed by 0.5mg/kg/day of prednisone with a taper to 5 mg/day between 30 to 45 days aftertransplantation. All patients received sulphametaxasol trimetropin for at least6 months for prophylaxis against Delayed graft function (DGF) was defined as the need for dialysis during thefirst week after transplantation, except for one dialysis due to hyperkalemia.Estimated glomerular filtration rate (eGFR) was calculated using the MDRDformula. Acute rejection episodes included biopsy-proven acute rejection (BPAR)(Banff 2005) and clinical acute rejections were episodes of acute graftdysfunction treated with methylprednisolone for at least 3 days withouthistological confirmation . All causes ofdeath and graft loss were assessed. Patients transferred to another center orthose with missing appointments for more than 6 months were considered lost tofollow-up.The number of outpatient visits and hospital readmission days were calculated inboth groups during the follow-up time in months. All serious adverse events(SAE) during each hospitalization were captured and classified according to theCommon Terminology Criteria for Adverse Events (CTCAE) version 4.0.t-test. Variables with non-normal distribution weresummarized by median and range and the differences were compared using thenon-parametric U Mann-Whitney test. Frequencies and the chi-square test wereused for qualitative variables. Uni- and multivariable risk analysis wasperformed using Cox regression and 95% confidence intervals. All tests wereanalyzed using the SPSS Statistics 18.0 program . Valuesof p < 0.05 were reported as statistically significant.The Kolmogorov-Smirnov test was performed to verify the normality of thenumerical variables. Variables with normal distribution were summarized by meanand standard deviation and differences compared using the Student'sOf 1873 adult recipients of first kidney transplants, 162 died, 159 had graftloss and 165 were lost to follow up 5 years after transplantation. Corresponding5-year graft and death-censored survivals were 91.4%, 82.9% and 90.7%,respectively. The 162 deaths were matched to 144 controls using the predefinedcriteria and small deviations were necessary for the remaining 18 controls. Among the 162 control cases,there were 9 graft losses, 11 losses to follow-up and 5 transplants after 2009,yielding 137 patients who completed 5 years of follow-up.diabetes mellitus, were on dialysis for a longer periodof time and three of them had prior contact with tuberculosis , and lower eGFRcompared to the control group during the 5 years of follow up .Patients who died had a higher number of visits to the transplant center,hospitalizations, days in the hospital, and adverse events . InfectiOverall, infection was the main cause of death followed by cardiovascular events. Risk fa,,-In this cohort of 1873 adult recipients of first kidney transplant, the 5-yearpatient 91.4%), graft (82.9%), and death-censored graft (90.7%) survivals are inagreement with other larger registry analyses.1.4%, gra,Diabetes mellitus is a well-known demographic characteristicassociated with increased risk of mortality after kidney transplantation.,diabetes mellitus was 24% with higher prevalenceamong patients who died during the 5 years of follow up. While a similar prevalenceof 23% is observed in Europe,The difference in the primary cause of death is due to a complex interplay of donor,recipient and environmental factors. Time on dialysis is associated with increasedrisk and severity of infections, cardiovascular diseases, and malnutrition, whichare comorbidities known to be associated with death after transplant.-,,The combination of inadequate deceased donor maintenance, the use of kidneys fromexpanded criteria, and the long cold ischemia time are known risk factors associatedwith the observed high incidence of delayed graft function. While a meta-analysisshowed no significant relationship between delayed graft function and patientsurvival at 5 years,,Patients who died had a higher prevalence of hospitalizations, hospitalizationdensity, and visits to the transplant center than patients in the control group,perhaps due to higher number of comorbidities, complications after the transplantsurgery, and worse transplant outcome. Hospitalizations are six times higher amongkidney transplant recipients than the general population.et al. showed thateven in the first 3 years after transplant, when Medicare guarantees access toimmunosuppression in the United States, patients with lower income present lowerpatient and graft survival.,,,Sociodemographic characteristics of the transplant population such as education,profession, income, and development index are associated with transplantoutcomes.Mortality in the general population is associated with HDI.This analysis has limitations, including the single center case-control retrospectivedesign using a relatively small cohort. By using a case-control design, importantrisk factors may have been hidden. The influence of immunosuppression could not beascertained due to the relative homogeneity of the protocols. Given the widegeographical disparities of Brazil, interpretation and extrapolation of our resultsto other regions requires caution.In summary, this analysis confirmed that infection is the leading cause of mortalityover the first 5 years after kidney transplantation. Several demographic andsocio-economic risk factors were associated with death, most of which are notreadily modifiable. Strategies to reduce mortality should include improvements ineducation, socioeconomic status, awareness and access to healthy habits includingfood and physical activity, increased social support, and easier access tohealthcare.


