From a recent meta-analysis it appeared that online post-dilution hemodiafiltration (HDF), especially with a high convection volume (HV-HDF), is associated with superior overall and cardiovascular survival, if compared to standard hemodialysis (HD). The mechanism(s) behind this effect, however, is (are) still unclear. In this respect, a lower incidence of intradialytic hypotension (IDH), and hence less tissue injury, may play a role. To address these items, the HOLLANT study was designed.HOLLANT is a Dutch multicentre randomized controlled cross-over trial. In total, 40 prevalent dialysis patients will be included and, after a run-in phase, exposed to standard HD, HD with cooled dialysate, low-volume HDF and high-volume HDF  in a randomized fashion. The primary endpoint is an intradialytic nadir in systolic blood pressure (SBP) of < 90 and < 100 mmHg for patients with predialysis SBP < 159 and ≥ 160 mmHg, respectively. The main secondary outcomes are 1) intradialytic left ventricle (LV) chamber quantification and deformation, 2) intradialytic hemodynamic profile of SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP) and pulse pressure (PP), 3) organ and tissue damage, such as the release of specific cellular components, and 4) patient reported symptoms and thermal perceptions during each modality.The current trial is primarily designed to test the hypothesis that a lower incidence of intradialytic hypotension contributes to the superior survival of (HV)-HDF. A secondary objective of this investigation is the question whether changes in the intradialytic blood pressure profile correlate with organ dysfunction and tissue damage, and/or patient discomfort.NCT03249532# . Date of registration: 2017/08/15.Registered Report Identifier:  Extracorporeal blood flow rate will be targeted at 350–400 ml/min and filtration fraction (blood flow rate / convection flow rate) at 25–30%, which have been proven to be feasible . SubstitFor a given patient, treatment settings will be kept similar in all treatment modalities, e.g. UF profile, start of treatment with either empty or filled lines, blood flow rate, session length and type of anticoagulant. Any clinically necessary change will be documented.2; sterilization by gamma radiation; capillary internal diameter 195 μm; B. Braun Avitum AG, Melsungen, Germany). In exceptional cases, the attending nephrologist can decide to treat the patient with a Xevonta® 18 dialyzer , or comparable.Both HD and HDF will be performed with high-flux dialyzers: Xevonta® 23 dialyzers , Hematocrit (HCT) sensor with integrated oxygen saturation (spO2) monitoring device, mantled with the captive tubing system DiaStream® iQ .All treatments will be performed with ultrapure (UP) dialysis fluids . Dialysate flow rate will be 500 mL/min during S-HD and C-HD, and 600 ml/min in LV- and HV-HDF . The electrolyte composition of the dialysis fluid is: Na 138–140 mmol/L; K 2.0–3.0 mmol/L; HCO3 30–35 mmol/L; Ca 1.25–1.75 mmol/L; Mg 0.5 mmol/L; Cl 108–109.5 mmol/L; glucose 5.6 mmol/L; acetate 3 mmol/L and will not be changed for each individual patient during the conduct of the study.Routine patient care is performed according to current national  and inteTable At baseline, all relevant information will be documented: i.e. demographical data, information on cardiovascular disease (CVD), cause of renal failure, time on dialysis, co-morbidity, medical history and medication. A history of CVD is defined as a confirmative answer on any of the questions regarding a previous acute myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, angina pectoris, stroke, transient ischemic attack, intermittent claudication, amputation, percutaneous transluminal angioplasty, peripheral bypass surgery, and renal percutaneous transluminal angioplasty.Data will be used from the last routine assessment as indicated by the national guideline : Hb, Ht,Before dialysis, the bodyweight and the interdialytic weight gain (IDWG) of the patients will be noted. During dialysis, hemodynamics will be recorded according to the protocol (see below) as well as all other treatment related variables, including UF volume, UF rate and online monitoring of estimated Kt/V from UV-absorbance measurements in spent dialysate via Adimea® . FurtherSince simple questions on intradialytic symptoms appear to predict patient outcomes better than complicated questionnaires –53, a moDiastolic (DBP) and systolic (SBP) blood pressure, pulse pressure (SBP minus DBP), mean arterial pressure (MAP: [(SBP + 2*DBP)/3]), heart rate (HR) and intradialytic hypotensive episodes IDH, see  will be During the first or second dialysis of the last week of every treatment modality, every 20 seconds MAP, stroke volume (SV), heart rate, total peripheral resistance and cardiac output (CO) will be obtained using the Clearsight monitor , which is a non-invasive arterial pressure measuring device. This monitor turns finger arterial pressure with a fast-pneumatic system to account, as well as photoplethysmography to detect changes in finger arterial diameter during inflations . A volumBody temperature will be assessed before and after each dialysis session by a tympanic thermometer .Speckle Tracking Echocardiography (STE) will be performed before, after 1 and after 3 h of treatment during the last dialysis of each modality. Two-dimensional left ventricular (LV) measurements of wall thickness and cavity diameters, 2D biplane Simpson measurement of volumes and ejection fraction are measured using a commercial scanner  with a fully sampled matrix array (S5–1) transducer. These measurements are indexed for body surface area (BSA). For the assessment of global longitudinal deformation (GLS) as well as distribution of regional longitudinal strain, 2DSTE is performed from an apical position. Diastolic LV function is measured by 2D LAVI , transmitral E/A ratio and deceleration time, e’ wave velocity, E/e’ ratio and SPAP (systolic pulmonary artery pressure). Estimated right ventricular function will be done by TAPSE (tricuspid annular plane systolic excursion), s’ wave velocity and RV (right ventricular) regional and global strain. The data will be recorded electronically and assessed off-line by a trained research physician in Xcelera Cardiology Information Management Version 4.1 .Blood sampling will be performed in the last session of each dialysis modality, after the long interdialytic interval see Fig. . Blood sSoluble CD14 (sCD14), interleukin-6 receptor (IL-6R), high sensitive C-reactive protein (hs-CRP), creatine kinase myocardial band (CK-MB), soluble vascular intercellular cell adhesion molecule 1 (sv-ICAM-1), and fibroblast growth factor 23 C-terminal (FGF23 C-term) will be assessed in EDTA or heparin plasma samples after being placed on ice and centrifuged within 30 min, at 1800 g for 10 min.Hematocrit measurements, reflecting relative blood volume (RBV), and spO2 will be assessed continuously in the ECC by the HCT sensor and with the integrated spO2-monitoring device located on the Dialog iQ® dialysis machine . RBV- and spO2 values will be read out from the trend-files, which are retrieved by service technicians. In addition, blood samples for pO2, pH, bicarbonate and base excess analysis will be drawn from the arterial line before and after treatment , and assessed directly with a point-of-care device .Microbial DNA (mDNA) will be assessed in EDTA blood with 16S–23S interspace (IS) pro after DNA isolation. In short, IS-pro is a eubacterial PCR-based technique for detection of most bacterial species within a sample, and is based on length and sequence polymorphisms of the bacterial 16S–23S ribosomal interspace regions. IS-pro has been optimized to detect bacterial loads as low as 1 CFU per 5 ml blood , 58.Citrate blood samples will be centrifuged for 15 min at 2500 g, 20 °C to remove red blood cells. Subsequently, the EV-containing supernatant is isolated and centrifuged again . The EV-containing supernatant will be frozen and stored at − 80 °C until further use. Before assessment, samples will be thawed at 37 °C. Subsequently, direct measurement of the EVs in plasma will take place, as extensively described by van der Pol et al. .The primary endpoint of this study is an absolute intradialytic nadir in SBP of < 90 and < 100 mmHg for patients with a predialysis SBP < 159 and ≥ 160, respectively.Secondary endpoints include: 1) intradialytic LV chamber quantification and deformation  and LV diastolic function; 2) the intradialytic hemodynamic profile of SBP, DBP, MAP and PP; 3) organ and tissue damage, such as the release of specific cellular components; and 4) patient-reported symptoms and thermal perceptions during each modality.p-value ≤0.05 is considered statistically significant. Statistical evaluations will be performed using IBM SPSS Statistics version 26.0  or RStudio version 1.1.456.Descriptive data will be represented as mean ± standard deviation (SD), median (interquartile range) or number (percentage), when appropriate. The between-treatment number of IDH episodes  will be analyzed using regression analysis with a Poisson distribution. The mean inter-treatment variability of continuous variables will be calculated using generalized linear mixed effects models with a random intercept, random slope or both, based on the lowest Aikaike’s Information Criterion. A two-sided We plan to include 40 patients. Loss to follow-up (due to an event) is expected to be about 20%. The number of patients with complete follow-up will be sufficient to detect a 40% lower risk  in the occurrence of the primary endpoint. The power calculation applied was designed for cross-over studies [Clinical data will be extracted from the hospital’s electronic information systems and dialysis machines. Data will be collected on electronic case record forms (CRF) using web-based Castor EDC . Data wiGiven the current COVID-19 pandemic and the fact that this study is carried out in a vulnerable population, it is conceivable that the practical implementation of this study will encounter some serious obstacles. As such, interventions requiring direct patient contact and performed solely in the interest of the study, such as cardiac ultrasounds, may be undesirable in times of alarming virus spread.The HOLLANT study is principally designed to evaluate prospectively whether intradialytic hypotension, as defined under the primary endpoint, is less frequently observed during HV-HDF than during the three other modalities . Second, the study aims to assess whether a more favourable intradialytic hemodynamic profile, as measured by various hemodynamic parameters including MAP and DBP, is associated with a lower degree of tissue injury and organ dysfunction, and a better patient tolerance. After all, it is conceivable that a lower blood pressure and/or diminished perfusion is accompanied by tissue injury, organ dysfunction and subjective discomfort, since pre-existing microcirculatory dysfunction is already present in the majority of patients with advanced CKD . In the As for the heart, functional changes as observed by STE, will be correlated with intradialytic hemodynamics and with biochemical signs of myocardial damage, such as an increase in the blood levels of CK-MB and release of EVs from cardiomyocytes. Considering the gut, hypoperfusion of the intestinal microcirculation may promote enterocyte injury, loss of the gut-blood-barrier function and increased permeability, thus permitting the intradialytic transfer of mDNA into the circulation. Any increase during dialysis will be correlated with both blood pressure alterations and changes in the inflammatory state, as measured by sCD14 and IL-6R. Tissue injury of various origin, including circulating blood cell elements, the endothelium and cardiomyocytes will be assessed by measuring alterations in the blood levels of EVs. The latter parameters will be correlated with intradialytic hemodynamics as well, and the aforementioned signs of tissue injury, including a rise in CK-MB and mDNA in the blood. Finally, all topics will be related to changes in tympanic body temperature, oxygen and inflammatory status, patient reported temperature sensations and treatment tolerance.If HV-HDF appears indeed to be associated with a better intradialytic hemodynamic profile and less tissue damage, this will enhance our understanding why HDF is associated with a superior patient outcome and allow the nephrological community to improve this treatment modality even further. If not, the outcome of this study will anyhow teach us if, and to what extent intradialytic hemodynamic instability is associated with tissue injury and patient discomfort, and thus help the medical staff to optimize dialysis treatment in individual cases.The largest strength of this study is its randomized cross-over design, which prevents that inter-individual differences, such as co-morbidity and prescribed medication, influence the results. An important limitation may be the duration of each dialysis modality, which may be too short to answer all questions. Yet, to minimize patients’ discomfort the underlying protocol was designed in its current form. Since this study is primarily designed to investigate the intradialytic hemodynamics and its consequences on organ and tissue damage between the four most practiced extracorporeal dialysis techniques , potential differences in thermal and sodium balance are not addressed. Another important issue of any study with a cross-over design is the duration of the wash-out period that will most likely prevent carry-over effects of the previous modality. For this study, a wash-out period of 1 week  was arbitrarily chosen, since relevant information on this topic is absent.The recruitment and inclusion of patients started at 29-08-2018. Currently, 25 (62.5%) of the intended 40 patients have been included in the study.


