We aimed therefore at evaluating a possible association between PaO2, circulatory failure and death during ECPR.High levels of arterial oxygen pressures  patients treated with ECPR to determine the association between the mean PaO2 , lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO2 was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements.Eleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaOIn conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage.The online version contains supplementary material available at 10.1186/s12872-021-02361-3. Howeerfusion , 9. In c studies , 11.2, we averaged the values of several PaO2 measurements during the first 24 h of ECPR, in order to take into account the duration of exposure to elevated PaO2 levels during this period of time. We then evaluated a possible association between PaO2 levels, circulatory failure and death during ECPR.Patients undergoing ECPR may be exposed to significant hyperoxia, given the ease to oxygenate blood through the oxygenator , and recThis study was approved by our ethical committee , as a retrospective use of clinical data with waiver of consent , and conforms to the STROBE statement for the report of observational studies. All methods were performed in accordance with the relevant guidelines and regulations. The cohort included 44 consecutive patients hospitalized in our 35-bed multidisciplinary ICU for refractory, non-traumatic and non-hypothermic, OHCA and IHCA treated with ECPR from June 2017 to June 2019. During this period, our internal recommendations for starting ECPR were: refractory OHCA or IHCA; no flow < 5 min; low flow < 80 min; age < 75 years; absence of major co-morbidities; absence of Do Not Resuscitate order. A subset of patients of the current cohort were also included in an unrelated study evaluating automated pupillometry during Veno-Arterial ECMO (VA-ECMO) for various indications .SO2) of 100% and a pump setting for a target blood flow of 40–60 ml/kg, using the Maquet Cardiohelp ECLS system®. Sweep gas flow was adapted to maintain normal PaCO2. Systemic anticoagulation (intravenous heparin) initiated at the end of surgery was maintained to achieve an anti-Xa activity of 0.3–0.5. A coronary angiography was performed at the discretion of the in charge physicians, when an ischemic origin of cardiac arrest was strongly suspected, according to internal recommendations. Noradrenaline (NA) and Adrenaline (Adre) were given to maintain mean blood pressure (BP) ≥ 65 mmHg. Intravenous (IV) fluids were administered to maintain the target blood flow. Mechanical ventilation was performed with a tidal volume of 6 ml/kg, rate of 10–15/min and PEEP of 6–10 cm H2O. Both FiO2 and FsO2 were set by default at 100% on ECPR initiation. Following these initial settings, decisions to reduce FiO2 or/and FsO2 were entirely at the discretion of the treating physicians, without specific recommendation. Sedation was maintained with Propofol (2–4 mg/kg/h) or Midazolam (0.05–0.15 mg/h). Targeted temperature management at 35–36 °C for 24 h was implemented in all patients. Criteria for discontinuing VA-ECMO were the absence of cardiac function recovery, intractable circulatory shock, or evidence of severe neurological injury , as described in [The insertion of venous and arterial femoral cannulas was performed in the hospital by a cardiac surgeon. Initial VA-ECMO settings included a sweep fraction of oxygen (Fribed in ). CriterDemographic variables included age, sex, location of CA , initial rhythm, duration of no flow and low flow , SAPS 2 score, ICU and hospital length of stay, duration of ECMO treatment, proportion of patients undergoing coronary angiography and angioplasty (PTCA), as well as the causes of death.Hemodynamic variables included: (A) Mean arterial blood pressure , from which we computed the average from all measurements performed each 2 h during the first 24 h (or until death if it occurred before 24 h). (b) Pulse pressure (systolic minus diastolic blood pressure), determined during the first 24 h as an indirect indicator of native cardiac output recovery , which w2 measured at 5 different times of ECPR  were averaged as the mean 24 h PaO2 . Arterial blood lactate was determined in the first arterial blood sampling (first 15 min of ECPR).Blood gas data were obtained from an indwelling intra-arterial catheter, whose position was recorded . The values of PaO2). We next applied a model including co-variables commonly considered as important clinical predictors of poor outcome, including age, low flow and no flow duration, shockable rhythm, the duration of ECMO, as well as mean PaO2. In both models, hospital mortality was the response binomial variable. Odds ratios (ORs) with 95% CI were calculated , and Wald statistics was used to assess the significance of each variable. Furthermore, due to the relatively low number of events in our cohort and the inherent risk of overestimating regression coefficients [2 and a second co-variable at a time . To control for possible type I error, we introduced a Bonferroni adjustment for assessing significance in these 3 models . To determine a possible association between PaO2 and circulatory failure, we performed bivariate analyses and simple linear regressions between mean PaO2 and mean blood pressure and between mean PaO2 and the amount of vasopressive catecholamines administered, with calculation of the Pearson r coefficient. To determine the influence of the arterial catheter position on PaO2, PaO2 values obtained in the different catheter positions were compared using Wilcoxon rank test. The JMP software, version 15, was used for all the analyses, and a p value < 0.05 was considered statistically significant.Continuous variables are expressed as means ± SD, or medians and interquartile ranges (IQR), and categorical data as absolute numbers and percentages. All comparisons were done using the Wilcoxon’s rank sum test for continuous variables and the chi-square test for categorical variables. We determined which variables were associated with survival using univariate logistic regression analysis for continuous variables and contingency analysis with Pearson’s test for categorical variables. To evaluate the association of hyperoxia with mortality, multivariable logistic regression was applied. We first considered a model including only co-variables significantly associated with mortality in univariate analysis ; 2 h: 287 ± 175 vs 164 ± 108 mmHg (p = 0.07); 6 h: 253 ± 148 vs 125 ± 78 mmHg (p = 0.02); 12 h: 161 ± 111 vs 85 ± 22 mmHg (p = 0.004); 24 h: 121 ± 44 vs 94 ± 21 mmHg (p = 0.02). At the respective time-points, the number of measurements were 11 in survivors and 31, 27, 27, 22 and 18 in non-survivors. Non-survivors also displayed lower mean blood pressure during the first 24 h, and received significantly more vasopressive catecholamines , also show an association between mean PaO2 and mortality following Bonferroni correction.Variables associated with in-hospital mortality at the 5% level in univariate analysis Table  included2 during the first 24 h was not different , acute hypoxic CA , primary arrhythmia n = 3, 7%), acute pulmonary embolism , toxic/metabolic origin , heart transplant rejection , undetermined cause , and other causes . The two main causes of death under ECPR were profound circulatory shock  and neurological injury . Other causes of death included hemorrhagic shock (n = 3). Multiple organ failure (n = 4), septic shock (n = 2) and technical issue . Comparisons between patients dying from circulatory or neurological causes are shown in Fig. , 7%, acu2 measured via a right arterial catheter was not different from that measured from a left radial catheter, but was lower than that measured via a femoral catheter, and mean PaO2 measured from a left radial catheter was not different from that measured via a femoral catheter , which reacts rapidly with nitric oxide (NO.) to form peroxynitrite, that can trigger significant vascular contractile failure through a number of processes [2 during ECPR, should be evaluated in future investigations to explore these mechanisms.Hyperoxia results in an increased vascular generation of superoxide  might develop more severe reperfusion injury under hyperoxic conditions, leading to predominantly vascular failure and early deaths, whereas those with less severe anoxia would survive the early stage and develop delayed hyperoxic neurological damage. This hypothesis should require validation in larger cohorts of patients treated with ECPR for refractory cardiac arrest.The two main causes of death were early circulatory failure and delayed neurological damage. Patients dying from either cause had similar durations of low flow and mean PaO2  among the 14 PEA patient, which may suggest that the avoidance of hyperoxia during ECPR could be critical to determine outcome in PEA patients undergoing ECPR.We did not find significant association between the initial rhythm and survival, which differs from the notion that survival under ECPR is better in patients with an initial shockable rhythm . This di2, survival in our cohort was significantly associated with the duration of low flow in univariate analysis, in line with previous investigations [2. We also included the duration of ECMO as a co-variate, given that the initial sweep gas oxygen fraction was set at 100%, which could have favored persisting hyperoxia in these patients. With the exception of mean PaO2, none of these variables displayed a significant association with mortality. Although these findings may suggest a particularly negative prognostic implication of hyperoxia in ECPR, they warrant cautious interpretation. Owing to the relatively small sample size in our study, the results of multivariate analysis may be subject to some bias related to an overestimation of regression coefficients [2, including no flow, low flow and initial rhythm, which confirmed the association of mean PaO2 with mortality. In addition, due to the retrospective nature of our study, the association of PaO2 with mortality could represent a surrogate for the sickness of patients. Physicians would indeed be inclined to maintain high levels of administered O2 to the most severely affected patients, and hyperoxia would therefore be a side effect of such management.Besides PaOigations –39. Howeficients . For thiOur study has several limitations. First, we must acknowledge the usual limitations related to the retrospective design of our study  and to i2 during the first 24 h of support is associated with worse outcome, possibly by promoting severe vascular failure and refractory circulatory shock. PaO2 should therefore be strictly controlled during the first 24 h of ECPR, via blood sampling from the right radial artery. Future studies should evaluate the impact of different PaO2 levels during ECPR on biomarkers of oxidative stress and inflammation, to provide further insights into possible mechanisms of hemodynamic collapse in this setting.In conclusion, although we acknowledge several important limitations, our study shows that, in patients undergoing ECPR for refractory cardiac arrest, a high PaOAdditional file 1:Supplementary Table 1. Study data set.