Certain professions, such as those related to emergency services, have usually been performed by men, progressively incorporating women into these professions. The main objective of our study was to determine, according to gender, how the use of level D biohazard personal protection equipment (PPE) affects emergency professionals during the performance of resuscitation. An uncontrolled quasi-experimental study was performed on 96 volunteers selected by means of random sampling stratified by gender. Baseline and final vital signs of the assessment activity were analyzed. This activity involves volunteers performing a simulated resuscitation in a controlled environment whilst wearing personal protective suits in a biohazard situation. gender, through a univariate model, we can observe that there is no interaction between tolerance and gender; that is, having good or bad tolerance does not depend on gender. Conclusion. This specialized skilled work can be performed by any properly trained professional. Analyzing the physiological tolerance pattern parameter by parameter, and according to For a long time, certain jobs have mainly been held by men. Here we specially refer to prehospital medical emergency services, rescue services, fire extinguishing services, police forces, army personnel, etc. . Women hSituations such as the recent Ebola virus disease epidemic in West Africa have requested the intervention of many professionals requiring precise technical knowledge, the use of appropriate personal protective equipment against certain risks, and an extra dose of physical effort. However, this equipment is not harmless as it creates mobility, hearing, and vision problems, impairment of thermoregulation, increase in energy demand, etc., thus increasing physiological stress , 7.Emergency services must contemplate within their competency-based curricular design, handling incidents involving biological hazards, including acts of God or resulting from terrorist acts –10. In gPerforming a conventional cardiopulmonary resuscitation requires skills, technical knowledge, and good physical condition (training) . PerformThe main objective of our study was to determine, according to gender, how the use of level D biohazard personal protection equipment (PPE) affects emergency professionals during the performance of cardiopulmonary resuscitation.The study was approved on 6 April 2016, by the Clinical Research Ethics Committee at Río Hortega University Hospital in Valladolid (Spain), with registration code #412016. All the participants had to read and sign the informed consent, and the entire study was carried out with the highest safety standards, protecting the physical integrity and confidentiality of the participants, complying with national and international regulations for the study in human subjects included in the Helsinki Treaty. gender and academic level  from an opportunity sample of 194 volunteers.An uncontrolled quasi-experimental study was carried out on 96 volunteers selected by means of random sampling stratified byThe sample was selected among physicians and nurses of the emergency services and students aged between 18 and 65 years of the Faculty of Health Sciences and who voluntarily decided to participate. Any volunteer presenting at least one exclusion criterion was rejected .2 laboratory with controlled environmental conditions (average temperature of 33.66°C and average humidity of 51.16 percent).The simulated resuscitation was performed in a 20 mAll the elements of the PPE used in the case study have a CE declaration of conformity and instruction manual. Elements are listed in the sequence for donning PPE according to the recommendations of the European Centre for Disease Prevention and Control (ECDC) . Two paiAll the participants in the study had the same prior information and the same equipment and electromedical devices for solving the same case scenario. heart rate, systolic blood pressure, diastolic blood pressure, tympanic temperature, total hemoglobin, perfusion index, and baseline lactic acid levels.Each participant was asked to sit on a chair, roll up one sleeve, and relax for five minutes, so that the measurements were made at rest. Subsequently, they underwent an electrocardiogram and spirometry to verify normal results. A second stage consisted of serial measurement of vital signs, includingBlood pressure and heart rate were measured with the use of oscillometric sphygmomanometry . For measuring tympanic temperature we used a Braun Thermoscan Pro 6000  with ExacTemp™ technology. Total hemoglobin values and perfusion index were monitored with a multiparameter monitor Pronto 7 , software version b99e80000004ef796 (2.2.15), and sensor revised version a83f90f0000c53f2. For the determination of lactic acid levels we used an Accutrend Plus meter , with a measurement