In all participants standard blood tests, total ghrelin and total adiponectin plasma concentrations and anthropometric measurements  were performed. The evaluation of energy and nutrient intakes was made using the three-day food record method. Results: Excessive body weight was found in 92.80% patients. The average daily energy intake was 1979.67 kcal/day . In the group with eGFR < 30 mL/min/1.73 m2 the analysis showed a negative relationship between ghrelin and WHR value, and the creatine and albumin concentrations. There was a positive correlation between ghrelin concentration and the consumption of carbohydrates and sucrose. In the group of patients with eGFR > 30 mL/min/1.73 m2, a positive correlation was found between the concentration of ghrelin and the consumption of vegetable protein, carbohydrates, and glucose. Conclusions: The study confirms the high prevalence of obesity in patients with DN-Excessive supply of protein was found in the patients’ diets, which may contribute to the deterioration of the course of the disease and its prognosis. In patients with eGFR < 30 there was a negative correlation between ghrelin concentration and nutritional status, and in patents with eGFR > 30 between ghrelin concentration and some nutrients intake.Background: Overnutrition is one of the risk factors of chronic kidney disease (CKD). The factors related to both obesity and CKD are adiponectin and ghrelin. The aim of the study was to assess if there is a link of nutritional status and selected nutrients intake with adiponectin and ghrelin in patients with diabetic nephropathy (DN). Methods: The study involved 55 patients diagnosed with DN in the pre-dialysis period (two groups: GFR < 30 and >30 mL/min/1.73 m Globally in 2017, there were 697.5 million cases of CKD (chronic kidney disease). Thus, the prevalence of CKD is higher than that of diabetes, osteoarthritis, chronic obstructive pulmonary disease (COPD), asthma, or depressive disorders. The prevalence of CKD was estimated as 9.1% in the world’s population, with CKD Stages 1–2 accounting for 5.0%, Stage 3 for 3.9%, Stage 4 for 0.16%, Stage 5 for 0.07%, dialysis patients for 0.041%, and those after kidney transplantation for 0.011%. Since 1990 the global all-age prevalence of CKD increased by 29.3%. In 2017, 1.2 million people died from CKD. It is predicted that in 2040 this number may increase to 4.0 million [Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease . In receThe factors related to both metabolic disorders, including obesity and chronic kidney disease, are adiponectin and ghrelin. Adiponectin is a cytokine produced by adipose tissue ,19,20,21Adiponectin has been shown to have anti-inflammatory, antifibrotic and antioxidant effects on kidneys through AMP-activated protein kinase (AMPK-activated protein kinase) activation. It has been found that adiponectin receptor ADIPOR1 and catalytic AMPK subunits are expressed in the cells constituting the glomerulus ,20,21,22Ghrelin, a peptide hormone released mainly by the X/A-like cells of the gastric mucosa, plays an important role in hunger regulation ,24,25,26It should be emphasized that CKD is preventable and treatable to a large extent . An impoThe aim of the study was to assess if there is a link of nutritional status and selected nutrients intake with the concentration of adiponectin and ghrelin levels in patients with diabetic nephropathy depending on the renal function.2. To assess the degree of renal function, the MDRD formula proposed by the Modification of Diet in Renal Disease Study Group was used [The research was conducted at the Department of Internal Diseases, Nephrology and Dialysis of the Military Institute of Medicine and at the Department of Clinical Dietetics of the Medical University of Warsaw. The study involved 55 patients (including 32 men and 23 women) with a mean age of 70.7 ± 12.1 years diagnosed with chronic kidney disease in the pre-dialysis period, Stages 2 to 4. Patients were divided into two groups depending on the degree of renal efficiency, GFR < 30 and >30 mL/min/1.73 mwas used , which, was used . Twenty-All patients underwent blood tests and anthropometric measurements that included body composition, and also dietary assessment that comprised intake of energy and selected nutrients.Body weight (BW) was measured with high-quality electronic calibrated scale and height with a wall-mounted stadiometer (to the nearest 0.5 cm). Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters .In addition, waist, and hip circumference (WC and HC) were measured. Based on these results waist–hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. According to WHO recommendations  waist ciBody composition analysis was performed based on bioimpedance spectroscopy (BIS) using a Body Composition Monitor . Measurements were conducted after a 5-min rest in a supine position. Pairs of electrodes were placed on one hand and on one foot. Among BIS measurements there were lean tissue mass (LTM), fat mass (FM) values. The average content of adipose tissue and lean tissue in the body for people aged ≥ 70 is 20–22% and 75–80% for men, and 28–36% and 70–75% for women, respectively .Blood tests included measurement of the concentration of creatinine, urea, total protein, albumin, prealbumin, lymphocytes, phosphorus, CRP, total adiponectin and total ghrelin. Blood samples were collected after an overnight fast . Phosphorus levels were measured using the appropriate chemical analyzer . Serum creatinine concentrations (SCr) were analyzed using Jaffe method , serum albumin levels (SA) using a BCP Albumin Assay Kit , and concentrations of high-sensitivity C-reactive protein were determined by a nephelometry assay (BN™ II System Siemens). All the above-mentioned blood tests were performed at the local Department of Laboratory Diagnostics.4–2.410 × 104 ng/mL, for male: 3000–2.11 × 104 ng/mL) and according to the manufacturer’s instructions. Mediagnost E09 Adiponectin ELISA detects all forms of Adiponectin present in human serum: the trimer at 65 kDa, the hexamer at 150 kDa and the high molecular weight forms of >280 kDa. The Mediagnost E09 Adiponectin ELISA therefore measures total Adiponectin.Total ghrelin and total adiponectin plasma concentrations were measured at the Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, by using enzyme-linked immunoassays (ELISA): ELISA Kit for Ghrelin (GHRL) CEA991Hu; Cloud-Clone Corp. , and Adiponectin ELISA, E09; Mediagnost . During a visit to a dietitian, the sizes of individual meals were precisely evaluated. To assess the nutritional value of patients’ diets the Dieta 5.0 software was used . The calculated nutritional data included: energy , total protein (grams) including animal and vegetable protein (g), carbohydrates (grams) including sucrose, glucose and fructose (grams), fiber (grams), fats (grams), potassium (grams), and phosphorus (grams) intake.t-test for independent samples.The analysis of the results included the analysis of the relationship between the variables and the verification of statistical significance of intergroup differences. Pearson’s r correlation coefficients were used in the analysis of the relationship between the variables. The verification of the statistical significance of intergroup differences was based on the values of the Student’s 2. BMI value indicating excessive body weight (≥25 kg/m2) was found in 92.80% of the participants. Overweight and obesity concerned a similar percentage of subjects . Abdominal obesity based on waist circumference and WHR was shown in 89.09% of participants (87.50% of men and 95.65% of women) and in 92.73% (96.88% of men and 86.96% of women) respectively. Based on the WHtR, a high metabolic risk was found in 8.2% of patients. The average content of adipose tissue in the body of the subjects was 41.03 ± 9.08%. Detailed data on the results of anthropometric measurements of patients is presented in The study was conducted among 55 patients including 32 men and 23 women. The mean value of BMI was 30.68 ± 6.40 kg/m2, creatinine 2.44 ± 0.93 mg/dL, and urea 92.64 ± 32.04 mg/dL. The ghrelin concentration was 171.45 ± 44.44 pg mL and the adiponectin concentration was 2709.74 ± 2433.66 ng/mL (median 1818.34 ng/mL). The detailed results are presented in The mean value of the eGFR MDRD was 27.99 ± 10.50 mL/min/1.73 mp < 0.0001) and the concentration of albumin was higher, at borderline of significance . There were no statistically significant differences in other blood parameters between two groups.In the group with eGFR > 30, the mean concentration of creatinine and urea was lower than in the eGFR < 30 group .2 there was a significant negative relationship between the ghrelin concentration and WHR value  showed a negative correlation (p < 0.05) between the concentration of ghrelin and the concentration of creatinine (−0.353) and albumin (−0.378) in the blood serum of patients with eGFR < 30 mL/min/1.73 m2. In both studied groups, no statistically significant relationships were found between the concentration of adiponectin and other blood parameters.The assessment of the relationship between the concentration of ghrelin and adiponectin from one side and other blood parameters on the other, in two groups of patients of different stage of the disease , carbohydrates (p = 0.05), glucose (p = 0.05), fiber (p = 0.05) and potassium (p = 0.05)  .This study confirms a high prevalence of excess body weight  in patients with diabetic nephropathy may complicate the treatment of chronic kidney