Background: The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on hypertension recommend a threshold blood pressure (BP) of ≥130/80 mmHg for diagnosis of hypertension and treating hypertension to a goal BP of <130/80 mmHg. For this study, we assessed the rate of compliance to the 2017 ACC/AHA hypertension guidelines by internal medicine residents and cardiology fellows in clinics affiliated with a teaching hospital in New York, New York.Methods: We conducted a retrospective medical records review for patients who had a clinical encounter at the internal medicine resident and cardiology fellow clinics from January to February 2019. To distinguish from adherence with prior guidelines, patients with BP of 130-139/80-89 mmHg (unless age ≥60 years and systolic blood pressure [SBP] 140-149 mmHg without chronic kidney disease or diabetes) were included. The primary outcome was accurate assessment of uncontrolled BP in accordance with the 2017 ACC/AHA guidelines.Results: Included in the analysis were 435 patients from the internal medicine resident clinic and 127 patients from the cardiology fellow clinic. Accurate assessment of uncontrolled BP was higher in the cardiology fellow clinic compared to the internal medicine resident clinic , even after adjusting for baseline characteristics differences between the 2 clinics. Multivariate regression analysis revealed that the type of clinic , established diagnosis of hypertension , and SBP  were independently associated with the primary outcome.Conclusion: Cardiology fellows were better at identifying hypertension diagnosis thresholds and BP treatment goals in accordance with 2017 ACC/AHA guidelines compared to internal medicine residents. In summary, the ACC/AHA defined hypertension as SBP ≥130 mmHg or DBP ≥80 mmHg based on ≥2 readings obtained on ≥2 occasions. BP goal was <130/80 mmHg for all adults. Pharmacologic therapy was recommended for anyone with BP ≥140/90 mmHg and for patients with BP 130-139/80-89 mmHg and established atherosclerotic cardiovascular disease (ASCVD) or an ASCVD 10-year risk of ≥10%.The Seventh Joint National Commission Report (JNC 7) published in 2003 defined hypertension as systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg and recommended treating blood pressure (BP) to a goal BP of <140/90 mmHg in the general population and <130/80 mmHg in patients with diabetes or chronic kidney disease (CKD).5 that have reported variable rates of physician adherence to the JNC 7 and JNC 8 guidelines on hypertension.2 Between May 2012 and April 2013, a cross-sectional descriptive survey investigated 59 primary care physicians working in 33 primary health centers in the Aljouf region of the Kingdom of Saudi Arabia and found that 80% adhered to the JNC 7 guidelines on hypertension.6 From February 2004 to October 2004, a retrospective medical records review of 345 patients evaluated physician adherence to the JNC 7 guidelines on hypertension using 22 criteria in 6 community-based clinics in Iowa and concluded that general adherence was 53.5%.7 A 2007 retrospective review of 251 medical records at West Virginia University, Charleston, found an overall BP goal achievement of 45.6% by internal medicine residents.8A review of the literature revealed a few small studies9 Our review of the literature showed a lack of studies assessing the implementation of the new guidelines in clinical practice. Specifically, to the authors’ knowledge, the implementation of the 2017 ACC/AHA hypertension guidelines based on the physicians’ levels of training has not been explored.Studies focusing on the 2017 ACC/AHA hypertension guidelines have primarily evaluated the change in incidence and prevalence rates of newly diagnosed hypertension.For this study, we assessed the rate of implementation of the hypertension diagnosis thresholds and treatment goals defined by 2017 ACC/AHA hypertension guidelines at the internal medicine resident and cardiology fellow clinics affiliated with a teaching hospital in a major city. We also explored the hypertension management practices by internal medicine residents and cardiology fellows.We reviewed the medical records of patients who had a clinical encounter at the internal medicine resident clinic and cardiology fellow clinic associated with Mount Sinai Beth Israel, a teaching hospital in New York, New York. The study periods for the internal medicine resident and cardiology fellow clinics were January 1 to January 31, 2019, and January 1 to February 28, 2019, respectively. The additional month for the cardiology fellow clinic study period was included to help offset the greater volume of patients seen in the internal medicine resident clinic.2 guidelines were excluded from the study. Hence, the study included (1) all patients with DBP 80-89 mmHg, (2) all patients with SBP 130-139 mmHg, and (3) patients with SBP 140-149 mmHg if they were ≥60 years of age without a history of CKD or diabetes. To reduce observer bias, the patients who were seen in the clinic by the investigators of this study were also excluded.Patients with recorded SBP ≥130 mmHg or DBP ≥80 mmHg during the clinical encounter were included in the study regardless of established diagnosis of hypertension. To avoid conflict with adherence to prior guidelines, patients whose BP would be considered appropriate by JNC 810 were noted. SBP and DBP were assessed as normal, elevated in isolation, or elevated in combination. Definitions of isolated SBP elevation (SBP ≥130 mmHg and DBP <80 mmHg) and isolated DBP elevation (SBP <130 mmHg and DBP ≥80 mmHg) were used to identify and differentiate these phenotypes. Serum cholesterol levels were noted from laboratory results obtained within 6 months prior to the clinic encounter. ASCVD 10-year risk percentage was estimated for patients aged 40 to 79 years with adequate data in accordance with the calculator from the ACC website.11 Patients with established ASCVD—defined as coronary artery disease, prior myocardial infarction, peripheral artery disease, or cerebrovascular disease—were excluded from ASCVD 10-year risk calculation in accordance with recommendations.The clinical progress notes from the encounters were reviewed, and the patients’ demographic information , BP, relevant medical history, medication list, and the parameters to calculate ASCVD 10-year riskFor the purposes of this study, patients with uncontrolled BP included patients with known hypertension and BP not at goal  and patients who presented for their initial encounter with BP that would be considered in the hypertensive range  and who needed reassessment at future visits to confirm hypertension.The primary outcome of the study was defined as the correct assessment of uncontrolled BP by physicians in accordance with the 2017 ACC/AHA guidelines. Physicians were noted to have correctly assessed uncontrolled BP if they fulfilled the following criteria: (1) For patients with an established diagnosis of hypertension, they mentioned in their clinic note that SBP ≥130 mmHg or DBP ≥80 mmHg was above goal, regardless of the intervention done; and (2) for patients without an established diagnosis of hypertension, they mentioned in their clinic note that SBP ≥130 mmHg or DBP ≥80 mmHg was elevated and would need to be reassessed.12; prescribing new antihypertensives; increasing the dose of existing medication; reviewing and reconciling medications; placing a consult to a specialist/hypertension nurse; and reassessing BP during the next visit.The secondary outcome was defined as the type of intervention done once uncontrolled BP was correctly assessed. Interventions included prescribing a home BP monitor; providing advice on lifestyle changes, including the Dietary Approaches to Stop Hypertension (DASH) diett test or nonparametric equivalent, and chi-square test (Fisher exact test in the case of sparse data) was used to compare categorical and nominal variables. Outcomes were assessed with logistic regression adjusting for risk factors described later in the text. Statistical significance was defined as a P value of ≤0.05. Data were analyzed using Stata, release 13 (StataCorp).Baseline characteristics were analyzed and summarized using descriptive statistics: mean ± SD for continuous parametric variables, median and interquartile range for nonparametric data, and frequency (percentage) for categorical or nominal variables. Baseline continuous variables were compared between the 2 groups using Approval for the study was granted by the institutional review board of the Mount Sinai School of Medicine. The authorization for use and disclosure of personal health information was waived because of minimal harm.We reviewed 1,175 and 405 charts from the internal medicine resident and cardiology fellow clinics, respectively. After application of inclusion and exclusion criteria, 435 (37.0%) patients from the internal medicine resident clinic and 127 (31.4%) patients from the cardiology fellow clinic were included for analysis (n=562).P=0.19). The proportion of female patients was higher in the internal medicine resident clinic compared to the cardiology fellow clinic . History of hypertension  and established ASCVD  were higher among patients seen in the cardiology fellow clinic vs the internal medicine resident clinic. Congestive heart failure  and atrial fibrillation  were also more prevalent among patients seen in the cardiology fellow clinic vs the internal medicine resident clinic. Average SBP was higher among patients from the cardiology fellow clinic vs the internal medicine resident clinic , whereas average DBP was lower for patients from the cardiology fellow clinic vs the internal medicine resident clinic . The cardiology fellow clinic had a higher percentage of patients with isolated SBP elevation than the internal medicine resident clinic  and a lower percentage of patients with isolated DBP elevation than the internal medicine resident clinic . Use of any antihypertensives , beta blockers , angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor neprilysin inhibitors (ARNi) , aspirin , and statins  was also higher among patients seen in the cardiology fellow clinic compared to patients seen in the internal medicine resident clinic. Notably, body mass index, active tobacco abuse, history of diabetes, CKD stage ≥3, cholesterol levels, and 10-year ASCVD risk for patients without established ASCVD were not statistically different between the 2 patient groups.The baseline characteristics of the patients seen in the 2 clinics are displayed in P<0.001) (P=0.034). Compared to patients from the internal medicine resident clinic, patients from the cardiology fellow clinic had higher rates of prescriptions for new antihypertensives , uptitration of the dose of antihypertensives , reconciliation of antihypertensives , and planned reassessment at the next visit . Differences in rates of home BP monitor prescriptions  and referral to a specialist  between cardiology fellow clinic patients and internal medicine resident clinic patients did not reach statistical significance.Accurate assessment of uncontrolled BP in accordance with ACC/AHA 2017 guidelines—the primary outcome of the study—occurred more frequently in the cardiology fellow clinic than the internal medicine resident clinic  . The occLogistic regression was performed to identify factors associated with the primary outcome . SecondaStepwise regression was performed to identify variables for multivariate regression. In multivariate analysis, clinic type, established diagnosis of hypertension, and SBP remained independently associated with the primary outcome.This study demonstrated that cardiology fellows were better at accurately assessing BP threshold for diagnosis of hypertension and hypertension treatment goals