range of 0.8-21.7 mmol/L.Participants put on their PPE following the instructions of a supervisor, according to the donning and removing steps of the European Center for Disease Prevention and Control . The plaParticipants had ten minutes to fully equip themselves, and they were guided by a specialist throughout the whole process. Then, the equipment was verified to ensure it had been put on correctly.Each participant had to look at himself or herself in a mirror and check that he or she was properly equipped. Afterwards, they did two squats to check the ergometry and the fit of the equipment, and then they were ready to start the study case.A case of cardiac arrest was designed so that each group of four volunteers had to perform resuscitation maneuvers on a simulation mannequin for a period of 20 minutes without stopping, so that they could carry out the appropriate life support techniques, including airway management, defibrillation, vascular access techniques, and chest compressions.Each group of four volunteers completed the same study case with the same sequence of events. They were reminded that the quality of the procedures would not be assessed, but it was emphasized that all the techniques and procedures had to be performed on the simulation mannequin in the most correct way.Once the participants had finished the case study, a supervised removal of the individual protection equipment was performed and after a 10-minute rest, a new serial measurement of the vital signs took place. p < 0.05.Data was collected and analyzed using Microsoft EXCEL version 14.4.0 and Statistical Product and Service Solutions (SPSS) version 20. Qualitative variables are expressed with their frequency distributions and the quantitative variables as mean and standard deviation (SD). Comparison of means was performed using Student's t-test. Statistical significance was determined where the null-hypothesis (no difference in categories) was rejected with a age with standard deviation (SD) of participants was 31.31 (10.81) years.  age distribution by gender. The body mass index (mean ± SD) was of 24.35 (4.12) kg/m2. It has been established as poor physiological tolerance to finish the simulated resuscitation having altered 5 or more of the 7 measured parameters. Of the total sample, 74 participants (77.08 percent) showed an acceptable physiological response , and 22 participants (22.92 percent) had an inadequate response to physiological stress generated during the test .  age and body mass index characteristics distributed by gender and physiological tolerance.Of all the subjects who did not meet exclusion criteria, 40 were male (41.7 percent) and 56 female (58.3 percent). Regarding the educational level, 49 subjects (51 percent) were students and 47 (49 percent) professionals of Health Sciences (nurses and physicians). The mean heart rate, systolic or diastolic blood pressure, lactic acid, and tympanic temperature and higher final values of perfusion index and hemoglobin than baseline ones.Baseline and subsequent measurements were compared in order to create a pattern of poor physiological tolerance after performing the simulated resuscitation whilst wearing biohazard PPE. It is considered a good physiological response finishing the test with lower final values of heart rate in final measurements is especially significant, with an average increase of 11.42 bpm , as well as in tympanic temperature, with an average increase of 0.55°C  with respect to the baseline measurements. In both systolic and diastolic blood pressure values, an average decrease of -4.36 mmHg  and -1.59 mmHg  was observed with respect to the basal values. Regarding all the rest of the vital signs studied, an increase in hemoglobin levels can be observed, with a mean increment of 0.48 mg/dL , as well as an increase in the perfusion index of 3.28 percent  and in lactic acid levels of 1.24 mmol/L  with respect to the initial measurements. It was established as a cutoff point of poor physiological tolerance, having altered 5 or more of the seven parameters analyzed. The parameters analyzed are tympanic temperature, heart rate, systolic blood pressure, diastolic blood pressure, hemoglobin, perfusion index, and lactic acid. Poor toleration was defined by finishing the test with more tympanic temperature, heart rate, systolic blood pressure, diastolic blood pressure, and lactic acid and with less hemoglobin and perfusion index, final compared to initial. The increase in gender shows significant increases in both genders, with mean increases in heart rate, tympanic temperature, lactic acid, hemoglobin, and perfusion index and decreases in systolic and diastolic blood pressure  and 8.89 bpm in females (95 percent CI 6.03 to 11.76) with respect to the baseline measurement (p = 0.273). Systolic blood pressure values showed a mean decrease of 3.55 mmHg (95 percent CI -7.84 to 0.74) from the baseline in men and 4.95 mmHg (95 percent CI -8.10 to -1.80) in women (p = 0.902).  