disease, accelerate the progress and aggravate the course of CKD ,41,42,432, a negative relationship between ghrelin concentration and WHR was demonstrated. This result seems surprising considering that ghrelin is an appetite-enhancing hormone. However, the study did not distinguish between the forms of ghrelin. It should also be emphasized that results of other studies differ in terms of the levels of acyl ghrelin (AG), with some studies suggesting higher levels in CKD patients whereas others show no difference [It should be emphasized that the average waist circumference and WHR indicated abdominal obesity ,48,49, afference ,52. AccoIt was worrying that there was a large proportion of fat tissue in the body composition of the subjects, which, together with a low proportion of lean body mass (mainly muscle tissue), may indicate sarcopenic obesity, common in patients with CKD ,34. It s2 we found a negative correlation between the concentration of ghrelin on one side and albumin and creatinine on the other. However, in our study we did not analyze the forms of ghrelin. The relation to albumin concentration can be explained by the already mentioned possible higher concentration of des-acyl ghrelin and low plasma levels of acyl ghrelin what may contribute to malnutrition [In the group of patients with eGFR < 30 mL/min/1.73 mutrition ,52 and tutrition . The acyutrition . These c2), and the energy and protein intake was 1369 kcal and 35 g/day, respectively, i.e., it was half that in our group of patients [2 is a selected group of patients with advanced kidney failure which can be associated with metabolic disorders. On the other hand, diabetes also induces neurological and metabolic disturbances. Therefore, we can suppose that this relationship can be different than in other studies. We also cannot rule out that this result was influenced by the medications taken by the patients. This finding suggests the need for further studies in a larger group of patients, including analyzes of both forms of ghrelinThe negative link of ghrelin to the concentration of creatinine is very surprising. Other authors showed that ghrelin levels positively correlated with serum creatinine and negatively with eGFR ,54. Incrpatients . It is, There was no correlation between the concentration of adiponectin and the results of anthropometric measurements and blood tests. In the El-Khashab and Behiry  study ad2 also the higher was the intake of vegetable protein, fiber, glucose, and potassium. This result suggests an orexigenic effect of ghrelin in the group of patients with a lower disease progression what corresponding with better nutritional status  in this group. Both total carbohydrates as well as sucrose and glucose are a good source of easily and quickly available energy, especially in the case of hunger. However, frequent consumption of these products may contribute to excess body weight, and with insufficient consumption of other nutrients, especially protein, for malnutrition. Sucrose accounted for 9.9% of the energy value of the diet, total carbohydrates about 60%. In other studies, percentage of the total calorie intake from carbohydrates was both lower [The significant prevalence of obesity in the study group did not reflect current excessive energy intake . However, energy intake was higher than in other studies conducted among patients with CKD where it was in the range 1334 –1394 3131 kcal/dth lower  and highth lower ,35,55. Ath lower  and highth lower ,37. Low-th lower  and thisth lower . CurrentIt should be emphasized that products rich in complex carbohydrates are an important source of vegetable protein. An increase in the percentage of calories from complex carbohydrate food may result in improvement in the outcomes of CKD and its accompanying comorbid conditions .Fructose intake in the course of kidney disease is also important. In the past, fructose intake was provided by fruits and honey and its daily intake was 16–20 g. However, in the last 30 years, daily fructose intake has increased up to 85–100 g due to the addition of sucrose, high fructose corn syrup (HFCS), honey, to carbonated beverages, fruit juices, canned fruits, and dairy products . One of 2. The implementation of these recommendations is possible if some of the products providing vegetable protein are replaced with special low-protein products . Therefore, these recommendations are easier to implement in countries with high levels of health care where dietary support is more readily available. In other countries, it is recommended to eat a diet with a higher protein content [Taking into account the adverse effect of excessive protein intake on the kidneys , and recommended dietary allowance for adult general population . This reOur study did not demonstrate the effect of the diet of patients on the concentration of adiponectin. Other studies found that the Mediterranean diet, the plant-based diet and diet with reduced energy value ,18, and The study confirms the high prevalence of obesity in patients with DN which may be both the cause of CKD and the cause of its complications. Excessive supply of protein was found in the patients’ diets, which may contribute to the deterioration of the course of the disease and its prognosis. In patients with eGFR > 30 there was a negative correlation between the concentration of ghrelin and WHR, creatinine and albumin, and in patients with eGFR > 30, a positive correlation between the concentration of ghrelin and vegetable protein, carbohydrates, glucose, fiber, and potassium intake. There was no relationship between adiponectin, diet, and nutritional status.


Nephrectomy is the management of choice for the treatment of renal tumors. Surgical pathologists primarily focus on tumor diagnosis and investigations relating to prognosis or therapy. Pathological changes in non-neoplastic tissue may, however, be relevant for further management and should be thoroughly assessed.Here, we examined the non-neoplastic renal parenchyma in 206 tumor nephrectomy specimens for the presence of glomerular, tubulo-interstitial, or vascular lesions, and correlated them with clinical parameters and outcome of renal function.We analyzed 188 malignant and 18 benign or pseudo-tumorous lesions. The most common tumor type was clear cell renal cell carcinoma  followed by papillary or urothelial carcinomas (n = 25). Renal pathology examination revealed the presence of kidney disease in 39 cases (18.9%). Glomerulonephritis was found in 15 cases (7.3%), and the most frequent was IgA nephropathy . Vasculitis was found in two cases (0.9%). In 15 cases we found tubulo-interstitial nephritis, and in 9 severe diabetic or hypertensive nephropathy. Partial nephrectomy was not linked to better eGFR at follow-up. Age, vascular nephropathy, glomerular scarring and interstitial fibrosis were the leading independent negative factors influencing eGFR at time of surgery, whereas proteinuria was associated with reduced eGFR at 1 year.Our large study population indicates a high incidence of renal diseases potentially relevant for the postoperative management of patients with renal neoplasia. Consistent and systematic reporting of non-neoplastic renal pathology in tumor nephrectomy specimens should therefore be mandatory.The online version contains supplementary material available at 10.1007/s40620-021-01030-0. According to the European Cancer Information System, kidney cancer was the seventh most common and eighth most lethal cancer type in Europe in 2018 . CKD is Therefore, we have evaluated the changes in the non-neoplastic renal tissue in more than two hundred specimens of (uretero)-nephrectomy for putative or confirmed kidney or renal pelvic tumors and correlated clinico-pathological findings with kidney function at time of surgery and at one-year follow-up.We prospectively collected non-neoplastic tissue from 129 adult tumor nephrectomy specimens and retrospectively re-evaluated 77 archived cases from our Department. Altogether, 206 cases of radical or partial nephrectomies were collected between March 2013 and March 2019. None of the patients had any intervention not required for clinical care. We performed the study following the Helsinki declaration and with the approval of the local ethics committee (nr. 2020/2019).We retrieved clinical and laboratory data from the computerized hospital information system or by contacting specialists providing follow-up care. Data included the patient’s demographic information, pre-operative kidney function (estimated glomerular filtration rate (eGFR)) calculated with the CKD-EPI equation, and urine analysis (significant proteinuria defined as more than 150 mg/24 h and sediment). To evaluate follow-up kidney function, we collected eGFR 12 months after surgery, when available. The routine pathological reports provided the diagnosis and classification of tumor lesions and pathological staging. Our detailed nephropathological workup is available in Supplementary Material S1.We present continuous statistical data as median and interquartile range (IQR), and categorical variables as absolute and relative frequencies. We used Mann Whitney U-tests and Chi-square tests to compare continuous and categorical data, and calculated Pearson’s or Spearman’s coefficients for correlations. Univariate linear regressions allowed the evaluation of renal function in subgroup analyses. After this step, relevant and significant variables  were integrated into multivariate linear regression models, excluding collinear variables. A