as specified by 2017 ACC/AHA hypertension guidelines than internal medicine residents even after adjusting for baseline characteristics differences between the 2 clinics. Besides the type of clinic in which the patients were assessed, the 2 other factors that were independently associated with the primary outcome were SBP and history of hypertension.14 is an important modifiable risk factor.15 Several factors can lead to uncontrolled hypertension, including nonadherence to antihypertensives, unsupportive health care systems, socioeconomic barriers to accessing health care, and physician inertia.16 Physician, or therapeutic, inertia is defined as the failure of health care providers to initiate or advance therapy when therapeutic goals are not met and has been well described with hypertension.18 With respect to clinician-specific factors, the initial step in management of new-onset or existing hypertension is recognizing when the BP is above the recommended goal, which was the intent of this study.Hypertension, known to be associated with significant cardiovascular events and increased mortality,The cardiology fellow clinic had a higher percentage of patients with an established diagnosis of hypertension, known ASCVD, and other cardiovascular comorbidities , and perhaps as a result, patients had higher use of antihypertensives, aspirin, and statins. Interestingly, patients’ lipid profiles, ASCVD 10-year risk profile among patients without known ASCVD, and prevalence of diabetes and CKD were similar between the 2 clinics. Despite adjusting for the differences, clinic type was independently associated with the primary outcome. Cardiology fellows were 3.6 times more likely to accurately assess uncontrolled BP compared to internal medicine residents. We hypothesize that this difference may be attributable to increased years of specific graduate training and focused cardiovascular care in the cardiology clinic.Established diagnosis of hypertension was also independently associated with the primary outcome, suggesting that trainees were more likely to accurately assess elevated BP in a patient with diagnosed hypertension than in a patient with an initial encounter whose BP is in the hypertensive range. In such cases, hypertension may not be the primary reason for the encounter and tends to be overlooked. We believe such encounters are missed opportunities for diagnosing new hypertensive patients and initiating measures early to prevent negative cardiovascular outcomes.19 data are mixed on the association of diastolic hypertension with cardiovascular outcomes,21 and the DBP goal of <80 mmHg was based on expert opinion.3We found a strong association between SBP and the primary outcome in this study. For every 1 mmHg increase in SBP, the odds of accurate assessment of uncontrolled BP increased by 17%. In univariate analysis, isolated elevated DBP was associated with significantly lower odds of achieving the primary outcome, but this correlation was no longer significant after adjusting for SBP in the multivariate analysis. Overall, the study suggests that physicians in this study placed a greater importance on SBP than DBP when addressing hypertension, which could be explained in part by the fact that while the recommendation for an SBP goal of <130 mmHg was based on a meta-analysis by the Evidence Review Committee,In this study, internal medicine residents focused on lifestyle changes, whereas cardiology fellows tended to make pharmacologic interventions. This difference is not unexpected, as cardiology clinic is often a referral clinic, and patients have likely had nonpharmacologic interventions before presenting to the clinic. Because of the small number of events, we did not adjust individual interventions for baseline differences between the 2 clinics. The higher proportion of patients with established atherosclerotic diseases and known hypertension seen in the cardiology fellow clinic was possibly associated with the higher number of medication-related interventions compared to the internal medicine resident clinic.8 Possible causes could be lack of awareness about the current guidelines among trainees, disagreement with the 2017 ACC/AHA BP guidelines, conflicting hypertension guidelines,23 insufficient patient encounter time, hypertension not being the primary reason for patient encounter, or physician inertia. We theorize that by excluding the population that would have met JNC 8 criteria, our study identifies a population subset that is easily missed when seen in an ambulatory setting. This study suggests that the inadequate rate of compliance with BP goals by trainee physicians is a potential barrier to adequate control of hypertension in the population and represents an area for improvement.The overall compliance rates among the trainee physicians in this study are far lower—29.1% in the cardiology fellow clinic and 10.3% in the internal medicine resident clinic—than the compliance rates reported in the studies of previous guidelines.Our study has several limitations. This retrospective study relied on information in the electronic medical records. Hence, if physicians recognized that BP was uncontrolled but did not indicate that in their notes, we could not accurately assess those encounters. Recorded race data for patients with Hispanic ethnicity were not reliable and hence not collected. ASCVD 10-year risk could not be calculated for some patients because of insufficient data, but the proportion of patients for whom ASCVD 10-year risk was not calculated was similar in both clinics. Because our study was retrospective, we were not able to assess the knowledge of the physicians regarding hypertension guidelines with a questionnaire beforehand, preventing us from definitively concluding that lack of awareness regarding the 2017 ACC/AHA guidelines among physicians contributed to the difference in assessment between the 2 clinics. Our study was a single-center study, so the results may not be generalizable to other centers. We are also limited in being able to comment on whether interventions such as focused lectures to trainees or programmed electronic medical record prompts for BP ≥130/80 mmHg would help improve BP assessment and eventually cardiovascular outcomes. These questions can be addressed by future prospective trials or quality improvement projects.In this retrospective study, cardiology fellows were better at identifying hypertension diagnosis thresholds and BP treatment goals in accordance with 2017 ACC/AHA hypertension guidelines compared to internal medicine residents. SBP and history of hypertension were also independently associated with accurate assessment of uncontrolled BP. We hope this study establishes a foundation for future studies examining educational tools to improve assessment and management of hypertension by trainee physicians.


Acute kidney injury (AKI) is defined as a rapid decline in kidney function. The associated syndromes may lead to increased morbidity and mortality, but its early detection remains difficult. Using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS), we analyzed the urinary metabolomic profile of patients admitted to the intensive care unit (ICU) after invasive surgery. Urine samples were collected at six time points: before surgery, at ICU admission and 6, 12, 24 and 48 h after. First, urine samples from 61 initial patients  were measured, followed by the measurement of urine samples from 60 additional patients . Glycine and ethanolamine were decreased in patients with AKI compared with non-AKI patients at 6–24 h in the two groups. The linear statistical model constructed at each time point by machine learning achieved the best performance at 24 h  for the 1st group. When cross-validated between the two groups, the AUC showed the best value of 70% at 12 h. These results identified metabolites and time points that show patterns specific to subjects who develop AKI, paving the way for the development of better biomarkers. Acute kidney injury (AKI) is defined as a severe decline in kidney function within a few hours. It is caused by various factors, including decreased blood flow during a major surgery or pain medication overuse. Because it is associated with morbidity and mortality, understanding the mechanisms underlying AKI progression and identifying body fluid biomarkers are urgently needed to develop medications for patients with AKI. To this end, several studies have investigated the molecular profiles of blood and urine during the progression of AKI. A change in serum creatinine is currently the gold standard marker for the onset of AKI as it is strongly associated with the filtering function of the kidney. In fact, the Kidney Disease: Improving Global Outcomes (KDIGO) criteria are based on serum creatinine levels and urine outputs . HoweverRecently, omics technologies have been applied to elucidate more comprehensive molecular profiles of the disease. The conducted studies differ not only by the body fluid type (blood or urine) but also by target molecules and measurement instruments used. The investigated molecular profiles and instruments include proteomes , peptSimilarly, we focused on patients admitted to an intensive care unit (ICU) after invasive surgery. Most patients recover in the ICU after major surgeries of organs, such as the brain and heart, but some patients develop AKI. The primary causes include ischemia during surgery, sepsis, drug-induced renal dysfunction and malignant tumors, and the disease is usually associated with the dysfunction of other organs and complications. In our present work, we conducted a comprehensive metabolome profiling of urine samples from patients with AKI. LC-MS has been one of the most widely used instruments for metabolome analyses. On the other hand, our institute has been developing CE-MS as a pioneer for twenty years . It has Urine samples were collected at six time points from patients who underwent surgery. To identify metabolites potentially associated with the progression of the disease, the metabolite levels in patients who developed AKI were compared with those who did not. Our study may provide targets for further biological studies to investigate disease progression mechanisms or potential biomarkers for the early detection of AKI.Urine samples were collected from patients in Nagoya University Hospital who were admitted to the ICU after invasive surgery. Urine samples were collected at six time points, including before surgery , on admission to the ICU  and 6 (time point C), 12 (time point D), 24 (time point E) and 48 h (time point F) after admission to the ICU a.We first selected 61 patients, designated as the 1st group, for the measurement of metabolome profiles. After admission, 24 and 14 developed mild and severe AKI, respectively (designated as mild AKI and severe AKI). The remaining 23 patients did not develop AKI (non-AKI). The 2nd group consisted of 20 mild AKI and 40 non-AKI patients . The changes in the metabolomic profiles over the six time points were analyzed using CE-TOFMS. We quantified 512 known metabolites and 155 uncharacterized peaks. The metabolite profiles of the two groups were measured on different days in different batches.To investigate differences in the level of metabolites between AKI (both mild and severe) and non-AKI patients at any time point, we calculated the log2-ratio of metabolite levels in AKI compared with non-AKI patients in the 1st group . No cleap < 0.05). At 24 h (E), the levels of five metabolites were significantly different between the three subject categories . For these metabolites, no correlation was observed between their level and the severity of disease, except for uncharacterized metabolite AU034, which showed a difference between