gender, with its statistical significance.Analyzing the physiological tolerance pattern parameter by parameter, and according to gender does not appear as statistically significant. This fact allows us to study gender separately. Having good or bad physiological tolerance does not depend on gender.In the application of the univariate model to each dependent variable, the interaction between tolerance and gender that could indicate a parameter that varies significantly; on the contrary, a uniform pattern could be observed throughout the sample. Participants who tolerated the test well exhibited a decrease in heart rate, systolic and diastolic blood pressure, lactic acid, and temperature; on the contrary, they presented an increase in perfusion index and hemoglobin values. The subjects that did not tolerate the simulated resuscitation with the personal protection equipment for biological hazards showed deviations in the expected values in five or more parameters studied.Variation in the values of the vital signs did not present differences by hemoglobin and perfusion index values. The physiological response to intense exercise and the release of catecholamines leads to peripheral vasoconstriction [ hemoglobin to central organs.The physiological model explains certain alterations, such as the increase intriction  which in heart rate values after the test showed an average increase of 11.43 beats per minute compared to the baseline measurement. This fact is justified by the increase in physical activity and the release of catecholamines [Despite the fact that once the participants had performed the simulation they removed their PPE following the protocol provided, and had a 10-minute rest,olamines , 19. blood pressure increases to compensate for the increased demand for energy production. At the end of the physical exercise, generalized vasodilatation occurs and, consequently, redistribution of blood flow and thus decreasing blood pressure. About 5-6 minutes after physical exercise blood pressure decreases to baseline resting values, and it continues decreasing to lower values, keeping this decrease in the following 5-6 hours [During moderate or high intensity physical exercise, as resuscitation could be performed whilst wearing biohazard PPE,-6 hours , 21.If we combine thermal stress with the physiological overload caused by heat (due to the effort involved in resuscitation maneuvers), working with biohazard PPE significantly alters physiological thermoregulation mechanisms . The heaRegarding the variation of lactic acid, it should be firstly mentioned that, in high intensity and short duration physical exercises (more the less trained the person is), the body does not have enough immediate available oxygen and must get energy by less efficient routes that generate more metabolic waste (glycolytic metabolism) . Consequ heart rate and blood pressure during the working time. This condition affects men and women equally.After the analysis, no statistically significant association was found between a good or poor tolerance to the proposed experimentation protocol and genre. This means that it is easy to demonstrate that having to perform a job wearing biohazard PPE complicates procedures at a technical level and that the use of this equipment involves a high intensity physical effort and high intensity work performance that does not allow working for very long periods of time. The use of this equipment makes transpiration and thermoregulation very difficult and can raise workers' body temperature, who may also have vision and hearing problems and increasedThe research is limited to the study of physiological and anthropometric parameters cited in the methodology, but the usefulness of other parameters such as cortisol, pH, or insulin levels is not discussed. These parameters were discarded from the study due to the complexity required to make the determinations.The study analyzes in detail the physiological behavior of the volunteers before a simulated resuscitation, but the study must be deepened to also evaluate the importance of the psychological component in the modulation of this physiological response.Like any research study, this one presents specific scientific objectives and has been carried out in a specific limited context, so the following limitations should be noted: gender.A homogenous distribution of the physiological and anthropometric parameters was observed, and no significant differences were found by gender. Therefore, this so technical and specialized work can be performed by any properly trained professional.We can conclude that, depending on the parameters studied, there is a metabolic pattern of poor physiological tolerance after the use of level D PPE for the observed sample, which may lead us, in future studies, to derive a predictive rule that allows us to assess what professionals may have better adaptability and tolerance in their work in a biological incident situation, but not influenced by the worker's


