The aims of this study were to estimate the prevalence of left ventricular systolic (LVSD) and diastolic (LVDD) dysfunction, and to test if BNP and urinary albumin excretion rate (AER) are related to LVSD, LVD and left ventricular mass (LVM) in asymptomatic type 2 diabetes patients.Presence of LVSD, LVDD and LVM, determined with echocardiography, was related to levels of BNP and AER in 153 consecutive asymptomatic patients with type 2 diabetes.LVSD was present in 6.1% of patients whereas 49%  had LVDD and 9.4% had left ventricular hypertrophy. Increasing age (P < 0.0001) was the only independent variable related to mild LVDD whereas increasing BNP (P = 0.01), systolic blood pressure (P = 0.01), age (P = 0.003) and female gender (P = 0.04) were independent determinants of moderate to severe LVDD. AER (P = 0.003), age (P = 0.01) and male gender (P = 0.006) were directly and independently related to LVM.About half of asymptomatic type 2 diabetes patients have LVDD. Of those, more than one third display moderate LVDD pattern paralleled by increases in BNP, suggesting markedly increased risk of heart failure, especially in females, whereas AER and male sex are related to LVM. The steadily increasing prevalence of diabetes constitutes a major health problem. By the year 2025, the prevalence of diabetes is estimated to be as high as 5.4% . This isThe study population consisted of 153 consecutive patients with type 2 diabetes with no history of symptoms of cardiovascular disease being part of a screening program for heart disease in type 2 diabetes patients without known macrovascular disease in Malmö, Sweden. This is a joint venture between the primary care in Malmö and the departments of cardiology and endocrinology at Malmö University Hospital. Patients with newly diagnosed diabetes without known cardiovascular disease are examined thoroughly, (e.g. with echo and a broad range of cardiovascular risk factors) and interventions are executed on the basis of the examination results. The patients were admitted consecutively and the mean age was 55 ± 11 years, though our aim was to examine newly diagnosed diabetes patients, the duration of diabetes was found to be longer than expected, 6.3 ± 7.2 years and 46% of the patients had hypertension. Clinical and biochemical characteristics are shown in table Blood pressure was measured three times in the right arm in seated position after 10 min rest and the mean value of the three recordings was calculated. Korotkoff sounds corresponding to 'phase I' was used to define the systolic and 'phase V' the diastolic blood pressure. Hypertension was defined as systolic or diastolic blood pressure of 140/90 mmHg or greater or use of antihypertensive medication.Diabetes mellitus was defined as a fasting whole blood glucose level greater than 109 mg/dL (6.0 mmol/L) or use of antidiabetic medication.All patients underwent complete 2-dimensional echocardiography and Doppler studies in the left lateral decubitus position from multipline windows, using commercially available equipment  with a phased array transducer of 2.5 MHz, and with a system equipped with Doppler tissue imaging technology. Pulsed Doppler tissue imaging is a new echo method based on the display of low frequency, high amplitude Doppler signals originated in the myocardium. A detailed concept and technical aspects of this approach have previously been published ,10. All In addition to pulsed Doppler tissue imaging, conventional echo was performed, including M-mode, 2-dimensional, pulsed and colour Doppler echocardiography. Right ventricular and left ventricular diameters, left and right atrium diameters, septal and posterior wall thickness were measured according to the recommendations of the American Society of Echocardiography, and left ventricular ejection fractions were calculated using the biplane Simpsons . The sevThe assessment of the severity of the valvular stenoses and regurgitations was performed using a combination of qualitative and quantitative analysis based on echocardiographic spectral and colour Doppler measurements.2 in women and 125 g/m2 in men. LV-mass (LVM) was calculated according to the formula:The assessment of diastolic heart function was defined according to European Society of Cardiology  and LVDDPWTd: posterior wall thickness in diastole, SWTd: septal wall thickness in diastole, LVIDd: left ventricular inner diameter in diastole.creat (mmol/l)) × (1:73 (m2)/BSA (m2)).At the time of echocardiography, venous blood was sampled and transferred into pre-chilled EDTA vacutainers for analysis of BNP. Immediately after sampling the tubes were placed on ice and centrifuged at 4°C before plasma aliquots were frozen at -70°C for later analysis. Plasma BNP was measured with the Triage BNP Assay from Biosite Inc, San Diego, CA, using the UniCel™ immunoassay System from Beckman Coulter Inc, Brea, Ca. Lower limit of detection is 1 pg/mL (0.29 pmol/L). Within assay CVs are 3.1% and 1.0% at the levels of 40.8 and 1343 pg/mL. Corresponding between assay CVs are 4.5 and 6.6%. HbA1c was analysed using the Variant II chromatographic method from Bio-Rad  with a coefficient of variance (CV) of 3.0% at HbA1c 4.4-8.8%. The urinary albumin concentration was measured in over-night urine collections (12 hours) using an immunoturbimetric method . Glomerular filtration rate (GFR) was calculated from the the Cockcroft-Gault formula; GFR (mL/min/1.73 m2) = ((140-age (years)) × body weight (kg))/. Univariate differences in continuous variables was tested using Student's t-test with skewed variables being ln-transformed before analysis whereas chi-2 test was used to for differences in dichotomised variables. Correlation coefficients were calculated using Pearson's or Spearman's correlation analysis depending on normality of the residuals. Linear regressions, with skewed variables were ln transformed, and logistic regressions were used to test for multivariate relationships with continuous and dichotomous variables, respectively. All baseline variables table  were entClinical