mild AKI and severe AKI. Of note, we did not find hard-to-interpret cases in which the median metabolite level in non-AKI patients was between those of the other two categories of AKI (mild and severe). The top three metabolites, including ethanolamine, glutamine (Gln) and glycine (Gly), are marked in the heatmap of We analyzed the differences in metabolite levels between non-AKI, mild and severe subjects in the 1st group for all metabolites and all time points except 48 h. The 48-h time point was excluded from this analysis because one of our purposes was to identify early biomarkers. In addition, we thought that metabolites from 48 h may have significant downstream effects on the disease onset. We conducted multiple testing corrections for all metabolites and time points. The results are shown in The raw metabolite levels (µM) were normalized by urinary creatinine levels (g/L). Thus, urinary creatinine levels impacted the statistical analysis results. We analyzed the non-normalized metabolite levels for the top three metabolites shown in In the analyses above, each time point was treated independently. To take time-series patterns of metabolite levels for each subject into account, we modeled the patterns using two linear mixed effects models. Using these models, we then tested whether there was any difference in the patterns among the three categories of subjects in the 1st group .p values < 0.05. The top three metabolites in In the first model, the metabolite level is assumed to be influenced by disease states, time points and subjects. Using this model, we tested whether disease states actually affected the metabolite level . We founp values < 0.05, piperidine being the most significant. These significant metabolites appeared to be substantially different from those shown in In the second model, the metabolite level is assumed to be influenced by disease states, time points and subjects. In addition, changes in the level of metabolites over the time points are assumed to be influenced by the disease state. We tested whether disease states actually affected the slopes of the changes in metabolite levels over the time points . We founThe patterns in the changes in ethanolamine, glutamine (Gln) and glycine (Gly) over the time points in the 1st group of patients are shown in Urinary NGAL (uNGAL) is a previously studied protein marker for AKI. We investigated uNGAL levels in the 1st group of subjects at 12 h and 24 h, the two time points that showed significant differences in metabolites between non-AKI and AKI patients. We observed substantial upregulation of NGAL in three subjects (extreme outliers) with AKI at both time points a. In addFinally, to determine which metabolites or clinical variables effectively predict AKI, we used LASSO, which automatically selects a set of metabolites and clinical variables for the prediction of disease states. It further generates a linear equation for predicting the states based on the selected metabolites and clinical variables. We used metabolome profiles at specific time points and four clinical variables, including age, gender, surgery duration and baseline serum creatinine level, as inputs and non-AKI or AKI (mild or severe) as outputs (targets).Based on the AUCs in the test sets (¼ of the subjects in the 1st group), predictions based on metabolome profiles at Pre, ICU, and 6 h in the 1st group of subjects  did not show high performance b, left. We also investigated the performance of predictions when the 1st and 2nd groups were used as training and test sets, respectively, for calculating AUCs  to be efficient predictors of AKI, but these variables were rarely selected by LASSO. In fact, there was no statistically significant difference in baseline serum creatinine levels or surgery durations among non-AKI, mild and severe AKI patients .p = 0.0395, ANOVA) and 24 h , although this result was not statistically significant after multiple testing corrections. Of note, Martin-Lorenzo et al. .g and 4 °C for 30 to 50 min. Finally, 7 µL of each sample were transferred to vials for metabolome analyses.Urine samples stored at −80 °C were thawed at room temperature, and 20 µL were transferred to 1.5-mL tubes. Next, 2 mM of internal standards (IS) within Milli-Q water were added. For the cation mode, methionine sulfone and 3-aminopyrrolidine were used as ISs. For the anion mode, trimesate, D-camphor-10-sulfonic acid sodium salt (CSA) and 2-(N-morpholino)ethane sulfonic acid (MES) were used. Milli-Q water was added for dilution based on the urinary Cr to achieve a Cr concentration of approximately 10 mg/dL . The samMethionine sulfone was purchased from Alfa Aesar , and hexakis--phosphazene (Hexakis) was obtained from SynQuest Laboratories . All other reagents were from Sigma-Aldrich  or Wako Pure Chemicals . All chemicals were of analytical or reagent grade. Water was purified with a Milli-Q purification system .v/v) containing 0.1 M Hexakis, was delivered at 10 L/min. Anionic metabolites were separated using a commercially available COSMO(+) capillary column coated with a cationic polymer . Ammonium acetate solution  was used as the electrolyte . The corresponding null model was β1 = 0.Model 1: The level of a specific metabolite β3 is the coefficient for the interaction term of disease state and time. The corresponding null model was β3 = 0.Model 2:Analyses using the least absolute shrinkage and selection operator (LASSO) were conducted with the glmnet package of R to construct linear models to predict the disease status of patients with metabolome profiles and clinical variables. Cross-validation of the models was performed within the 1st group by randomly dividing the patients into training (¾) and test (¼) sets. The optimal parameter (λ) was selected through five-fold cross-validation within the training set using deviance as the loss function. This procedure was repeated 100 times. Alternatively, cross-validation was conducted using the entire 1st group as the training set and the entire 2nd group as the test set.Our CE-MS-based time-series urinary metabolomic profile analyses identified metabolites and time points that show patterns specific to patients who develop AKI, and our statistical models and machine learning technique were efficient for the identification from large size of the metabolome data. Using an increased number of patients with similar clinical backgrounds, more accurate predictions may be possible, leading to the development of more efficient biomarkers for AKI.


Objectives: We aimed to validate the accuracy of blood pressure (BP) measurement using a smartwatch in patients with Parkinson's disease (PD).Materials and Methods: We compared 168 pairs of BP (n = 56) measurements acquired by a smartwatch (SM-R850) with those measured by a sphygmomanometer (reference device).Results: Differences between the smartwatch BP and reference BP measurements were compared. The mean and standard deviation of the differences systolic BP (SBP) and diastolic BP (DBP), measured by smartwatch and reference device, fulfilled both criterion 1  and criterion 2  of the BP validation criterion of the International Organization for Standardization.Conclusion: BP measurement using a smartwatch with a photoplethysmography sensor is an accurate and reliable method in patients with PD. Autonomic dysfunction is highly prevalent in patients with Parkinson's disease (PD) . A studyRegular and repetitive measurement of the BP to detect fluctuations in BP is crucial for the management and diagnosis of PD , 6. RecePatients with PD were recruited from the Department of Neurology, Samsung Medical Center, from October 2020 to November 2020. The diagnosis of PD was made using the United Kingdom Parkinson's Disease Brain Bank criteria . The incAn SM-R850, 41 mm , a smartwatch released on August 6, 2020, in South Korea, was used for BP measurement. The device uses a light-emitting diode PPG sensor for the measurement of the BP and was approved as a medical device by the Korean Ministry of Food and Drug Safety on April 20, 2020. The SM-R850 was calibrated with an aneroid sphygmomanometer  prior to BP measurement. Three pairs of smartwatch and reference BP measurements were obtained for each participant.Calibration of the tested device was conducted using the following steps, as recommended by the manufacturer: (1) the observer ensured that the smartwatch was securely fastened 2 cm proximal from the participant's less affected side wrist; (2) the observer fit the BP cuff on the opposite-side arm of the participant and started to measure the BP using a sphygmomanometer; (3) the watch captured the BP of the participant, and the measured BP was entered using a sphygmomanometer on the smartphone application . If the watch was unable to correctly capture the participant's BP, the same protocol was attempted once more. (4) The participants were asked to remain still and not talk while the BP was being measured by the watch. None of these measurements were used to calculate the accuracy of the smartwatch.A trained observer measured the reference BP using aneroid sphygmomanometers and a “Y” connected teaching stethoscope . Korotkoff K1 was used for the reference SBP and K5 for the DBP in all subjects. Three cuff sizes were used according to the mid-arm circumference: a small cuff for arm circumferences of 18–23 cm; a standard cuff (medium), 24–32 cm; and a large cuff, 32–42 cm.The test BP using a smartwatch was measured on the less affected side wrist in sitting position, between 9 a.m. and 2 p.m., after at least 5 min of rest. The BP measurement was performed in the medication “on” state. The reference measurement of the BP was also measured simultaneously at the level of the heart on the opposite-side arm of the participants according to the guideline of the manufacturer, and the same protocol was repeated three times with at least 1 min of interval between each measurement. Each smartwatch measurement was compared with the reference measurement, which was taken simultaneously with the smartwatch.Data were analyzed according to two criteria required by the International Organization for Standardization (ISO), which is designed to provide 98% confidence interval and a statistical power of 95% . For criSixty-two participants were screened, and six of them were excluded for the following reasons: two because of arrhythmia, one with a difference in BP > 10 mm Hg between the two arms, and three were not included in the final analysis because they failed to obtain three pairs of BP measurements using the test device because of resting tremor. Therefore, 56 participants were enrolled and included for the final analysis in the study. The characteristics and demographics of the participants are described in r = 0.967, p < 0.001; DBP, r = 0.916, p < 0.001). The SBP measured by the test device was positively correlated with BMI , but not with age , disease duration , UPDRS III , H & Y stage , and LED . No correlation was found between DBP and clinical features, including age , disease duration , BMI , UPDRS III , H & Y stage , and LED .The SBP and DBP measured by each device were highly correlated  in patients with PD. Our study showed that using a smartwatch with a PPG sensor is an accurate and reliable method for measuring BP in patients with PD. Using the presented device, patients can measure their BP easily, regardless of time and place.PPG sensors for assessing BP have been introduced as reliable and accurate tools. Recently, several cuff-less wristwatch-type BP-monitoring devices with PPG sensors have been introduced and have shown good accuracy , 15. Howvice versa. Therefore, timely diagnosis, proper management, and monitoring of treatment-associated side effects of OH and SH are critical. A smartwatch is reproducible and able to monitor BP for a longer period than conventional ambulatory BP measurement devices, and it allows measurement of the BP whenever patients feel symptoms associated with OH, such as dizziness, faintness, and headache (The results of the study suggest that BP measurement using a smartwatch will become an important tool in monitoring of PD. In PD, 32% of patients had OH, but only one-third of them had symptoms associated with OH , 17. Theheadache . In the headache . MaintaiThis study has several limitations. First, the sample size was small, but it is acceptable, considering that the validation protocol recommended at least 35 participants for a special population . Second,In conclusion, BP measurement using a smartwatch with a PPG sensor is accurate and reliable for patients with PD. The use of the device can be expanded to include detection and monitoring of the treatment response and side effects of OH and/or SH. Thus, we consider that smartwatches with PPG sensors will be highly valuable for management and future studies of PD.