Background: Bariatric surgery is efficiently associated with the long-term resolution of obesity and its related morbidities. Not only can this surgical modality improve the metabolic profile, diastolic and systolic cardiac functions, and the clinical symptoms of heart failure or cardiomyopathy, but it can also reduce the atherosclerosis risk, ventricular mass, and pericardial fat thickness. The aim of the present study was to evaluate the effects of weight loss on echocardiographic parameters 1 year after sleeve gastrectomy.Methods: This quasi-experimental study, conducted in Modarres Hospital, Tehran, Iran, from September 2016 to September 2017, recruited 101 patients. Those with morbid obesity (body mass index ≥40 kg/m2) had undergone surgery 1 year before the study commencement. All the patients underwent sleeve gastrectomy. The data of echocardiographic indices before and 1 year after surgery were recorded and analyzed.Results: The mean age of the participants was 37.11±9.81 years. The majority of the study participants were female . During the first postoperative year, the mean weight loss was 43.82±14.53 kg. The mean systolic blood pressure was 137.96±19.60 mmHg and 123.37±9.60 mmHg before sleeve gastrectomy and 1 year afterward, respectively (P<0.001). The mean left ventricular size was 48.22±4.04 mm and 44.97±5.70 mm before sleeve gastrectomy and 1 year postoperatively, correspondingly (P<0.001). The mean pulmonary artery pressure was 28.88±5.25 mmHg and 24.10±4.78 mmHg before sleeve gastrectomy and 1 year after surgery, respectively (P<0.001). The mean left atrial size was 35.72±3.32 mm and 33.12±3.52 mm before sleeve gastrectomy and 1 year thereafter, correspondingly (P<0.001).Conclusion: Weight loss resulting from sleeve gastrectomy may improve systolic blood pressure, left atrial and left ventricular size, and pulmonary artery pressure.  The prevalence of obesity has been dramatically increasing in both developed and developing countries over the last decades.2. Bariatric surgery is efficiently associated with the long-term resolution of obesity and its related morbidities. Not only can this surgical modality enhance the metabolic profile, diastolic and systolic cardiac functions, and the clinical symptoms of heart failure or cardiomyopathy, but it can also diminish the atherosclerosis risk, ventricular mass, and pericardial fat thickness.   5 Conservative intentional weight-loss strategies, including lifestyle modification and medication therapy, are generally considered inefficient in enduring weight management and diminishing the rate of cardiovascular events. So far, bariatric surgery has been the most effective intervention to obtain a sustained and significant weight loss in obese patients with a body mass index (BMI) >40 kg/m6, 7 A resolution to the co-morbidities allied to obesity, sleeve gastrectomy is easy to perform, results in minimal nutritional deficiencies, and is well tolerated by patients.   8 Sleeve gastrectomy is deemed the most effective method of bariatric surgery; it is a standard surgical method indicated in patients with severe morbid obesity.9-11 Nevertheless, most of these studies have included follow-up periods of 3 and 6 months and failed to assess most cardiac function indices through modalities such as echocardiography. Therefore, the aim of our study was to evaluate the effects of weight loss on the cardiopulmonary function 12 months after sleeve gastrectomy.Previous studies have demonstrated that sleeve gastrectomy is capable of improving the cardiopulmonary function and its predisposing factors.2) had undergone surgery 1 year prior to the commencement of the study. Based on the patients’ past medical history, physical examination results, and findings obtained from electrocardiography and echocardiography, those diagnosed with cardiac diseases , untreated cardiopulmonary diseases, addiction, and psychological disorders, as well as those with poor image quality, were excluded from this study. Ultimately, the study population was composed of 101 patients.This before-and-after study conducted in Modarres Hospital, Tehran, Iran, from September 2016 to September 2017, recruited 130 patients. Those with morbid obesity  and recorded to the nearest 100 g. Blood pressure was taken on the right arm at 2 intervals of 5 minutes after the patient rested for 15 minutes in a sitting position. A standardized mercury sphygmomanometer  was utilized. Consequently, the mean of the measurements at the 2 intervals was calculated for analysis. Hypertension was defined as systolic blood pressure ≥140 mmHg and/ or diastolic blood pressure ≥90 mmHg or the current use of an antihypertensive medication based on the JNC7 . 