two-sided p-value of less than 0.05 was considered statistically significant. For statistical analysis, we used Prism 8 for macOS , which provided graphs as well, or IBM SPSS Statistics 24 for cross tabs and regression analyses .2 (54–87). Data analysis was corrected for patients with eGFR < 15 mL/min at surgery. We excluded these cases (n = 6) in Table 2) which was significantly lower than that at the time of surgery (54 mL/min/1.73 m2 (38–68), p < 0.001, Fig. Eighty-eight patients 42.7%) were females, with a median age of 70 years (58–76), and 118 were males (57.3%), median age 66 years (59–76). Total or partial nephrectomy was performed in 188 (91.2%) and 18 (8.7%) cases, respectively. Median eGFR at the time of nephrectomy was 73 mL/min/1.73 m.7% were Tumor details and nephropathological findings are reported in Table Electron microscopy was performed in 23 cases (11.2%). While mesangial matrix augmentation and thickened basement membranes of the glomerular capillaries supported the diagnosis of diabetic nephropathy, electron-dense deposits at higher magnification confirmed the immune complex-based glomerulonephritides.Patients were significantly older in the group with neoplastic diseases than in the group with non-neoplastic diseases (69 years (60–76) vs. 55 20–64), p = 0.002), irrespective of individual tumor subgroup , and were older in the group with malignant than in the group with benign tumors (69 (60–76) vs. 55.2 47–71), p = 0.01—Table , p = 0.00–64, p =All cases of glomerulonephritides occurred in patients with malignant tumors . Glomerulonephritis was associated with less arteriosclerosis (1 (1–2) vs. 1 (0–2), p = 0.04), but was not associated with age, degree of mesangial expansion, glomerular sclerosis or any of the other histologic lesions we studied of our histologic lesions.There was no statistically significant difference in any single histological lesion when comparing malignant to benign tumors, but more extensive interstitial fibrosis and tubular atrophy was observed in non-neoplastic diseases than in clear cell renal cell carcinoma (CCRCC) or chromophobe renal cell carcinoma (ChRCC) (1 (0–3) vs. 0 (0–1) vs. 0 (0–1), p = 0.04 and p = 0.03, respectively). This was primarily attributable to the four pseudo-tumorous interstitial nephritides among the seven tumor-like conditions. Vascular nephropathy and TIN were not associated with any tumor subgroup or differed when comparing benign and malignant tumors, although TIN was highly represented in the non-neoplastic conditions.2: 87 (70–97) vs. 73 (58–86) vs. 74 (48–88) or 68 (51–90) or 64 (49–86), all p ≤ 0.05, Table Age was strongly correlated with eGFR at the time of nephrectomy  and kidney function at nephrectomy was better in the non-neoplastic group than in the groups of CCRCC, papillary neoplasms (PNe), neoplasms originating from intercalating cells of distal tubules (ICNe), or urothelial carcinoma (UrC) (eGFR in mL/min/1.73 m2 = 0.35). Neither adding malignancy of the tumor  = 14.238, p < 0.001, R2 = 0.35), nor restricting the analysis to the group of malignant diseases modified the model considerably  = 14.248, p < 0.001, R2 = 0.366; Fig. For the whole cohort, the strongest correlations with eGFR at surgery were with age, vascular nephropathy, glomerular scarring and severe interstitial fibrosis —Fig. 2 = 439) in benign lesions). None of the other subgroup analyses provided further meaningful insights.For each tumor group, the multivariate analysis (provided in Supplementary Tables S4–7) identified various negative factors: age and severe interstitial fibrosis for CCRCC  = 7.261, p < 0.001, RRegular follow-up was performed in the majority of cases on an outpatient basis. Details were therefore available for only about one-third of patients (36%) with other relevant nephropathological diagnoses. Data on nephrological care for the other patients were not available, partly because postoperative care was not performed in our institution. One patient with IgA nephritis received an angiotensin-converting enzyme (ACE) inhibitor, one patient with interstitial nephritis was treated with corticosteroids, and one patient with vasculitis received corticosteroids and rituximab. Seven patients required dialysis after nephrectomy, one because of surgery on a single kidney, two because of double nephrectomy and one because of transplant-nephrectomy. Two patients were already on dialysis at the time of surgery. Four further patients received a kidney allograft during follow-up. Five patients died within the first postoperative year. All of these were excluded from the follow-up analysis of eGFR at one year.2 (43–89) vs. 55 (40–68) for nephrectomy; p = 0.16) and a trend towards a lesser eGFR decline (9 ml/min/1.73m2 (1–21) vs. 20 (8–33); p = 0.11; Fig. Age correlated well with eGFR at 12 months follow-up . Partial nephrectomy was associated with a non significantly better follow-up eGFR (69 ml/min/1.73m2 = 0.15—Table S8). Accordingly, the group with proteinuria had a significantly higher eGFR decline at 12 months (32 (19–48) vs. 15 (3–27), p = 0.004; Fig. 2 = 0.123), though this stayed true for malignant diseases alone . No significant factor was identified in further tumor subgroup analysis (data not shown).Proteinuria was the sole significant factor negatively influencing the eGFR slope at 12 months post-surgery in linear regression analysis Supplementary file2 (TIFF 23923 KB)Below is the link to the electronic supplementary material.


Objective: To identify single nucleotide variants (SNVs) associated with lisinopril effectiveness. Materials and methods: This was an observational study using a candidate gene approach to examine SNVs associated with lisinopril effectiveness. Drug effectiveness was defined as 10% decrease in systolic blood pressure at 1 week follow-up. We used the Illumina GWAS MEGA chip to examine variants in the renin/angiotensin pathway that may be associated with drug effectiveness. Results: 61 subjects were enrolled, and 33 (54.1%) were responsive to lisinopril therapy. SNVs in AGT (p = 0.0141), REN (p = 0.0192), and ACE2 (p = 0.0002) were found to be associated with successful treatment on lisinopril. Conclusion and relevance: SNVs in the renin and angiotensin pathway are associated with lisinopril effectiveness in a pilot cohort of patients with uncontrolled hypertension.  What is known about this subject Only 50% of patients receiving antihypertensives achieve blood pressure control. Angiotensin converting enzyme inhibitors are the most commonly prescribed antihypertensive medication Interindividual genetic variants may contribute to drug effectiveness What this study adds Genetic variants in AGT, REN, and ACE2 genes were associated with failure to achieve 10% systolic blood pressure decrease due to lisinopril. Larger studies are needed to determine if variants in the renin and angiotensin pathway affect lisinopril effectiveness. Hypertension (HTN) affects more than 1 billion people worldwide . DespiteHTN is a complex, polygenic disease which may contribute to the shortcomings of conventional HTN treatment strategies. A novel approach to HTN therapy is to use genomic analyses to inform drug choices. Testing each patient for variants in drug targets, metabolic enzymes, and other genes involved with absorption, distribution, metabolism, and elimination allows the provider to select a drug based on an individual’s genomic profile. This could decrease adverse drug events, improve time to ideal HTN control, and result in fewer follow-up visits. Our objective was to identify single nucleotide variants (SNVs) associated with lisinopril effectiveness. 2, pregnancy, American Association of Anesthesiologists (ASA) classification of > 3, prisoners or wards of the state, decisionally challenged individuals, heart rate < 60 beats per minute, AV block > 240 ms, active reactive airway disease, illicit drug use in the preceding 30 days (excluding marijuana), allergy to metoprolol succinate, severe peripheral arterial circulatory disorders, or patients with secondary causes of HTN. The study was approved by the Colorado Multiple Institutions Review Board and adheres to the Declaration of Helsinki. We evaluated and identified genetic markers associated with response to lisinopril, an angiotensin-converting enzyme inhibitor (ACEI). Our research is a pilot study, and secondary analysis of a prospective observational parent study (NCT02293096) which evaluated the pharmacogenomic effectiveness of metoprolol succinate. Patients with uncontrolled HTN, as defined by the JNC-8 guidelines, were referred from clinics and other clinical areas at the University of Colorado Hospital in Aurora, CO. Our secondary analysis included a subset of patients between 30 and 80 years of age started on lisinopril in addition to metoprolol succinate. Exclusion criteria included end-stage liver disease, glomerular filtration rate < 60 mL/min/1.73mEnrolled patients were managed according to the JNC-8 HTN treatment guidelines. Patients were started on lisinopril 10 mg daily at the initial visit, and blood pressure was re-evaluated 1 week later. Those who responded to lisinopril were defined as individuals who had either a 10% decline in systolic blood pressure (SBP) or SBP < 140 at the week-1 visit. All others were considered non-responsive. The Ilumina MEGA chip , which interrogates 1,696,817 SNVs was used for genetic analyses. Clinically relevant variants in the pathway for ACEI treatment  were incData were analyzed using the R programming language. SNV association tests were performed with the SNVStats R package . Associa61 subjects with HTN were included in the analysis. 