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Samsung Medical Center Instituitional Review Board. The patients/participants provided their written informed consent to participate in this study.JHA and JWC: conceptualization, methodology, and writing—review and editing. JS, IC, and JHA: data curation. JHA: formal analysis and writing—original draft. JHA, JY, and JWC: investigation and resources. JWC: project administration and supervision. JS, IC, JWC, and JY: validation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Chromaffin cell-centered pheochromocytoma (Pheo) is a rare tumour. Pheochromocytoma and how it affects the heart will be the topic of this article. Due to the comparable symptoms and indications of the sympathetic nervous system, a pheochromocytoma might be difficult to detect early. There are also other frequent differential diagnoses that might delay the detection of a pheochromocytoma. One of the most common side effects of pheochromocytoma is unmanageable hypertension. Hypertensive crisis (extreme increases in blood pressure) can develop, which is a life-threatening condition that leads to strokes or arrhythmia. Estimated to affect African Americans significantly, they frequently go undetected due to a lack of resources or accessibility of services. Because this tumour is difficult to identify and its symptoms often resemble those of other diseases, it is frequently overlooked. A pheochromocytoma's long-term consequences can include cardiac muscle deterioration, congestive heart failure (CHF), a higher diabetes risk and possibly death. Masked hypertension (MH) is more common in people with adrenal pheochromocytoma, which has been related to an increased risk of heart disease. With the use of ambulatory blood pressure monitoring, this research set out to find out how common mental health issues are among people with APs. There were 85 participants in all, 43 of whom had APs and 42 of whom had the same age, gender, BMI, smoking and diabetes as the AP patients. Measurements were made of the BP and AP in both the diseased and control groups. Retrospective data collection was used to gather biochemical, hormonal and radiological information on the patients. The Pearson–Boltzmann CNN method was then used to assess risk based on the diagnosis results. Furthermore, depending on the risk score, more nonselective blockers  have been used to lower perioperative catecholamine levels, hence reducing illness risk. After a successful surgical excision of the tumour, the recommended therapy can usually be stopped quickly. In health and sickness, catecholamine production in several chromaffin cell organsVariations in the catecholamine synthesis enzymatic machinerySubstrate availabilityThe size and quantity of secreting tissue, as well as its metabolic functionsCatecholamine secretion typeThe amount of catecholamine secretedCatecholamine secretion patternEnd-organ injury and a slew of other factorsIn the extra-adrenal paraganglia or in the medulla of the adrenal gland, chromaffin cells develop into cancerous tumours called pheochromocytomas. When it comes to sympathetic paragangliomas, which arise from the pheochromocytoma, only 23% of them produce norepinephrine or epinephrine and release it into the body. Pheochromocytomas are cancers of the adrenal glands and tumours of the sympath paraganglia. Pheochromocytomas occur in 0.2%–0.6% of people with hypertension. As a result, pheochromocytoma diagnostic workup is hampered by clinical symptoms that are indistinguishable from those of idiopathic hypertension, hyperthyroidism, heart failure and headaches. About 95% of pheochromocytoma patients experience hypertension as a result of catecholamine excesses. The clinical manifestations of hypertension can be long-lasting or short-lived. Hypertensive paroxysms may occur in certain individuals, despite the presence of a steady bp. Pheochromocytoma patients, on the other hand, account for a small but significant percentage of those diagnosed. The underlying pathophysiologic mechanisms of pheochromocytoma-related hypertension are examined in the following section. It is possible for patients with pheochromocytoma to also suffer from headaches and palpitations. Hypertension caused by pheochromocytoma was significantly connected to the Catecholamine Biosynthesis. Catechumin-positive secretory granules may also be seen in the parasympathetic paraganglia in the adrenal gland or autonomic paraganglia, which are both home to chromaffin cells that manufacture and release catecholamines. The enzyme machinery of catecholamine-producing cells is critical to the generation of catecholamines. A catecholamine-producing cell enzyme known as tyrosine hydroxylase (TH) converts L-tyrosine into dopa in the first step of the process. A negative feedback loop is created when tertahydropteridine (TH4) is oxidised by catecholamines, which generally co-factors with molecular oxygen and stops TH4 from operating. A co-factor for aromatic L-amino acid decarboxylase (AADC) is pyridoxal phosphate, which decarboxylates L-dihydroxyphenylethylamine (dopamine). The dopamine-hydroxylase (DBH) in the neurosecretory vesicles subsequently hydroxylates dopamine to L-norepinephrine. Norepinephrine is converted into epinephrine by the enzyme phenylethanolamine-N-methyl transferase (PNMT). While pheochromocytoma is an excellent mimic, it is also one of the most intriguing clinical paradoxes, with symptoms and indications that vary to nearly incomprehensible degrees in clinical circumstances that look identical. There are several pathophysiologic elements that contribute to clinically significant challenges to understand this paradox. Some of these factors, such as, for instance, are as follows:To understand pheochromocytoma clinically, a detailed understanding of catecholamine synthesis and metabolism is essential. The purpose of this study was to determine the prevalence of hypertension in patients with pheochromocytoma. The rest of the paper may be broken down into the following sections: In , resistaα1, α2 and β1 receptors are stimulated by norepinephrine, whereas β1 and β2 denotes receptors that are only activated by epinephrine. Dopamine has no impact on any of the adrenergic receptors at normal dosages, but if the plasma level of dopamine rises , dopamine may activate both adrenergic receptors simultaneously. 1-adrenergic receptors may elicit vasoconstriction when activated in several parts of the skeletal system, including the kidneys, the brain, the heart and many other arteries and veins. As a result, systemic pressure rises and organ perfusion falls. In cardiomyocytes, it likewise has a favourable inotropic effect  in the cell may raise epinephrine levels. For some reason, although extra-adrenal tumours have PNMT incidence that is higher than in adrenal pheochromocytomas, the PNMT levels in these tumours are lower than those in normal adrenal tissue. As a therapeutic diagnostic tool, pheochromocytoma's secretory properties will be used. Most tumours that originate outside of the adrenal gland produce norepinephrine, but dopamine-secreting tumours are rare. Many endocrine tumours type 2 are associated with adrenal pheochromocytomas, which produce a mixture of epinephrine and norepinephrine (MEN 2). Von Hippel-Lindau disease tumours secrete only norepinephrine. The only site where dopamine-secreting tumours may be found is in the extra-adrenal pheochromocytomas. DBH expression is decreased in several cancers, which suggests that norepinephrine and dopamine production are decreased. Pheochromocytomas generate a variety of hormones and peptides, including adrenalomedullin, vasoactive intestinal polypeptide, ACTH, neuropeptide Y, endothelin-1, somatostatin, atrial natriuretic factor and parathyroid hormone-related peptide. An additional neuroendocrine product's vasoconstrictive or vasodilatory properties, together with hypercatecholaminemia in the bloodstream, would decide the clinical presentation. Hypertensive paroxysms may be caused by regular exercise  or tumour manipulation, and the pattern of catecholamine production from the tumour might be steady, episodic, or both. Catecholamine secretion by tumours cannot be predicted because of the lack of information on when and how much catecholamines will be released during each secretory episode. It seems that hypertension symptoms and phenotype are connected. Norepinephrine-producing tumours are more likely to cause hypertension, while epinephrine-producing tumours are more likely to cause paroxysmal and orthostatic hypertension. With dopamine-secreting tumours, most patients do not have high blood pressure .2) is a simple matter of multiplying one's weight (kg) by one's height (m2).Single-center, retrospective and cross-sectional design were used in this study's research design. The study took place at the Guangdong Heart Hospital in China between 15 December 2020 and 15 March 2021. People with and without NFAIs were both included in this research. Clients in the NFAI team had OBP readings of less than 140/90 mmHg and more than 120/80 mmHg  and BP (high)), respectively, on a regular basis. Participants' demographic and clinical data were recorded in the study database. When it comes to NFAIs, 43 persons above the age of 18 who were scanned for other medical reasons and found to have nonmalignant adrenal neoplasms would be included. Clinical and hormonal assessments have previously deemed the patients to be nonfunctioning or nonaggressive. Noncontrast computed tomography imaging (10 Hounsfield units) or CT with delayed contrast absolute washout >60% were used in all instances to measure the size of the adenoma. AIs were ruled out as functioning after a series of hormone tests, according to current guidelines. A positive control of 42 healthy persons was constructed based on age, age distribution, BMI, hypertension, tobacco and alcohol misuse. Antihypertensive and antihypertensive history medication use, persistent myocardial infarction (mi) , performance enhancing drugs and oral contraceptives and main or metastases adrenal cancers are all considered risk factors for cardiovascular disease. It was also thrown out of the research for individuals with blood cortisol levels below 1.8 g/dL after taking 1 mg DST. In cases where there was a lack of data, patients who had not been sufficiently checked hormonally and those who had adipose tissue diameters between 10 and 40 mm were excluded from the research. Calculating body mass index , OMRON HEALTHCARE Co., Ltd. KYOTO, 617–0002 JAPAN). Participants were encouraged to abstain from drinking, smoking and coffee/tea for at least 30 minutes before to the blood pressure measurement. In a sitting position with the arm supported at heart level and a cuff size appropriate for patients, the patient's blood pressure was measured. At 5-minute intervals, OBP was measured twice in both arms. For both arms, two measurements were averaged, and the highest value was recorded as BP. According to the OBP measurement, optimal blood pressure was <120/80 mmHg, normal blood pressure was 120–129/80–84 mmHg, high normal blood pressure was 130–139/85–89 mmHg and hypertension was ≥140/90 mmHg.Only the patient's nondominant arm was subjected to ABPM using the Oscar II device from Suntech . Recording their sleep and wake times was instructed to the patients. Before ABPM, they were told to stay away from strenuous physical activity. ABPM was done 30 times a night and 15 times a day when the subjects were awake (sleep). At rest, the patient has a BP of 130/80 mmHg, while during the day, it is 135/85 mmHg and at night, it is 120/70 mmHg [After a 12-hour fast, all participants had their venous blood samples obtained. The patients' fasting blood glucose, urea, creatinine, estimated glomerular filtration rate (eGFR), sodium, potassium, total protein, albumin, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride levels were all measured. An automated clinical chemistry analyzer was used to measure HDL, LDL and TC values in the blood (Abbott Architect c16000). The CKD-Epidemiology Collaboration (CKD-EPI) was used to determine the eGFR. A Roche Cobas 8000 automated analyzer was used to measure biochemical parameters .