4 level. Overt hypothyroidism was defined as serum thyroid-stimulating hormone >5.06 mIU/L with free T4<0.91 ng/dL.The participants were divided into 2 groups of current smokers, who smoked every day or occasionally, and nonsmokers, who had never smoked or had quit smoking. Type II diabetes was defined as fasting plasma glucose ≥7.0 mmol/L and/or 2-hour postprandial plasma glucose ≥11.1 mmol/L or being on antidiabetic medications. Subclinical hypothyroidism was defined as serum thyroid-stimulating hormone >5.06 mIU/L with a normal free T2). BMI loss was calculated as preoperative BMI−current BMI. The study questionnaire was completed for all the patients 12 months after surgery.The BMI was calculated as weight (kg)/height×height , the stomach was resected about 6 cm proximal to the pylorus and on to the Hiss angle on a 32-F Bougie. The omentum was thereafter over-sewn continuously with absorbable 2-0 polydioxanone (PDS) sutures to reinforce the staple line. Next, a 16-F drain was placed along the staple line and externalized through the 5-mm port from the left flank. At the end of the procedure, the peritoneal cavity (above the stomach and under the diaphragm) and the bed of the spleen were irrigated with a bupivacaine 0.25% solution (30 cc) to reduce postoperative pain.Echocardiographic studies were performed using a Sonos 7500 . Two-dimensional guided M-mode echocardiographic tracings in the parasternal long-axis view were performed to measure left atrial (LA) diameter and the parameters of left ventricular (LV) geometry. The mean pressure and the mean end-diastolic pressure in the pulmonary artery were directly assessed by measuring the peak and end-diastolic velocities of the pulmonary regurgitant jet using the following equations: a) diastolic pulmonary artery pressure (PAP) = pulmonary regurgitation end-diastolic pressure gradient + right atrial pressure and b) mean PAP = pulmonary regurgitation peak pressure gradient + right atrial pressure. Furthermore, diastolic dysfunction was assessed according to the recommendations of the American Society of Echocardiography and the European Association of Cardiovascular Imaging.t-test or the Mann–Whitney test (if necessary) between the independent groups. The differences between the cardiopulmonary parameters before and after sleeve gastrectomy were assessed using the paired t-test or the Wilcoxon signed-rank test. The independence of the 2 categorical variables was assessed by using the χ2 test or the Fisher exact test. Additionally, the McNemar test was applied to compare the before-and-after paired nominal data. The association between weight loss during the follow-up and the cardiopulmonary function as the outcome was investigated through a generalized estimation equation (GEE) method. The GEE approach widely used an estimation method for the marginal  modeling of the repeated data. In brief, the GEE utilized the generalized linear model to estimate more efficient and unbiased regression parameters relative to ordinary least squares regression in part because they permit specification of a working correlation matrix that accounts for the form of the within-subject correlation of responses on the dependent variables of many different distributions, including normal, binomial, and Poisson. All the models were adjusted for age, gender, smoking status, hypothyroidism, sleep apnea, diabetes, and pulmonary diseases as time-varying confounders. All the analyses were performed separately for different obesity phenotypes using STATA statistical software (version 13 MP). Values <0.05 were considered statistically significant.The demographic characteristics were presented as the mean (standard deviation [SD]) for the numerical variables and numbers (percentages) for the categorical measures. Departure from normality assumption was assessed using the Kolmogorov–Smirnov test. Differences in the descriptive baseline characteristics were explored using the Student independent A total number of 101 morbidly obese patients were enrolled in this study. The demographic and clinical baseline characteristics of the participants are presented in During the first postoperative year, the mean weight loss was 43.82±14.53 kg. A history of sleep apnea was present in 51 (50.5%) patients before surgery, which decreased to 1 patient 1 year postoperatively (P<0.001). The McNemar test showed that the frequency of diabetes mellitus was not statistically decreased during the 1-year period after surgery (10% vs. 7.9%). The effects of weight loss on the study variables in the univariate analysis are demonstrated in The mean±SD systolic blood pressure was 137.96±19.60 mmHg and 123.37±9.60 mmHg before sleeve