34 subjects were male (55.7%). The most common races and ethnicities included Caucasian , African descent , and Hispanic or Latino . The mean age of patients enrolled in this study was 48.9 years (SD 9.2). 9 subjects (14.8%) reported a diagnosis of diabetes mellitus, and 11 (18.0%) reported current smoking. 33 subjects (n = 54.1%) responded to lisinopril therapy. Mean starting SBP was similar between responders and non-responders (SBP 169 mmHg (SD 19.8) vs. 163 mmHg (SD 21.5), t = 0.87) although, as expected, the responders had significantly lower SBP at 1 week (SBP 139 mmHg (SD 20.7) vs. 160 mmHg (SD 23.7)), t = 0.0003*). Diastolic BPs (DBP) followed the same pattern (baseline DBP 95.4 mmHg (SD 9.7) vs. 94 mmHg (SD 19.9)). Genomic analyses revealed numerous SNVs associated with effectiveness of ACEI therapy in the targeted analysis  and GWASACE2) were found in intronic regions of genes directly involved in the renin-angiotensin-aldosterone pathway. Intronic regions affect the rate of transcription, nuclear export, and transcript stability [ACE2 encodes angiotensin converting enzyme (ACE), which catalyzes the cleavage of angiotensin I into angiotensin II leading to vasoconstriction and increase in blood pressure  K23 GM110516, NIH R35GM124939-01 and NIH CTSI UL1 TR001082. This project received seed grant funding from the American Medical Association Foundation. There is no conflict of interest for any author. Supplemental material


Treatise on Febrile Diseases, was widely used for CHF. In this study, we try to conduct a prospective, double-blinded, randomized, controlled study to evaluate the efficacy and safety of ZWD in the treatment of CHF patients in China.Chronic heart failure (CHF) is the end stage of several cardiac diseases. 50% of patients with severe CHF would survive less than 1 year, which has seriously affected patients’ survival and quality of life. The current modern therapy could improve survival and quality of life. However, a larger number of patients still suffer from repeated hospitalization, unsatisfactory efficacy, and many side effects. In China, Zhen Wu Decoction (ZWD), a classic prescription recorded in Patients will be randomly divided into treatment group and control group in 1:1 ratio. Guideline directed medical therapies and ZWD will be provided for patients in treatment group, while guideline directed medical therapies and ZWD-granules simulations for control group. Left ventricular ejection fraction, left ventricular end diastolic diameter, left ventricular end systolic diameter, b-type natriuretic peptide, NT-proBNP, peak VO2, VO2 maximum, exercise time, and walking distance will be recorded. The data will be analyzed by SPSS 22.0.The results will evaluate the efficacy and safety of ZWD in the treatment of CHF patients.OSF registration number: DOI 10.17605/OSF.IO/G3QNU. The prevalence of CHF is increasing and it is predicted that there will be 8 million patients by the year 2030 in the USA. CHF patients commonly suffer from fatigue, shortness of breath, excessive tiredness, and leg swelling that limit activities in daily life. It is a potentially fatal condition, and about 35% might die in the first year after diagnosis. 50% of patients with severe CHF would survive less than 1 year, which has seriously affected patients’ survival and quality of life.Chronic heart failure (CHF) is a group of manifestations caused by either cardiac structure change or heart dysfunction resulting in impaired ventricular filling and/or ejection ability. At present, treatment against CHF still focuses on the improvement of the symptoms and prevention of the progression. Common standard therapy includes angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB), β-receptor blockers, aldosterone receptor antagonists, inotropic drugs, and diuretics. The current therapy could improve survival and quality of life. However, a larger number of patients still suffer from repeated hospitalization, unsatisfactory efficacy, and many side effects. Though cardiac resynchronization therapy has been rapidly developed, it is expensive and difficult for most patients to accept, particularly in low- and middle-income countries.CHF is the leading reason of older adults for hospital admission.–9 In China, Zhen Wu Decoction (ZWD), a classic prescription recorded in Treatise on Febrile Diseases, was widely used for CHF. However, it is still lack of high-quality and well-designed randomized, controlled trial to evaluate its efficacy and safety against CHF. Therefore, in this study, we try to conduct a prospective, double-blinded, randomized, controlled study to evaluate the efficacy and safety of ZWD in the treatment of CHF patients in China.Traditional Chinese medicine could significantly improve the clinical symptoms, delay the development of the disease, and improve the long-term prognosis of CHF patients based on the common modern therapy.22.1 and the results will be reported according to the CONSORT Statement extension for trials. The study was registered in open science framework (registration number: DOI 10.17605/OSF.IO/G3QNU). All patients will provide a signed written informed consent at enrollment.The double-blinded, randomized, controlled trial will be carried out in The People's Hospital of Dazu, and it has been approved by the Health Research Ethics Board of The People's Hospital of Dazu. The protocol conforms to SPIRIT 2013 Statement,Patients aged over 18 years with CHF in stable condition, New York Heart Association functional class II or III, left ventricular ejection fraction of <40% will be recruited. Patients will be excluded with the following criteria:(1)new onset atrial fibrillation or atrial flutter;(2)complex ventricular arrhythmia at rest or presenting with exertion;(3)serious liver and kidney function damage or malignant tumor;(4)cognitive or neurological problems;(5)respiratory infection in the previous 30 days.2.2Patients will be randomly divided into treatment group and control group with a 1:1 ratio  10 g, Radix Paeoniae Alba (Baishao) 10 g, Rhizoma Atractylodis Macrocephalae (Baizhu) 10 g, Poria cocos (Fuling) 10 g, Rhizoma Zingiberis Recens (Shengjiang) 10 g. The herbs will be provided as concentrate-granules and quality controlled by Beijing Tcmages Pharmaceutical CO., Ltd. The patients will be taught to dissolve the granules in 50 mL and orally take it, twice a day, for 14 days.In the treatment group, patients will take Chinese herbal formula ZWD, composed of While in the control group, ZWD-granules simulations will be taken twice a day, for 14 days. The simulations, composed of amylum, share the same appearance, taste, dosage, and administration methods with the formula in the treatment group.2.4The primary outcome is the change of left ventricular ejection fraction during the treatment. The secondary outcomes are left ventricular end diastolic diameter, left ventricular end systolic diameter, b-type natriuretic peptide, NT-proBNP, peak VO2, VO2 maximum, exercise time, and walking distance. All adverse events will be also recorded.2.5In our preliminary trial, the change of left ventricular ejection fraction in the treatment group is 19%, and 10% in the control group. Taking α = 0.05, β = 0.2, 27 patients will be needed in each group. Considering a loss to follow-up of 10%, the estimated total sample size will be 60.2.6The supervisor will decide for discontinuing. Case report forms (CRFs) will be used in data collection to record demographics, assessment, reasons of patient drop out. All case report forms will be preserved for at least 5 years, and the access to the original data are available from the corresponding author on reasonable requests.2.7T test, Mann–Whitney U test, χ2 test, or Fisher's exact test will be applied accordingly. P values less than .05 will be considered statistically significant.The data will be analyzed by SPSS 22.0 , with presented as mean ± standard deviation for measurement data, and percentages for count data respectively. Independent-samples 3,15 The standard therapy of beta blockers, ACEI, or ARB could improve the survival rate of patients. However, long-term western medicine treatments may have many adverse reactions. With the advantages of multi-target, multi-component, multi-pathway, traditional Chinese medicine has been widely applied in the treatment of CHF. It could not only improve the clinical symptoms, but also has fewer side effects. In China, ZWD is a commonly used herbal formula for heart failure caused by various heart diseases such as coronary heart disease, rheumatic heart disease, and dilated cardiomyopathy. However, it is still lack of high-quality and well-designed randomized controlled trials to evaluate the efficacy and safety of ZWD against CHF. In this study, we try to conduct a prospective, double-blinded, randomized, controlled study to evaluate the efficacy and safety of ZWD in the treatment of CHF patients in China.CHF is the final stage in the development of various heart diseases. Its morbidity and rehospitalization rate are high, which seriously affects patients’ health and quality of life.Data collection: Jian Liang, Xianming Tao.Funding support: Yi Cao.Investigation: Xianming Tao.Literature retrieval: Jian Liang, Dabi Hu.Software operating: Yi Cao, Dabi Hu.Supervision: Dabi Hu.Writing – original draft: Jian Liang, Xianming Tao.Writing – review & editing: Jian Liang, Yi Cao.