μg/day) levels tested. Assays were performed on urine samples. Miodobenzylguanidine Screening was started here for the purpose of radiological screening. In the study, screening with I-mIBG imaging was linked to a 21% reduction in ICD utilization, resulting in a screening number of 5 to prevent 1 ICD placement. In comparison to no screening, screening lowered expenses per patient by $5500 and $13,431 (in 2013 dollars) over 2 and 10 years, respectively, and resulted in losses of 0.001 and 0.040 life-years, respectively. Over two and ten years, screening was cost-effective, with savings of US  per quality-adjusted life-year lost, respectively. Patients with an ejection fraction (EF) of 25%–35% saved more money in secondary outcomes than those with an EF of less than 25%.The availability of NFAIs was assessed using the ESC Clinical Practice Guidelines as a guideline. Clinical signs and symptoms of primary hyperaldosteronism, Cushing syndrome, sex hormone–producing adenoma, pheochromocytoma and malignancy were assessed in all patients. All patients had their morning cortisol (g/dL), adrenocorticotropic hormone , dehydroepiandrosteronesulphate, plasma renin activity (ng/mL per hour), plasma aldosterone (ng/dL) and 24-hour urine metanephrine/normetanephrine (F(l) is a functional matrix and W is the classifier of the dual variables.The Pearson–Boltzmann CNN technique was used to calculate the risk score based on the collected data. The ultimate purpose of the Pearson–Boltzmann CNN classification is to determine hypertension risk, indicating whether or not a person is at danger. When each anomalous data's posteriori probability is calculated. Comparing the symptoms of the disease to the disease forecast using the known real goal value by replicated processing, the classifier can make decisions about outcomes that include disease symptoms. The target value could be the known value for the sake of estimation. To lower the average squared error between the prediction and the true value, a weight set is updated for each datum. The results of the decision classifier used in the classifier are used to make these changes. The ranking process is sped up as a result of these revisions. Inputs, outputs and mistakes were among the parameters that were addressed in the steps. It can be expressed mathematically:After that, we need to discuss about the relationship among the data,The feature error can be classification using the following equation:q denotes the query data and s is the signal score value.Finally, a ranking is generated for the abnormality matching distance of base data.The score classification was concluded as follows:The procedure for the risk score evaluation is shown in Based on the risk rating, the client was prescribed one of four drugs: prazosin, doxazosin, terazosin and metyrosine.This drug is taken orally and has a rapid absorption rate; peak plasma concentrations are reached within one to two hours after ingesting it. Since it has a half-life of 2.5 h, it must be done twice or thrice a day. A particular cytochrome P450 involved in its metabolism has yet to be identified. Despite renal disease or aging, the pharmacokinetic of prazosin were unaffected.Terazosin is a long-acting, highly selective 1-receptor blocker in the treatment of BPH symptoms. Regardless of whether or whether it is taken with or without food, it is effectively absorbed. It takes an hour for plasma concentrations to reach their maximum. The peak plasma concentration is slowed by around 40 minutes when taken with meals. Due to its slow first-pass liver metabolism, the parent drug accounts for approximately all of the medication's circulating dose. One dosage of Terazosin each day is needed since it has a 12-hour half-life. Due to an aged population's decreased plasma clearance, terazosin's half-life is prolonged (approximately 14 hours).As a result of its lengthy half-life of 16 hours, Doxazosin may be used once a day as a selective 1-receptor blocker. Take it with meal if you want it to work. Both young and elderly persons have the same oral clearance and plasma half-life. Due to the fact that it is metabolised in the liver, those with compromised renal function should be cautious while using it. Renal impairment has little effect on the pharmacokinetic characteristics of patients.Tyrosine 3-monooxygenase inhibitor metyrosine is used in the treatment of pheochromocytoma with excessive sympathetic stimulation. Catecholamine synthesis is inhibited by tyrosine 3-monooxygenase inhibitor. Patients with pheochromocytoma who have too much sympathetic activity might benefit from this treatment.This section depicts a full explanation of the proposed system's performance analysis: a high-risk patient was recommended for experimentation .The high-risk patient here has a tumour that emits hormones that can cause high blood pressure, headaches, sweating and panic attack symptoms . A pheocThe negative predictive value of plasma and urine catecholamine testing at different pheochromocytoma prevalence revealed that a positive test result for the disease's state prediction was negative .Depending upon the drug, the production of the catecholamine was adjusted and the specificity values are obtained.The relation between the specificity and the sensitivity of the catecholamine production was illustrated in A positive or a negative result for the test of plasma or catecholamine changes the probability of having the pheochromocytoma –17 in reIn Improved symptoms and quality of life, less bladder outlet blockage, better cholesterol profiles and lower blood pressure in hypertensive males are all good results of blocker medication. However, it might produce side effects like asthenia (10%), dizziness (10%), postural hypotension (50%) and syncope (4%) (0% to 1%). For optimal effectiveness and tolerance, 32-blocker medicine should be started at a low dosage, then gradually increased. After many days without a dosage of a -blocker, the medicine must be reproceeded with the original dosing schedule and titrated to therapeutic levels. Other antihypertensive drugs may have similar side effects as selective 1-blockers, which were originally used to treat hypertension. This means that -blocker side effects may occur as a consequence of lowering blood pressure. To understand how blood pressure is affected by the 1B and 1D subtypes, it is necessary to understand how vascular smooth muscle is mediated by these subtypes. Pheochromocytoma blood pressure changes were only shown to be identical with postural hypotension. Studies suggest that conventional -blockers' side effects are caused by processes other than blood pressure reduction and that the pace at which blood pressure drops present themselves may be more important than their quantity in producing unpleasant responses. Blocker tolerance may be influenced by other mechanisms, including as changes in how drugs enter the brain or how quickly they are excreted. Symptomatic enhancement in pheochromocytoma patients treated with -blockers has been associated to physiological deterioration, according to studies. As a consequence, we opted forprazosin, doxazosin, terazosin and metyrosine as preferred options. During follow-up investigations with these individuals, more than one symptom ratings and urine retention rates must be taken into account. Finding the root cause of pheochromocytoma and hypertension might help prevent long-term complications that may arise in certain patients.


Early intraoperative hypotension (eIOH) is a common complication of general anesthesia and is significantly associated with postoperative morbidity and mortality. The incidence of eIOH was high, especially in resource-limited settings. Identifying the factors associated with the occurrence of eIOH might allow avoidance and planning of a timely treatment of it.XX Comprehensive Specialized Hospital, North-central Ethiopia, 2021.To assess the incidence of early intraoperative hypotension and its associated factors among surgical patients undergoing Surgical procedures under general anesthesia at A total of 424 surgical patients under general anesthesia were included in this prospective observational study. The data were collected by a structured questionnaire. Variables with p-values of less than 0.2 in the bivariable logistic regression were fitted to multivariable logistic regression. Data was presented in odds ratios with a 95% confidence interval. Descriptive statistics were used to summarize data.The incidence of early intra-operative hypotension (eIOH) was 21.2%. In this study older age (age≥ 60 years) ), ASA physical status ), III), a BMI of 25–29.9 kg/m2 , a BMI of ≥30 kg/m2 ), emergency surgical procedures ), the estimated blood loss greater than 500 ml ) were found to be independent factors of eIOH.This study revealed that the incidence of eIOH was high (21.2%). Older age, ASA II and III, BMI ≥25, emergency surgical procedures, and a significant amount of blood loss (EBL ≥500 ml) were the main predictors of an increased occurrence of eIOH. •Early intraoperative hypotension is associated with postoperative morbidity and mortality.•Emergency surgical procedures, and a significant amount of blood loss are the main predictors of an increased occurrence of eIOH.•Thyroidectomy has a relatively short duration and less amount of estimated blood loss when compared to major surgical procedures.•The occurrence of eIOH after general anesthesia for general surgery is a common problem.