and biochemical characteristics are shown in table In a univariate analyses lnAER was significantly correlated  and lnBNP showed a strong tendency without reaching the level of statistical significance  with LVM. However, in a multivariate linear regression model including all baseline covariates . However, in a multivariate logistic regression analysis, increasing age (P < 0.0001) remained the only independent variable related to mild LVDD.When comparing patients with and without mild diastolic dysfunction (patients with moderate to severe LVDD excluded), we found no difference in lnBNP or lnAER, although there was a tendency towards higher lnBNP in patients with mild LVDD . Patients with mild LVDD were found to be significantly older , have longer duration of diabetes  and lower GFR (99 ± 27 vs 120 ± 33 ml/min/1.73 m2 P < 0.005). In multivariate logistic regression analysis the OR for moderate to severe LVDD per one unit increase in the respective variable was calculated. BNP, systolic blood pressure (SBP), age and female gender were all independently influencing the risk of moderate to severe LVDD per one unit increase in the respective variable. The multivariate adjusted OR (95% CI) for moderate to severe LVDD was 1.14 (1.03-1.25) for BNP, 1.05 (1.01-1.09) for SBP, 1.10 (1.03-1.16) for age and 3.61 (1.03-12.7) for female gender. Furthermore, a ROC analysis was performed to evaluate the diagnostic performance for BNP as a discriminator for the detection of moderate to severe LVDD, and was expressed as a calculation of area under curve (AUC) level. Regarding the ability to diagnose if moderate to severe LVDD was present, ROC analysis showed a significant diagnostic performance for BNP (AUC = 0.74 (0.62-0.85), p < 0.0001) for the detection of moderate to severe LVDD.Patients with moderate to severe LVDD had significantly higher lnBNP   in presumably heart healthy asymptomatic patients with type 2 diabetes. These findings are well in line with earlier studies i.e. data from Poirier et al were 46 men with type 2 diabetes who were aged 38-67 years; without evidence of diabetic complications, hypertension, coronary artery disease, congestive heart failure, or thyroid or overt renal disease; and with a maximal treadmill exercise test showing no ischemia, were studied. Twenty-eight of the subjects (60%) were found to have LVDD, of whom 13 (28%) had moderate LVDD and 15 (32%) had mild LVDD .In our study, LVH was observed in only 9.4% of the patients. Fang et al. reported that in asymptomatic patients with diabetes mellitus without known cardiac disease, which underwent clinical evaluation and detailed echo assessment, approximately 20% fulfilled the criteria for LVH.It has recently been published data by Srivastava and coworkers, showing a high prevalence of LVDD and LVH (59% and 70% respectively)  in patieWe have previously reported that patients with type 2 diabetes have higher levels of BNP compared to patients without diabetes, indicating a high prevalence of asymptomatic heart disease . HoweverOn the other hand, we did not found any significant relationship between BNP and mild LVDD or LVM, respectively. In accordance with the latter finding, screening with BNP for the presence of LVH in hypertensive patients has showed limited value .Whereas BNP was not associated to LVH, our data suggests that AER could be useful as a marker for LVH, as estimated by LVM, given its independent and direct relationship with LVM. An independent relationship between LVM and AER has not been reported earlier in type 2 diabetes and further emphasizes increased CVD risk and need of antihypertensive treatment in type 2 diabetes patients with microalbuminuria. Thus, this finding might serve as an explanatory model for the known risk of CVD in patients with microalbuminuria , since LThe correlation between male gender and LVM is in line with the study by Concardy et al in 2004, in which it was shown that the LVH estimation without sex-specific criteria underestimated the prevalence of LVH in women and overestimates it in men, and even if sex specific definitions for LVH was used male gender still contributed to the prevalence of LVH in this study .Another interesting finding from the present study is the increased risk for moderate LVDD for female study subjects. The mechanism behind such a gender dependent pathophysiology is unclear. However, the results of the Framingham study revealed that between the ages of 45 and 75, men and women with diabetes had a two-fold- and five-fold increase in risk of developing heart failure, respectively, compared to patients without diabetes. This risk persisted even after considering age, blood pressure, cholesterol, weight, and history of coronary artery disease . FurtherIn our study almost half of the study population had LVDD and nearly ten percent had LVH. The treatment of LVH and LVSD is well established and has proved to reduce cardiovascular complication ,5. HowevIn conclusion, this study has demonstrated that echo screening of asymptomatic diabetic subjects with apparently normal cardiac function may identify significant numbers of patients with asymptomatic LVDD and LVH. Almost half of the presumably heart healthy population had LVDD. BNP discriminates patients at high risk for moderate to severe LVDD, and might therefore be used as screening tool in order to capture patients eligible for further risk stratification with echo. LVH was associated with male gender and AER, whereas moderate LVDD was associated with female gender and BNP, implying gender specific mechanism in the development of CVD.The authors declare that they have no competing interests.MM and OM have participated in the design of the study, performed the statistical analyses and drafted the paper. SJ, LG and BI conceived the study, participated in its design and coordination and helped to draft and review the manuscript. KS helped in the data organization and retrieval, English editing and final draft preparation. All of the authors have read and approved the final manuscript.