Unlike other non-steroidal anti-inflammatory drugs, indomethacin has been shown to be highly effective in two forms of trigeminal autonomic cephalalgias, hemicrania continua and paroxysmal hemicrania and in some forms of idiopathic stabbing headaches. This specificity is unique in the headache field. Previous findings suggest the involvement of the trigeminal autonomic reflex to play an important role in the pathophysiology of these diseases.22 healthy participants were enrolled in a double-blind, three-day within-subject design. The participants received indomethacin, ibuprofen or placebo in a randomized order. After an incubation period of 65 min the baseline lacrimation and the lacrimation during intranasal stimulation evoked by kinetic oscillation stimulation were assessed using Schirmer II lacrimation tests. The lacrimation difference in mm was calculated and compared in a repeated measures ANOVA.No significant differences were found between the three conditions.In our study, neither indomethacin nor ibuprofen had an inhibitory effect on the trigeminal autonomic reflex. We suggest that blocking this reflex may not be the treatment mechanism of indomethacin. The indole acetic acid derivative indomethacin as well as ibuprofen and naproxen belong to the group of the non-steroidal anti-inflammatory drugs (NSAIDs). They act as “pain killers” by non-selectively inhibiting the activity of cyclooxygenase enzymes and thereby inhibiting the synthesis of prostaglandins . Althoug59Indomethacin inhibits cyclooxygenase activity and therefore reduces the production of prostaglandins . Prostag1419The aim of the present study was therefore, to investigate the modulatory effect of indomethacin and ibuprofen on the trigeminal autonomic reflex in humans focusing on the possible inhibitory effect of the two medications on the parasympathetic arc of the trigeminal autonomic reflex using the method of nasal kinetic oscillation stimulation (KOS) –7.We recruited 25 healthy participants via local internet platforms for the measurement of lacrimation, elicited by kinetic oscillation stimulation (KOS). Exclusion criteria comprised primary headache or any other chronic pain condition, smoking, psychiatric or neurological diseases, contraindications against NSAID or nasal kinetic oscillation, and analgesics intake 24 h before the study. Occasional and rare unspecific headaches following a trauma or an infection were allowed see .The study included a double-blind, randomized, three-day within-subject design. Participants were instructed not to eat within 2 h before the respective study appointment and were asked to fill in a headache questionnaire, the general health questionnaire German version (PHQ-D) and gave written and informed consent, according to the ethics committee (Ärztekammer Hamburg PV5873) and the Declaration of Helsinki. The participants were asked to lie down in supine position for blood pressure assessment. Subsequently the participants received oral medication, blinded as two identically looking red capsules, containing either ibuprofen (800 mg) indomethacin (150 mg) or placebo. For the incubation period of 65 min, the participants were carefully observed and blood pressure was assessed every 25 min (blood pressure cuff and stethoscope), for a detailed overview see Trigeminal autonomic stimulation using KOS procedure. Kinetic oscillation stimulation (KOS)  is used to treat chronic rhinitis  incubated for 5 min. Sterile Schirmer II tear strips  were placed into the lower eye lid for the measurement of lacrimation at rest over 5 minutes. After the measurement at rest, a balloon catheter was moistened with paraffin and placed into the participants’ left nostril. The catheter was attached to a fixation frame placed on the head of the participants, in order to prevent the catheter from moving during the procedure. After an initial tearing reaction, the KOS device was switched on and reached 50 mbar and 40 Hz after an initial ramp up phase. The Schirmer ll strips were placed into the lower eye lid 1 min after start of the KOS and the lacrimation was measured again for 5 minutes. For every minute the lacrimation in mm was filled into a standardized documentation form during measuring at rest and during the KOS procedure.An aliquot of a human serum sample (250 µL) was mixed with 50 µL of the internal standard mefenamic acid (0.2 mg/mL). 500 µL acetonitrile was added to precipitate serum proteins. After centrifugation at 14500 rpm for 5 min at 20°C, 100 µL of the supernatant was diluted to a total of 1000 µL with water in a glass microvial. The injection volume was 50 µL.A high-performance liquid chromatography with diode array detection (HPLC–DAD) method was used for the analysis of ibuprofen and indomethacin serum samples. Chromatography was performed on a Thermo Scientific Accela Liquid chromatography system consisting of an autosampler, quaternary pump and a photo diode array detector with a thermostated column compartment . The chromatographic separation of ibuprofen, indomethacin and internal standard was carried out on a reversed phase Varian Polaris C18-A (250 × 4.0 mm) with particle size of 5 µm and a Varian Polaris® C18-A (250 × 4.0 mm) with particle size of 5 µm and a C18-pre-column  using a flow rate of 1.0 mL/min at 25°C. The mobile phase consisted of 37.5% buffer pH 2.3  and 62.5% acetonitrile. The wavelength detection was set at 276 nm (indomethacin), 219 nm (ibuprofen), and 351 nm (mefenamic acid). Chromeleon™ 7 Chromatography Data Systems Software  was used for the control of the instruments and data acquisition. The assay was calibrated using six standards of spiked blank human serum  and  there were also two independently prepared quality control samples included in each analytical series. Validation parameters including accuracy, interferences, linearity of calibration and in-process stability complied with international standards. The limit of quantification was 2.5 mg/L for ibuprofen and 0.3 mg/L for indomethacin.During the measurement of lacrimation, elicited by KOS, the perception inside the nostril was assessed on a visual analogue scale (VAS) for pain between 0 (no pain) and 10 (worst imaginable pain) two minutes after start of the KOS Schirmer II test for each of the three conditions.For the statistical analysis, three subjects had to be excluded due to more than five unspecific headache days within three months before the study, leaving a sample of 22 participants . The Schirmer ll tear strips have a maximum capacity of 35 mm. If the maximum was reached, the subsequent time points within the 5 minutes of the Schirmer ll test were labelled as missing values ,31. NormNo significant difference was observed between indomethacin, ibuprofen and placebo in the calculated repeated measures ANOVA see  for the No significant difference in blood pressure in the repeated measures ANOVA was found between indomethacin, placebo and ibuprofen after intake of medication. Indeed blood pressure declined over time in all three conditions, probably due to the long resting time.For the assessment of pain on the visual analogue scale (VAS) no significant difference was found between the three conditions indomethacin, placebo and ibuprofen .Before taking the blood sample the participants were asked to report any adverse events during the study. Adverse events were mild to moderate and short-lasting.In this study we were not able to show an inhibitory effect of indomethacin or ibuprofen on the parasympathetic output of the trigeminal autonomic reflex. This is contrary to previous studies in rodents which suggested that indomethacin may have an effect on the parasympathetic reflex arc. This animal study has shown that neuronal firing on the trigeminal nociceptive brainstem neurons is reduced under indomethacin if the superior salivatory nucleus was also stimulated, and thus the trigeminal autonomic reflex arc was simultaneously activated. In this rodent model indomethacin inhibited evoked firing in the trigeminocervical complex by 30% whereas evoked firing was only inhibited by 15% when nociceptive input came from the dura alone. Naproxen also inhibited neuronal responses but to a lesser extent than indomethacin. In this study indomethacin also reduced lacrimal duct flow in rats, which is correlated to cranial autonomic discharge ,26. The One could argue that KOS directly provoked parasympathetic stimulation and that the autonomic response (lacrimation) is not mediated versus the trigemino-autonomic reflex arch. However, since the postganglionic parasympathetic neurons have no specific receptors that could be evoked with the aim to send signals to the effector organ, it needs a central signal to evoke a transmitting signal to the target, i.e. the lacrimal gland here. Stimulating the trigeminal nerve would elicit parasympathetic discharge using the VIIth cranial nerve via the sphenopalatine ganglion . In huma2+ inducing smooth muscle relaxation in the blood vessels (If indomethacin does not affect cranial parasympathetic discharge, how does it elicit its unique therapeutic effect on PH and HC compared with other NSAIDs? A study by Summ and colleagues  showed a vessels . The eff vessels  that pla vessels . Goadsby vessels . It needThe findings of the present study contribute to the understanding of the effect mechanisms of indomethacin in TACs, especially in HC and PH suggesting that indomethacin is not simply effective by specifically modulating the parasympathetic reflex arc. Since we investigated healthy volunteers we cannot make inferences regarding the pathophysiological activation of the trigeminal autonomic reflex, i.e. in patients. Our data suggests however, that indomethacin may be effective through other, for example direct neuronal or NO-dependent inhibitory pathway activity .Unlike other non-steroidal anti-inflammatory drugs, indomethacin has been shown to be highly effective in two forms of trigeminal autonomic cephalalgias. This specificity is unique in the headache fieldPrevious findings suggest the involvement of the trigeminal autonomic reflex to play an important role in the pathophysiology of these diseases.In our study, neither indomethacin nor ibuprofen had an inhibitory effect on the trigeminal autonomic reflex and blocking this reflex may not be the treatment mechanism of indomethacinIndomethacin may be effective through other mechanisms, for example direct neuronal or NO-dependent inhibitory pathway activity