•Arterial hypotension in patients undergoing surgery under general anesthesia usually described by the very general term intraoperative hypotension. Hypotension was defined as either mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP<60 mm Hg. A decline in arterial blood pressure of 30% from the preoperative reading value is another definition of it. The other definition of eIOH is a decrement in systolic blood pressure SBP less than 90 mmHg.In this study, early intraoperative hypotension (eIOH) was defined as a decrease in systolic blood pressure SBP< 90 mmHg, which was supported by recent literature that might lead to similar conclusions for having postoperative IOH-related risk of morbidity and mortality in contrast to a decline of arterial blood pressure from a baseline .Early inArterial hypotension in patients undergoing surgery under general anesthesia usually described by the very general term ‘intraoperative hypotension (IOH) is highly prevalent and associated with unfavorable patient outcomes. An arterial blood pressure decline below the lower limit of the vascular autoregulation curve might lead to ischemia of vital organs  . An assoIn recent years, evidences are growing that the development of IOH is associated with adverse postoperative outcomes in terms of both morbidity and mortality. In a large observational study in 10,440 adult patients undergoing non-cardiac surgery increased durations of IOH (defined by MAP thresholds between 50 and 80 mmHg) were strongly associated with 30-day mortality. In another large retrospective cohort study in 18,756 patients undergoing non-cardiac surgery these findings again confirmed the case, as an increase in 30-day mortality was found for patients with either SBP <70 mmHg, MAP <49 mmHg, or DBP <30 mmHg for at least 5 min.Multiple other studies have shown the association between IOH and postoperative morbidity in terms of myocardial and acute kidney injury and possibly for the occurrence of ischemic stroke too. Importantly, these studies also demonstrated that even short instances of IOH (in some studies as short as 1 min) were associated with adverse outcomes. For example in one of these studies performed in 33,330 patients underwent non-cardiac surgery, the odds ratio of postoperative myocardial injury and kidney injury when MAP was lower than 55 mmHg for only 1–5 min. Moreover, even short periods of post-induction hypotension before surgical incision are associated with postoperative acute kidney injury .Intraoperative blood pressures, MAP less than 55 mmHg was associated with the development of acute kidney injury, myocardial injury, and cardiac complications .Arterial hypotension during the early phase of anesthesia can lead to adverse outcomes such as a prolonged postoperative stay or even death. Predicted hypotension during anesthesia induction is complicated by its diverse causes .XX Comprehensive Specialized Hospital.The occurrence of eIOH after general anesthesia for general surgery is a common problem, especially in resource-limited settings like ours. Knowing the incidence and associated factors causing eIOH helps urgent need of safety and treatment in the service of anesthesia and surgery. This research can also help as formulate baseline information for future researches in Ethiopia. This study will help to determine the incidence and factors associated with eIOH in surgical procedures under general anesthesia in 22.1XX compressive specialized Hospital is a public Hospital established in 1934 and located in South Gonder Zone, Amara region 667 km northwest of Addis Ababa, the capital city of Ethiopia at Debre Tabor town which is 97 km to the southwest of Bahir Dar, the capital city of Amara region. According to the 2007 census, the total population of this town was 155,596. The study was conducted in Debre Tabor Town at XX Referral Hospital 2021 GC. It has one referral hospital, and its altitude of 2706 m or 8878 feet above sea level [2.2http://www.researchregistry.com with a registry number 6911.A prospective Observational study design was used, this study has been registered in a research registry www.strocssguideline.com, in which a completed STROCSS checklist stating the page numbers.Our work is fully compliant with the STROCSS criteria 2.32.3.1All elective and emergency surgical patients who would undergo surgery under general anesthesia.2.3.2All elective and emergency surgical patients who would undergo surgery under general anesthesia met the inclusion criteria during the study period.2.42.4.1Early intraoperative Hypotension (Yes/No)2.4.2: demographic variables; Age, sex, ASA physical status, BMI (Kg/m2), patient has any co morbidity, Use of chronic medicationsSection 1: Surgery-related variables: Surgeon experience, Planned procedure, Urgency of the procedure, Estimated blood loss, Intraoperative positioning, Duration of surgery,Section 2: Anesthetic related variables:Anesthetist experience, Premedication, Preoperative fluid intake, Intravenous induction agent, Analgesics used, Muscle relaxant used, ETT size, Number of Intubation attempts, Intraoperative fluid, Intraoperative vasoactive agent.Section 32.52.5.1The sample size was determined by taking the following assumption; since there is no previous study conducted in Ethiopia. We will assume the proportion is 50%, confidence interval of 95% and margin of error of to be tolerated 0.05%.The sample size to be taken for the study was determined using the formula.20.5(1–0.5)/0.052–385, by adding 10% non-response rate the total sample size was 424.n= (1.96)2.5.2The final study subjects were chosen by a consecutive convenience sampling technique. The study units that happen to be available at the time of data collection were the participants of the study.2.62.6.1All age ≥18years patients who came to OR for elective and emergency surgery under GA during the study period were included.2.6.2✓Shocked patient✓Pregnant mother✓Cardiac patient✓ASA IV and more✓Two or more intubation attempts2.72), patient has any comorbidity, use of chronic medications), surgery-related data of the study participants , and anesthetic related data of the study participant .This tool was developed after searching various literatures related to this topic [Data was collected using structured questionnaires prepared in English. Data was collected by trained anesthetists. the study tool includes demographic data of the study participants  and benefit of the study as clearly as possible to the study participants.Ethical approval was obtained from the Ethical Review Committee of 2.9CC specialized and teaching hospital. The completed questionnaire would have been submitted and reviewed daily to avoid loss of data. Close supervision and daily information exchange including by telephone would have been used as a means to correct problems during the data collection period. Data consistency and completeness would have been made throughout the data collection, data entry, and analysis.To ensure the quality of data, a pre-test of the questionnaire was performed on 5% of study populations who fulfill the inclusion criteria at 2.10The data were coded and entered and in SPSS version 25 statistics software for analysis. The association between the dependent variable (eIOH) with independent variables was analyzed by bivariable logistic regression and multivariable logistic regression. Variables with p-values of less than 0.2 in the bivariable logistic regression were fitted to multivariable logistic regression. Data was presented in Odds ratios with a 95% confidence interval. Descriptive statistics were be used to summarize data. Tables were used to present the data.2.11Early intraoperative hypotension: Is a systolic blood pressure less than 90 mmHg during the first 30min of surgery .Baseline blood pressure: The measurement of arterial blood pressure taken before the induction of anesthesia.33.1Four hundred twenty-four adult elective and emergency surgical patients under general anesthesia took part in this study. Among the participants, 59.9% were male. In this study, 70.75% were ASA I, and the majority (85.85%) did not have co morbidities .Table 1D3.2From 424 surgical patients majority of the surgery constituents abdominal and elective surgical procedure accounts 349(82.32%) and 307(72.4%) respectively and incidence of early intraoperative hypotension during emergency surgery accounts 41(9.67%) .Table 2S3.3(67.69%) took less than 1000 ml of crystalloids in the intraoperative period (The majority of study participants (41.04%) were induced ketamine. The majority of study participants (89.15%) did not take vasopressors, and most of surgical patients e period .Table 3A3.4In this study, Early intraoperative hypotension was found in 90 (21.2%) of study participants. The majority of (19.6%) of the eIOH occurred within 5 min after the induction of anesthesia .Fig. 1Th3.52 was 2 times  more likely to develop eIOH when compared with patients having normal BMI, a BMI of ≥30 kg/m2 was 3 times ) more likely to develop eIOH when compared with patients having normal BMI, emergency surgical procedures were 2.2 times ) more likely to develop eIOH when compared with elective surgical procedures, the estimated blood loss greater than 500 ml was 2.5 times ) more likely to develop eIOH when compared with patients having an estimated blood loss less than 500 ml (In this study older age 2 times (age≥ 60 years) ) more likely to develop eIOH, ASA II patients had 2.2 times ) more likely to develop eIOH as compared to ASA I patients, ASA III patients were 2.8 times ) more likely to develop eIOH when compared to ASA I patients, a BMI of 25–29.9 kg/mn 500 ml .Table 4V4Early intraoperative hypotension is associated with postoperative morbidity and mortality. In this study, we found that the incidence of early intraoperative hypotension within 30 min after general anesthesia in major surgery was 21.2%. In line with our finding, a study conducted by Su et al.  found thIn this study, early intraoperative hypotension (eIOH) was defined as a decrease in systolic blood pressure SBP<90 mmHg. Some recent studies support this approach, revealed that definitions of eIOH using SBP less than 90 mmHg might lead to similar conclusions for having postoperative IOH-related risk of morbidity and mortality when compared with a lower arterial blood pressure from baseline  ,3.In this study older age (age≥ 60 years), ASA physical status , BMI (>25 kg/m2), emergency surgical procedures, estimated blood loss greater than 500 ml were found to be independent factors of an increased occurrence of eIOH.In this study ASA physical status  was found to be an independent factor of an increased occurrence of eIOH. In line with this study, Su et al.  revealedIn this study older age (age ≥60 years) was an independent risk factor for eIOH. Similarly, a study conducted by Su et al.  found thIn our study emergency surgical procedures were associated with the occurrence of eIOH. In line with this study, Su et al. revealed that emergency surgical procedures were the predictors of eIOH(6). This finding might reflect the fact that patients undergoing emergency surgical procedures compared with elective surgical procedures are more likely to develop cardiovascular dysfunction.In this study BMI >25 kg/m2 was found to be independent factors of an increased occurrence of eIOH. In contrast to our result Kalezic et al.  revealedThe definition of hypotension is the main problem of this study. The variability of definitions of eIOH, significantly impacts comparisons and interpretations of the results of studies concerning the occurrence of eIOH(2). The other limitation could be this study does not take into consideration the duration of hypotension, and managing eIOH according to the available medical equipment and drugs  could be the limitations of this study.5The incidence of eIOH was high (21.2%). Older age, ASA II and III, BMI ≥25, emergency surgical procedures, and a significant amount of blood loss (EBL ≥500 ml) were the main predictors of an increased occurrence of eIOH. Identifying those factors might allow the avoidance and planning of a timely treatment of hypotensive episodes during general anesthesia.Ethical clearance was obtained from Debre tabor University research review committee.No funding is required.All authors equally contributed to the study concept or design, data searching, data analysis or interpretation, writing the paper.Mr. Netsanet Temesgen.Not applicable for that.None.The authors declared that there is no conflict of interest.