Unconventional therapy (UT) is a therapeutic practice of alternative and complementary medicine that is not currently considered an integral part of modern medical practice. The aim of this article is to investigate the experience of Saudi patients with UT modalities in the treatment of asthma.We carried out a cross-sectional study of asthma patients referred to King Abdulaziz Medical City, Riyadh, Saudi Arabia, during the year 2004. Information was collected using a pre-designed questionnaire administered through interviews.P = 0.029) and among those with longer duration of disease (P = 0.009). However, there was no significant correlation observed between the use of UT and gender, FEV1, or disease control. The most commonly used form of UT was recitation of Holy Quran (9%), honey (24.5%), herbs (23.5%), cautery (12%), and blackseed (10%). There was no significant correlation between disease control and the use of modalities.Two hundred consecutive patients with a mean age of 52.3 years (±18.7) were included in this study. Sixty-nine (34.5%) of those patients used some form of UT in the previous year. There was a tendency to use UT among the older age group (Unconventional therapy is frequently practiced by asthma patients in Saudi Arabia, who commonly believe that UT will lead to improvement. The lack of evidence necessitates the fostering of a national project to address the practice of UT. Asthma is a chronic inflammatory disorder with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. These episodes are usually associated with reversible airflow obstruction. Modern gSaudi Arabia is a country that has invested heavily in the infrastructure of a modern health care system in the past three to four decades. The world map developed by the World Health Organization shows that more than 95% of the Saudi population has access to asthma medications. Neverthe1) was done by Jaeger Master Lab, Germany. FEV1 was calculated from the best of three trials according to the criteria recommended by the American Thoracic Society.[A cross-sectional study was carried out on patients diagnosed with asthma who were referred to the Adult Pulmonary Clinic during the year 2004 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. The inclusion criteria included age above 21 years, history of asthma for more than a year, and consenting to answer the study questionnaire. The patients were interviewed using a pre-designed questionnaire that included demographic data, compliance to medications, and the use of unconventional modalities in the previous year. Disease severity was determined by the application of the Global Initiative for Asthma (GINA) classification of disease severity. Forced e Society. The assoContinuous variables were summarized by calculating the mean and the standard deviation, whereas categorical variables were summarized by calculating the number and percentage. The association between the use of UT and the different categorical variables was assessed by using the Chi-squared test , whereas the t-test was used for the association with continuous variables by using SPSS program.1 within 12 months prior to the interview was 74% (±28.7%). Sixty-nine (34.5%) patients used unconventional therapy. P = 0.66).Two hundred consecutive patients were interviewed. The mean age was 52.3 years (±18.7). There were 78 males and 122 females, with male:female ratio of 1:1.56. The educational level was more than the high school level in 113 patients (56.5%). The percentage of mean FEVP value = 0.938). There was a tendency to use UT among the older age group with mean age of 56.2 years (±18.7), compared to mean age of 50.2 (±18.2) for those who did not attempt UT (P = 0.029). There was also a trend of using UT in asthma patients with longer duration of disease, with a mean duration of 16.0 months (±12.2), compared to mean duration of 11.2 (±11.9) for those who did not attempt UT (P = 0.009). The mean percentage of FEV1 was 69.8% (±29.7%) for those who used UT, compared to 76.1% (±28.1) for those who did not use UT, which did not reach statistical significance (P = 0.15). Fifty (44.3%) patients with educational level more than the high school level used UT, compared to 19 (21.9%) patients with educational level less than the high school level who used UT (P < 0.001).Twenty-seven (34.2%) male patients used UT to 42 (34.7%) female patients, which was not significant , garden cress , acupuncture, tea, and mint.[and mint.–12 Thereand mint..P = 0.1).By applying the newly introduced disease control index, 96 (48.0%) patients had controlled disease, 38 (19%) had partially controlled disease, and 66 (33%) had uncontrolled disease. Out of the 69 patients who used UT, 39 (57.0%) claimed to have observed some benefits; out of whom 26 (66.7%) would advise their friends to try UT. Nevertheless, 59 (85.5%) believed that modern therapy was more effective than UT. Most of the study population (98.5%) continued to use conventional medical treatment, including those who were trying UT.Unconventional therapy has grown considerably in the past decades despite the limited evidence of the efficacy of most UT modalities. The incrth century had their origins in folk medicine and were developed by isolating the active substances or duplicating them in the form of synthetic products.