High blood pressure is a major risk factor for cardiovascular disease. Visit-to-visit blood pressure variability (BPV) has recently been shown to predict cardiovascular outcomes. We investigated the predictive value of BPV for major adverse cardiovascular events (MACE) among patients with coronary artery disease (CAD), with and without type 2 diabetes mellitus (T2DM).Patients with stable CAD were enrolled and monitored for new MACE. Visit-to-visit BPV was defined as the coefficient of variation (CV) of systolic and diastolic BP across clinic visits. Multivariable logistic regression analysis was performed to evaluate the association of BPV with MACE. Area under the receiver operating characteristic curve (AUC) was used to assess its predictive ability.P = 0.002/0.007). In subgroup analyses, higher CV of systolic BP remained significantly associated with an increased risk for MACE in patients with and without T2DM, whereas the association of CV of diastolic BP with MACE was observed only in those without T2DM.Among 1140 Chinese patients with stable CAD, 192 (17%) experienced a new MACE. In multivariable analyses, the risk of MACE was significantly associated with CV of systolic BP , and diastolic BP , after adjustment for variables of the risk factor model  and mean BP. The risk factor model had an AUC of 0.70 for prediction of MACE. Adding systolic/diastolic CV into the risk factor model with mean BP significantly increased the AUC to 0.73/0.72 (Visit-to-visit variability of systolic BP and of diastolic BP was an independent predictor of new MACE and provided incremental prognostic value beyond mean BP and conventional risk factors in patients with stable CAD. The association of BPV in CAD patients without T2DM with subsequent risk for MACE was stronger than in those with T2DM.The online version contains supplementary material available at 10.1186/s12933-021-01280-z. Individuals with coronary artery disease (CAD) are at increased risk of recurrent cardiovascular events and death. Intensive risk factor management and lifestyle modification are essential for secondary prevention of cardiovascular disease (CVD) , 2. HighMany of the CVD risk estimation scores include BP as one of the core variables. Nonetheless BP is prone to variation so a risk score that relies on a single measurement may underestimate the true effect of the association . Recent In this study, we investigated the association of visit-to-visit BPV with risk for major adverse cardiovascular events (MACE) in CAD patients with and without T2DM. We also evaluated the contribution of BPV to cardiovascular risk prediction beyond mean BP and conventional risk factors.Consecutive patients with stable CAD who attended follow-up at the Cardiac Clinic, Queen Mary Hospital, Hong Kong between December 2003 and December 2014 were recruited. CAD was defined according to the American College of Cardiology guidelines . All patThe procedure for measuring BP followed standard guidelines. At each clinic visit, two brachial BPs were measured in the right arm by a nurse using an automated oscillometric device (Dinamap PRO 100) with the patient seated and having rested for 10 min and the mean value recorded. BP measurements taken after the baseline clinic visit and before the occurrence of event of interest or censoring were retrospectively retrieved from patient’s electronic medical record to calculate the mean BP and visit-to-visit BPV. For each patients, mean BP was calculated as the average of the BP readings taken during the follow-up period. Visit-to-visit BPV was defined using coefficient of variation (CV), standard deviation (SD) and average real variability (ARV). All parameters were evaluated for both systolic BP and diastolic BP. Formulas used to calculate the metrics of BPV are presented in Additional file P < 0.10 in the univariable analyses were included in the multivariable linear regression model. Pearson correlation coefficient used to measure the relationship between number of BP measurements and risk factors.Continuous data are expressed as mean ± SD and categorical data as number and percentage. The Kolmogorov–Smirnov test was used to evaluate the normality assumption for continuous variables. Any variable with skewed distribution was transformed using natural logarithms prior to analysis. Each BPV measure was categorized by quartile, with the lowest quartile used as the reference. Comparisons between groups were evaluated using Analysis of Variance for continuous variables and Chi-square test for categorical variables. Multivariable linear regression analysis was performed to determine which factors were independently associated with CV of BP. Variables with Logistic regression models were used to assess the association of CV of BP with MACE, adjusting for age, gender, clinical risk factors , history of myocardial infarction, use of antihypertensive medication , number of BP measurements, and mean BP level during the same period of BPV measurement. Multivariable models were applied separately for systolic BP and diastolic BP. Details of variable selection for the logistic regression models are described in Additional file To account for the number of BP measurements varied between patients, we performed a sensitivity analysis based on BP measurements from the first 6 visits and tested whether the CV calculated from these measurements was associated with MACE. Intraclass correlation coefficient was used to assess the agreement between CV calculated from different number of measurements.P value < 0.05 was considered statistically significant.Statistical analyses were performed using STATA statistical software (version 14.0) and R-programming language (version 3.5.3). A two-sided After excluding 73 patients who attended fewer than four clinic visits during the follow-up period, 1140 patients were included in the final analysis and the missing anthropometric data (n = 57) were imputed . In addition, patients with a MACE were less likely to be prescribed beta-blockers. Nevertheless there were no significant differences in body mass index or lipid levels between those with and without MACE. Compared with non-T2DM patients, patients with T2DM were older, more likely to be female and had a slightly higher body mass index  and were entered into the multivariable model . Likewise, the CV of diastolic BP was significantly associated with a higher risk for MACE; the adjusted odds ratio for the highest versus lowest quartile of CV of diastolic BP was 2.39 . The results were consistent when modeling the variability of systolic and diastolic BP using SD and ARV  for systolic BP and 0.72  for diastolic BP. There was no significant increase in AUC when only mean systolic or diastolic BP was added to the risk factor model (Table The risk factor model (composed by covariates in Model 2) yielded an AUC of 0.70 (95% CI 0.65–0.74) for prediction of MACE Table . The addPinteraction, 0.027 for systolic CV; 0.035 for diastolic CV). No significant interaction of age or gender with CV of systolic and diastolic BP  was observed in the multivariable models.Interaction analyses showed that the association of CV of systolic and diastolic BP with occurrence of MACE differed between patients with and without T2DM (P < 0.001). After full multivariable adjustment (Model 3), higher CV of systolic BP remained significantly associated with MACE in both patients with and without T2DM, whereas a significant association of CV of diastolic BP with risk of MACE was observed only in patients without T2DM  with the BPV calculated from 12 measurements. The CV of systolic and diastolic BP increased when more BP measurements were added into the calculation . In addition, we found high concordance between BPV calculated from 12 measurements and BPV calculated from 6 or 8 measurements, suggesting that a shorter duration of measurements could potentially be used for monitoring BPV. A recent study has also shown similar levels of concordance when compare the BPV derived from 20 measurements with the BPV from 6 or more measurements, and proposed to use a minimum of 6 measurements for a reliable estimation of visit-to-visit BPV .Our study has several limitations. First, we did not obtain information on the dosage of antihypertensive drug or patient compliance with treatment, both of which have been shown to contribute to BPV . Second,Visit-to-visit variabilities of systolic BP and diastolic BP are independent predictors of new MACE in patients with stable CAD. Moreover, systolic and diastolic BPV provide additional predictive information beyond mean BP and conventional risk factors for future cardiovascular events. The association of BPV in CAD patients without T2DM with subsequent risk of MACE is stronger than in those with T2DM. Our findings support the potential utility of visit-to-visit BPV in risk stratification and management of high-risk patients.Additional file 1. Supplemental MethodsAdditional file 2: Figure S1. Flow chart of study recruitment. BP, blood pressure; BPV, blood pressure variability; CAD, coronary artery disease.Additional file 3: Table S1. Comparison of baseline characteristics in patients with and without T2DM. Table S2. Baseline characteristics according to quartiles of coefficient of variation of SBP. Table S3. Baseline characteristics according to quartiles of coefficient of variation of DBP. Table S4. Multivariable linear regression models for coefficient of variation of SBP/DBP. Table S5. Pearson correlation coefficient analysis based on number of BP measurements. Table S6. Logistic regression analysis for predicting MACE in stable CAD patients. Table S7. Odds ratios for MACE associated with quartiles of SD and ARV of SBP/DBP. Table S8. Odds ratios for MACE associated with CV of SBP/DBP, based on six BP measurements. Table S9. Intraclass correlation coefficient for CV of SBP/DBP.


Acute, severe traumatic spinal cord injury often causes fecal incontinence. Currently, there are no treatments to improve anal function after traumatic spinal cord injury. Our study aims to determine whether, after traumatic spinal cord injury, anal function can be improved by interventions in the neuro-intensive care unit to alter the spinal cord perfusion pressure at the injury site.We recruited a cohort of patients with acute, severe traumatic spinal cord injuries . They underwent surgical fixation within 72 h of the injury and insertion of an intrathecal pressure probe at the injury site to monitor intraspinal pressure and compute spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure. Injury-site monitoring was performed at the neuro-intensive care unit for up to a week after injury. During monitoring, anorectal manometry was also conducted over a range of spinal cord perfusion pressures.2O, which is considerably lower than the average for healthy patients, previously reported at 99 cmH2O. Mean resting anal pressure versus spinal cord perfusion pressure had an inverted U-shaped relation (Ȓ2 = 0.82), with the highest resting anal pressures being at a spinal cord perfusion pressure of approximately 100 mmHg. The recto-anal inhibitory reflex , which is important for maintaining fecal continence, was present in 90% of attempts at high (90 mmHg) spinal cord perfusion pressure versus 70% of attempts at low (60 mmHg) spinal cord perfusion pressure (P < 0.05). During cough, the rise in anal pressure from baseline was 51 cmH2O at high (86 mmHg) spinal cord perfusion pressure versus 37 cmH2O at low (62 mmHg) spinal cord perfusion pressure (P < 0.0001). During anal squeeze, higher spinal cord perfusion pressure was associated with longer endurance time and spinal cord perfusion pressure of 70–90 mmHg was associated with stronger squeeze. There were no complications associated with anorectal manometry.Data were collected from 14 patients with consecutive traumatic spinal cord injury aged 22–67 years. The mean resting anal pressure was 44 cmHOur data indicate that spinal cord injury causes severe disruption of anal sphincter function. Several key components of anal continence  markedly improve at higher spinal cord perfusion pressure. Maintaining too high of spinal cord perfusion pressure may worsen anal continence.The online version contains supplementary material available at 10.1007/s12028-021-01232-1. Traumatic spinal cord injury (TSCI) is a devastating event resulting in life-long disability, including limb weakness, bladder and bowel incontinence, sexual dysfunction, autonomic dysfunction, and, in cervical trauma, impaired breathing. TSCI affects approximately 180,000 people globally each year . Bowel dAnal function may be assessed with anorectal manometry (ARM), which measures anal pressure (AP), rectal sensation, and the neural reflexes needed for normal defecation . ARM allTo improve the management of patients with TSCI in the neuro-intensive care unit (neuro-ICU), our group has developed monitoring from the injury site –9. We moOur objective was to test the effect of TSCI on anal function in the acute care setting. We performed ARM while also monitoring ISP and SCPP in the first 10 days after TSCI. We hypothesized that AP, change in AP (ΔAP) during squeeze or cough, recto-anal inhibitory reflex (RAIR), and rectal sensation are all influenced by ISP and SCPP. We also hypothesized that interventions to normalize these parameters could improve anal sphincter function.www.ClinicalTrials.gov under identifier NCT02721615.Approvals for the Injured Spinal Cord Pressure Evaluation (ISCoPE) study, including the consent form and patient information sheet, were obtained by the St. George’s Joint Research Office and