The following parameters were evaluated for all patients: postural steadiness through the fall index using posturography, functional balance through the Berg Balance Scale (BBS), the Timed Up and Go test (TUG), and fear of falling through the Falls Efficacy Scale-International (FES-I). The IVS group showed a significantly greater balance impairment in fall index, BBS, and TUG, as well as greater fear of falling on the FES-I than the NVS group. The linear regression analysis showed that the fall index was associated only with the VPT, whereas BBS, TUG, and FES-I were associated with the VPT, age, and/or lower extremity muscle strength. VPT, age, and/or muscle strength were identified as predictors of balance and fear of falling in patients with type 2 DM. Therefore, along with age and lower extremity strength, the VPT can be useful for balance assessment in patients with type 2 DM.Diabetic peripheral neuropathy (DPN) is a common complication of type 2 diabetes mellitus (DM). DPN causes a decrease in proprioception, which could reduce balance ability. We investigated the association of impaired vibration sense, based on vibration perception threshold (VPT), with assessments of balance and other factors affecting balance impairment and fear of falling in patients with type 2 DM. Sixty-three patients with DM aged >50 years were categorized as having normal vibration sense (NVS;  Diabetes is a serious and chronic condition that negatively affects human life and burdens the health care system. The global prevalence of type 2 diabetes mellitus (DM) is increasing annually and was estimated at 6059 cases per 100,000 in 2017, and the number is predicted to rise to 7079 cases per 100,000 by 2030 ,5. AdultThe proprioceptive feedback of the lower extremities, in combination with visual and vestibular senses, provides the main sensory information to maintain and control posture. DPN causes a decrease in proprioception, such as a sense of position, decrease in the sense of vibration, loss of somatosensory feedback, and inappropriate motor response, which can reduce the ability to control balance ,10. In fDPN can be assessed in several ways using different types of symptom scores and several kinds of measurements . The vibIdentifying factors associated with balance impairment is another essential part of fall risk assessments of patients with type 2 DM. Although previous studies have reported that DPN is associated with an impairment of balancing ability ,14,15,16The objective of this study was: (1) to investigate the association between VPT and various balance measures, including postural steadiness, functional balance, and fear of falling, and (2) to identify significant factors affecting balance and fear of falling in patients with type 2 DM.In this cross-sectional study, a total of 63 patients with type 2 DM were recruited as subjects among patients who visited the diabetes clinic in the Department of Endocrinology and Diabetes of the University Hospital for the purpose of controlling type 2 DM. All subjects were over 50 years of age, medically stable, understood the instructions , and were able to stand independently. Subjects were excluded if they had musculoskeletal disorders , rheumatic disease, surgery , history of trauma of the lower extremity that could impair balance ability and lower extremity function, neurological disorders , visual impairment, or any other vestibular disease. All subjects provided written informed consent, and this study was approved by the Institutional Review Board of our hospital (EMCS 2020-04-023).The VPT was measured using a vibratory sensory analyzer VSA-3000 , a quantitative sensory testing (QST) computerized device. The examiner, who was not involved in administering the balance outcome measures, explained VPT test methods to the patients. Before the test trial, three practice trials were conducted to allow the examiner to explain the procedure and to help the patient become acquainted with the test. The patients were asked to sit on a chair. The VPT was assessed at four sites of the bare testing sole   by delivThe nerve conduction study (NCS) was performed to assess DPN severity by the physician experienced in the electrodiagnostic study. The composite score was calculated to confirm the significant difference in DPN severity between the two groups based on VPT, and the correlation between VPT value and composite score. The composite score consisted of peroneal motor distal latency, peroneal motor amplitude, peroneal motor conduction velocity, tibial motor distal latency, and sural sensory amplitude. The peroneal motor nerve was stimulated at the ankle and fibular head, with recording over the extensor digitorum brevis muscle. The conduction velocity was measured between the ankle and fibular head. The tibial motor nerve was stimulated posterior to the medial malleolus, with recording over the abductor hallucis muscle. The sural nerve was stimulated at 14 cm proximal to the lateral malleolus in the posterior calf line, with recording posterior to the lateral malleolus. Each component was transformed to an abnormal percentile relative to the distribution of the values of normal NCS . The points of the five components were totaled, divided by the number of attributes with available values, and multiplied by five .®  with the supervision of a physical therapist. The device has four individual plates  for measuring the vertical pressure fluctuations with a single axis load cell, which is one of the load sensor types using the strain gauge [® software to obtain the fall risk index, stability index (ST), Fourier index (FI), weight distribution index (WDI), and synchronization index. The patients stood in the center of four force plates and were instructed to maintain eight different postures, such as head rotation, upward, and downward, with eyes open, eyes closed, and on unstable surfaces. In this study, the postural steadiness was estimated with reference to the fall risk index, ST, and FI for a medium to high frequency of 0.5–1 Hz [Postural steadiness was evaluated by static posturography using the Tetraxin gauge . The ver0.5–1 Hz ,35,36,37® program [Fall risk index: The fall risk index is globally calculated using the data of ST, FI, WDI, and synchronization index, considering the oscillation velocities computed by the Tetrax program ,36,37. I program ,35,36,37Stability index (ST): The ST indicates the patient’s overall stability and ability to control postural change. The amount of postural sway is analyzed using the square root of the sum of the squared differences between consecutive pressure signals. Then, it is divided by the patient’s body weight ,35,37. AFourier index (FI): The FI is a regression analysis of the intensity of postural sway mathematically calculated using a Fourier transformation. It represents the frequency of postural sway within a variable spectrum between 0.01 and 3.0 Hz. Fourier power values are compared with the regression curve calculated by the software, evaluating the difference of coefficient between a graph of measured data and theoretically ideal regression . The FI The functional balance assessments were conducted by a physical therapist with 30 min of rest period after a postural steadiness assessment. The general instruction of functional balance tests was explained before the actual examination.Berg Balance Scale (BBS): The BBS is a tool for evaluating the functional balance required for movements related to actions encountered in daily life. It is composed of 14 tests, with each test scored from 0 to 4 points. The maximum score is 56 points, and a higher score reflects better functional balance ,40.Timed up and go (TUG) test: The TUG test was performed 30 min after the evaluation of BBS. The TUG test is a dynamic functional balance test, which measures the time it takes to stand up from the chair, turn around at a turning point at a 3 m distance at ordinary walking speed, and sit back on the same chair. The TUG test is useful for assessing a person’s functional mobility and the risk of falls in community-dwelling older people. In older adults, if the TUG test requires more than 12 s, the risk of falls is high ,42.Falls Efficacy Scale-International (FES-I): The FES-I is a widely used self-report questionnaire tool for evaluating concerns about falls while carrying out routine activities. The FES-I is simple and easy to administer, and its score categories cover both easy and difficult physical and social activities inside and outside the house . It is cp-value was <0.05, and removed variables for which the p-value was >0.1. All statistical analyses were performed using SPSS version 22.0 . Statistical significance was set at p < 0.05.To confirm the differences in fall index, BBS, TUG, and FES-I between the two groups (NVS and IVS) in this exploratory study, the sample size was calculated based on effect size = 0.8 (the large effect by Cohen), alpha = 0.05, power = 0.8, by an independent sample t-test using G-power 3.1.2 . The minimum required sample size was 26 in each group. Therefore, it was intended to enroll more than 26 patients per group. The baseline characteristics were analyzed using an independent sample t-test for continuous variables and a chi-squared test for nominal variables. An independent sample t-test was performed to assess the difference in postural steadiness and functional balance capabilities between the two groups. A Pearson’s correlation analysis was used to assess the correlation between balance parameters and VPT. Finally, a stepwise multiple linear regression was used to evaluate factors that affect postural steadiness and functional balance, respectively. Independent variables included age, sex, height, weight, body mass index (BMI), DM duration, glycated hemoglobin levels (HbA1c), Medical Research Council (MRC) score, presence of hypertension, chronic kidney disease, retinopathy, and the value of the VPT. To determine the final regression model, a variable was added to or removed from the model according to the repeated stepwise method algorithm that included variables for which the n = 34) and IVS (n = 29) groups. Demographic and clinical differences between the two groups are shown in p < 0.01). The composite score in the NCS was significantly higher in the IVS group than in the NVS group (p < 0.001). In the correlation analysis, there was a significant correlation between VPT and composite score . The differences in the other studied parameters  were not significantly different between the two groups (p > 0.05). Regarding the MRC score, five patients had lower limb weakness in the IVS group even though they had no musculoskeletal or neurological disorders belonging to the exclusion criteria of this study.Sixty-three subjects were recruited for this study and completed all the tests. Based on the VPT value of 8.9, the patients were classified into two groups: NVS , with increased TUG test scores  compared to the NVS group. The FES-I score was significantly higher in the IVS group than in the NVS group .p < 0.001; p < 0.001) and TUG test  for eight postural conditions.p < 0.001. In the multivariate analysis of BBS, a higher VPT and older age were associated with lower BBS with beta coefficients (95% CI) of −0.412 (−0.529–−0.294), p < 0.001; and −0.264 (−0.369–−0.160), p < 0.001, respectively. In the multivariate analysis of TUG, a higher VPT, older age, and lower MRC score were associated with a higher TUG with beta coefficients (95% CI) of 0.103 (0.017–0.188), p = 0.020; 0.209 (0.134–0.283), p < 0.001; and −1.848 (−3.133–−0.562), p = 0.006, respectively. In the multivariate analysis of FES-I, higher VPT, older age, and lower MRC score were associated with higher FES-I with beta coefficients (95% CI) of 0.209 (0.050–0.369), p = 0.011; 0.207 (0.067–0.347), p = 0.004; and −2.871 (−5.270–−0.472), p = 0.020, respectively.These results indicate that patients with DM with IVS, as indicated by the VPT, exhibited decreased postural steadiness and functional balance and increased fear of falling compared to those with NVS. The current study also suggests that the VPT value, as well as the presence of IVS, were significantly associated with postural steadiness, functional balance, and fear of falling. Diminished vibration sense contributes to balance deficits and increased fall risk ,47. In HTo date, the NCS is the most common method for the evaluation of DPN. However, it is painful, expensive, requires specific training, and quantitative assessment of the severity of DPN is more difficult compared to the use of VPT . The VPT® showed that only the VPT value influenced postural steadiness. Emam et al. reported that poor glycemic control, as assessed by HbA1c, along with DPN diagnosed by Hoffman’s reflex and electromyography, influenced postural instability using computerized posturography [® posturography assessment. This result suggests that in cases where it is necessary to evaluate the balance deficit exclusively due to DPN, postural steadiness assessment may be required.We identified differences in factors related to postural steadiness and functional balance capability in patients with type 2 DM. In terms of postural steadiness, computerized posturography using Tetraxrography . Guy et rography . DiffereThe results of this study showed that the VPT score and age had a significant association with the BBS and TUG test scores, which act as indicators of functional balance. This finding is consistent with previous studies that evaluated DPN by other methods ,52. BogdIt was identified that muscle strength is a factor that influences functional balance in patients with type 2 DM in this study. The muscle strength is related to the severity of DPN and may be caused by neurogenic atrophy due to axonal degeneration of the motor fibers . The musThe patients with IVS had a greater fear of falling than patients with NVS. This result is consistent with previous studies ,57. In B® posturography, patients with a relatively high level of functioning who could stand independently were enrolled in this study. However, it is meaningful that the VPT is useful for assessment of balance ability even in these patients who may not be suspected of poor balance in an outpatient setting. Using the advantage of VPT as a simple screening method, further research is needed in patients with type 2 DM with more severe disability and limited mobility.This study had some limitations. First, because the follow-up evaluation was not performed, which is a limitation of cross-sectional studies, we could not confirm any association between changes in the VPT and changes observed in balance. A prospective follow-up study is required in the future. Second, for evaluation of TetraxThis study demonstrated significant associations between VPT and several measures of balance ability in patients with type 2 DM. Postural steadiness was mainly affected by the VPT; however, age and/or muscle strength in the lower extremity were also related to functional balance and fear of falling. Therefore, along with age and lower extremity strength, the VPT might be useful for balance assessment, thus serving as a marker for fall risk in patients with type 2 DM.