gastrectomy and 1 year after surgery, respectively (P<0.001). The mean (SD) LV size was 48.22±4.04 mm and 44.97±5.70 mm before sleeve gastrectomy and 1 year afterward, correspondingly (P<0.001). The mean±SD PAP was 28.88±5.25 mmHg and 24.10±4.78 mmHg before sleeve gastrectomy and 1 year thereafter, respectively (P<0.001). The mean±SD LA size was 35.72±3.32 mm and 33.12±3.52 mm before sleeve gastrectomy and 1 year postoperatively, correspondingly (P<0.001).The results from the GEE analysis demonstrated a relationship between losing weight and the LV, PAP, and LA measures . The resOur results demonstrated that a reduction in weight per kg caused a statistically significant drop in PAP with a coefficient of 0.1. In addition, in this model, smoking  and age  affected PAP. The results also showed that a 1-kg weight loss caused a reduction in LA size by a factor of 0.05. The other variables that were entered into the model did not yield statistically significant results. Our findings showed no relationship between LV hypertrophy and diabetes mellitus and weight loss due to sleeve gastrectomy.13, 14 Still, the absence of long-term outcomes in the studies hitherto conducted may raise concern over pathophysiological consequences beyond the weight loss obtained.   15 The results of the present study demonstrated the positive effects of weight loss on cardiac function by decreasing LV and LA size, as well as PAP. The increasing prevalence of obesity represents a major health burden worldwide and bariatric surgery, and in particular sleeve gastrectomy, has become an important pillar of treatment in severely obese patients.   9  showed a significant reduction in myocardial wall thickness after a 1-year weight-reduction program. Kokkinos and colleagues,   10  in a study of 37 morbidly obese patients, showed that all echocardiographic parameters improved significantly at 6 months in comparison with the baseline values. Benaiges and coworkers,   11  in a cohort study on 197 morbidly obese patients, reported a 68.1% reduction rate in hypertension 1 year after the surgical procedure. Previous studies have demonstrated that obesity is associated with an increase in wall thickness and chamber size.   16  Ayer et al.17 reported that the BMI was an independent determinant of LA size in their investigation. The findings from the abovementioned studies are in line with our study results. Impaired pulmonary and cardiac functions and indices are commonly observed in obese patients, even in those who are yet asymptomatic. Nevertheless, these changes are reversible following weight loss. Held and colleagues2, as well as in high-risk patients, to a more complex definitive procedure.   18  In addition to its use in staged approaches in high-risk, high-BMI patients, laparoscopic sleeve gastrectomy is now commonly performed as a stand-alone bariatric operation for both high-risk and super-morbid-obese patients, as well as for patients with a lower BMI.19 Although it has been classified among the restrictive procedures, there is increasing evidence in the literature that laparoscopic sleeve gastrectomy acts with more than one mechanism. Studies have shown weight loss and diabetes resolution similar to Roux-en-Y gastric bypass.   20  Morbid obesity has become a worldwide concern because of the increase in the risk of diabetes, hypertension, heart disease, sleep apnea, and the other risk factors of cardiopulmonary disease.   21 Laparoscopic sleeve gastrectomy was introduced as a restrictive procedure for obese patients, and it was initially described as a feasible first-stage operation in super-obese patients with BMI >60 kg/mOur result showed that the frequency of sleep apnea statistically decreased 1 year after surgery. The patients with diabetes mellitus after losing weight had a significant reduction in blood glucose levels. We also found that the frequency of diabetes mellitus was not statistically decreased during the 1-year period after surgery (10% vs. 7.9%). The findings of the current study should be confirmed by randomized controlled trials with a large sample size. Additionally, the measurements of body composition would be of interest, but test methods leading to valid data are a challenging issue in severe obesity. Moreover, it is already known that especially during the first months after sleeve gastrectomy, the marked decrease in body weight corresponds in part to fat-free mass. Therefore, patients should be re-evaluated after a longer period  when weight loss has a higher impact on adiposity. These studies might rather focus on comparing different types of procedures such as Roux-en-Y gastric bypass, which is a simultaneously restrictive and malabsorptive operation.In our study population, weight loss resulting from sleeve gastrectomy improved high systolic blood pressure, PAP, and LA and LV size.