the National Research Ethics Service–Camberwell St. Giles Ethics Committee (No. 10/H0807/23). ISCoPE is registered at We recruited patients with consecutive TSCI who were enrolled in the ISCoPE trial in the period of June 2018–August 2019. Inclusion criteria for ISCoPE were severe TSCI , age 18–70 years, and surgery performed within 72 h of TSCI. Exclusion criteria were major comorbidities, the inability to obtain consent, and penetrating TSCI.All patients were admitted to the neurosurgical unit at St. George’s Hospital and underwent an International Standards for Neurological Classification of Spinal Cord Injury AIS assessment by a neurosurgical resident trained in AIS, which was repeated at discharge and at the follow-up outpatient clinic. All patients had computed tomography and magnetic resonance imaging of the spine before surgery and within 4 weeks of surgery.In clinic, functional and quality of life measures were completed using two standard scales, the Spinal Cord Independence Measure III (SCIM III) bowel score  and the Surgical decompression, including laminectomies and spinal instrumentation, was performed based on patient requirements and surgeon preference. Lateral mass screws  or pedicle screws (thoracolumbar spine) were inserted above and below the fracture and were linked to rods secured with blockers using Oasys or Xia 3 . Postoperatively, all patients were managed in the neuro-ICU.During posterior surgery, a pressure probe  was inserted through the skin into the wound cavity. Using a microscope, the dura and arachnoid were opened one level below the injury. The pressure probe was inserted intradurally, with the tip placed at the site of maximal cord swelling. The dural opening was sutured. This technique is described in detail elsewhere , 18, 19.www.neurosurg.cam.ac.uk/icmplus). ISP and ABP were used to compute SCPP = MAP − ISP.The ISP probe was connected to a Codman intracranial pressure box linked via an ML221 amplifier connected to a PowerLab running LabChart 8 . Blood pressure was recorded from a radial artery catheter connected to the Philips IntelliVue MX800 bedside monitoring system  and, in turn, connected to the PowerLab system. ISP and arterial blood pressure (ABP) signals were sampled at 1 kHz, and patients were monitored for up to 7 days. Figure Patients were transferred to the neuro-ICU following surgery and remained there for the duration of spinal cord monitoring and clinical need. Patients were nursed on pressure-relieving mattresses on their side, when possible, to take pressure off the laminectomy site. Antibiotic prophylaxis was given for 48 h after surgery with vancomycin and gentamicin, which is the standard regimen in our hospital for instrumented spinal fusion. Subcutaneous prophylactic low-molecular-weight heparin was started at 24 h post surgery . Mechanical  thromboprophylaxis was used throughout. Ventilatory support was managed by the neuro-ICU team. MAP targets were at the discretion of the neuro-ICU (unrelated to ISP or SCPP), except for when the SCPP was altered to produce low and high SCPP for ARM measurements. Ionotropic support was provided with intravenous noradrenaline through a central venous line or, while central access was being established, with intravenous metaraminol via a peripheral venous line. All patients were reviewed and examined daily by the research team, and any complications or concerns were recorded and actioned immediately. Per neuro-ICU protocols, daily blood tests were performed, including full blood cell count, renal and liver profile, cardiac enzymes, C-reactive protein, and clotting function.All patients underwent ARM in the neuro-ICU over a wide range of SCPPs in the week following surgery. The duration of ARM was determined by how long the patient was able to tolerate the intervention and whether the clinical condition of the patient was appropriate for this testing. AP was sampled at 1 kHz with a 4-channel water perfused manometer  leveled at the anal verge . To assess RAIR, cough, and rectal sensation , SCPP was manipulated using noradrenaline. Each patient had a period when the dose of noradrenaline was reduced and a period when the noradrenaline was increased. Each figure highlights the average SCPP for each patient at their low and high SCPP periods of monitoring. We also asked the patients to strain at different SCPPs. To minimize bias, the ARM data were obtained without knowledge of the SCPP.Ȓ2) were computed using MyCurveFit (https://mycurvefit.com), with Ȓ2 values greater than 0.5 being considered a strong correlation. The relation between mean values of components of RAIR  and cough  at high and low SCPP were compared using Student’s t test. The correlation between AIS grade or SCPP and anal sphincter outcome was assessed using Kendall’s tau-b correlation coefficient. Analysis was done using XLSTAT Biomed v2018.1 for Mac . Statistical significance was taken as P values of less than 0.05.Plots of ARM parameters  were fitted with the best-fit quadratic or linear regression curve, chosen to minimize the Akaike information criterion. Adjusted coefficients of determination (Data were obtained from 14 patients aged 22–67 years (mean 47.4): 13 men and 1 woman. Most (64.3%) patients had complete (AIS grade A) injuries, and most (64.3%) had cervical injuries. All patients had posterior surgical bony decompression, including laminectomy and fusion, with 21.4% also requiring anterior stabilization. The mean follow-up time was 8.1 months (range 2–19). At follow-up, most (71.4%) patients had improved by one of more AIS grades, 21.4% remained the same, and 7.2% deteriorated by one AIS grade. These demographics are summarized in Table We monitored resting AP for an average of 1.9 h per patient (range 0.4–12) over an average of 2.1 days per patient (range 1–4). Per patient, the average number of coughs was 11.8 (range 1–36), the average number of voluntary squeezes was 4.9 (range 0–13), and the average number of RAIRs was 10.9 (range 0–19). In some patients, the cough and squeeze tests could not be performed because of sedation used for respiratory support. At follow-up, the NBD score classified 21.4% of patients as having minor, 28.6% moderate, and 50.0% severe bowel problems. For the SCIM III bowel scores, 7.1% of patients scored 0, 50.0% scored 5, 28.6% scored 8, and 14.3% scored 10. Details are in Table There were no complications associated with ARM. Seven patients had asymptomatic pseudo-meningoceles on the postoperative magnetic resonance imaging scan, five were treated for chest sepsis, one had a pulmonary embolism, and one developed a sacral pressure sore.2O, which is considerably lower than the average for healthy male patients, previously reported at 99 cmH2O [Ȓ2 = 0.82; Fig. Altogether, we collected 26.3 h of resting AP data, i.e., 1.9 ± 0.8 h per patient. Average resting AP was 44.3 cmH99 cmH2O . For mos2O, respectively), and the RAIR was more likely to be present at the higher SCPP (89.7 vs. 69.5% of attempts). When considering only the AP traces with the RAIR present, there was no difference in the RAIR characteristics  at low versus high SCPP. The RAIR is an essential reflex for the voluntary control of defecation because it enables the rectum to discriminate between gas, liquid, and solid contents [The RAIR was observed in all 13 patients in whom it was tested but not in all traces from each patient  on average. The increase in AP compared with resting pressure prior to the cough was also higher at high versus low SCPP by approximately 14.7 cmH2O (P < 0.0001) on average. Because episodes of incontinence are more likely during cough, our data indicate that anal sphincter continence is improved at higher SCPP.Cough tests were performed in all patients. In 11 patients, cough was assessed at high (81.6 mmHg) and low 61.4 mmHg) SCPP  [Ȓ2 = 0.87).Increase in AP during squeeze was significantly reduced in our patients compared with reported normal male controls  . Figure Threshold tests for rectal sensation were performed in 10 of 14 patients at high and low SCPP. The other four patients were sedated for ventilatory reasons. Six of ten patients reported rectal sensation during the tests . At follow-up, all six patients who had rectal sensation at presentation had the same or improved AIS grade. The four patients lacking rectal sensation at presentation all had AIS grade A and remained so. The probability of experiencing rectal sensation, first urge to defaecate, or maximum tolerance versus volume of the balloon was the same at high and low SCPP .Ȓ2 = 0.07) and only a weak correlation between ΔAP and MAP (Ȓ2 = 0.47). We conclude that MAP is not a good surrogate for SCPP.We tested whether MAP could be used as a surrogate for SCPP . In all patients, there was a strong positive correlation between MAP and SCPP but with wide interpatient variability. As MAP increases, mean AP increases and then plateaus, but as SCPP increases, mean AP rises and then falls Fig. . For proP < 0.05) but not with the SCIM III bowel score . There was a significant correlation between the average SCPP on admission and anal sphincter function at follow-up assessed with the NBD score  suggest that interventions to optimize injury-site physiology may improve anal function. This is further supported by the finding that the average SCPP on admission correlated with the NBD score at follow-up. Ultimately, a randomized controlled trial is required to definitively determine whether intervening to optimize the SCPP improves outcome. Intervention to increase SCPP (SCPP = MAP − ISP) may be achieved by increasing the MAP using inotropes  or by reARM offers mechanistic insight into the impact of TSCI on anal sphincter function. We found that in the acute phase, TSCI causes relaxation of the anal sphincter. The anal sphincter no longer contracts effectively in response to cough or voluntary squeeze, and the RAIR is not always present. As a result of these disruptions, fecal continence can no longer be maintained.We did not detect an effect of increasing SCPP on the rectal volumes required to elicit sensations . The data show a trend, i.e., increasing SCPP reduces the rectal volume required to first produce desire to defecate or to first produce maximum tolerance, although these findings did not reach significance. The small number of patients in our study may be the limiting factor here, and it is possible that increasing the number of patients may yield significance.Our study has limitations. First, some patients were sedated because they required ventilation, which prohibited them from participating in the squeeze and sensory threshold tests. Second, some patients received noradrenaline infusions, raising the possibility of a direct effect of noradrenaline on the anal sphincter. Our finding that the dose of noradrenaline does not correlate with resting AP suggests that a direct effect of noradrenaline on the anal sphincter is unlikely. Third, because of the acute intensive care unit setting, we were unable to perform additional studies, e.g., high resolution ARM or anal ultrasound. Fourth, the number of patients in our study is relatively small because of the difficulty in performing multiple ARM assessments in patients with acute injuries in the neuro-ICU. Importantly, no patient experienced complications directly related to ARM testing. The outcomes of patients with TSCI who undergo monitoring from the injury site are comparable with the outcomes of patients who were not monitored, as previously reported .The finding that optimizing SCPP is associated with improved anal sphincter function is in line with our earlier findings that optimizing SCPP is associated with improved limb motor score , 13, senOur ARM findings suggest that individualized therapy in acute TSCI, through monitoring and optimizing spinal cord physiology and metabolism, may improve not only limb motor function, sensation, and urinary function but also anal sphincter function.Supplementary file1 (PDF 1329 kb)Below is the link to the electronic supplementary material.