[ma huang. Theophylline was found in tea leaves. An anticholinergic effect was achieved by heating henbane leaves. Cromolyn, which is a derivative of Ammi visnaga, is the source of the bronchodilator Khella, found in the Middle East.[The favored conventional drugs used in the second half of the 20products. Ephedrindle East.17vs. the benefits of UT.In this study, approximately one-third of the study population had tried UT. In the United Kingdom, 60% of people with moderate asthma and 70% with severe asthma have used complementary or alternative medicine. Another {If Allah touch thee with affliction, none can remove it but He; if He touch thee with happiness, He hath power over all things} . There are several verses in the Holy Quran related to the healing effect {O mankind!, there hath come to you an admonition from your Lord and a healing for the (diseases) in your hearts and for those who believe, a Guidance and a Mercy} . This verse explains why the believers would ask for Quran recitation to heal their disease.The author has observed that Holy Quran recitations are frequently practiced for healing purposes in Saudi Arabia, which is related to the deep belief prevailing in the studied community that One-quarter of the study population used honey as UT for asthma. To the best of author's knowledge, there is no available scientific evidence yet to support the use of honey in asthma.There is healing in the blackseed for every disease except death,” prophet Mohammed said over fourteen centuries ago. Ibn Sina (980–1037), in describing the blackseed, said, “It stimulates the body's energy and helps recovery from fatigue or disspiritednessy.” A report from Saudi Arabia showed that blackseed has thymoquinoneinduced relaxation of guinea-pig isolated trachea, either alone or in combination with honey.[Ten percent of the study population used blackseed. “th honey. There isth honey.–27Arabic: attar). These were given as unknown mixtures to the patients. The contents of such mixtures raise genuine concerns since some perfume makers may mix asthma medications such as theophylline and corticosteroids with herbs.[Garlic, which was used in 4.5% of the patient population, has some physiological value in that it improves natural body defenses and may be beneficial to chronic airway inflammation. In a Cocth herbs. In a natth herbs. In a sysSome limitations should be noted with regard to this study. The patients represented those referred to a tertiary care center, where more patients are expected with moderate and severe disease. Also this sample might not represent the pattern of all UT modalities used in the community, as some patients may have felt reluctant to disclose to a health care professional the type of UT that they used.Unconventional therapy is frequently practiced by patients with asthma in Saudi Arabia who hold the common belief that it will lead to improvements. This would lead to certain implications from this study: (1) it is recommended that the use of UT undergo further investigation to evaluate the extent of the use and efficacy; (2) it would be interesting to conduct randomized controlled studies to obtain evidence for the benefits of UT and to evaluate the positive perception that patients have observed form UT; (3) because individuals using UT are more involved in the decision-making process and have more control of the illness, they would attempt to use these modalities. This nec


The health-related quality of life (HRQOL) of hypertensives may be influenced by blood pressure, adverse effects of drugs used to treat hypertension, or other factors, such as the labelling effect, or beliefs and attitudes about illness and treatment. There is paucity of information on the determinants of HRQOL among black hypertensives especially in the developing countries such as Nigeria. This study describes the HRQOL and its determinants among black patients diagnosed and treated for Hypertension in Nigeria.The study was a cross sectional in design that involved 265 hypertensive patients receiving treatment at the medical outpatient unit of the Federal Medical Centre Abeokuta, Nigeria. They were all consecutive patients that presented at the hospital during the period of the study who meet the inclusion criteria and consented to participate in the study. Demographic data, disease characteristics such as symptoms and signs and recent drug history were obtained from the patients and their hospital records as documented by the physician. The SF-36 questionnaire was administered once by interview to the participants to measure their HRQOL. Descriptive statistics was used in summarizing the demographic data and hypertension related histories of the participants. Multiple linear regression was used to model for the influence of socio demographic and clinical variables of the hypertensives on their HRQOL.Physical functioning domain mean score was far below average (33.53 ± 29.65). Role physical and role emotional domains were a little above average . Role Physical (p = 0.043), Role Emotional (p = 0.003), Vitality (p = 0.014) and Mental Health (p = 0.034) domain mean scores for patients with controlled BP were significantly higher than patients with uncontrolled BP. The overall HRQOL was significantly better in the group of hypertensives with controlled blood pressure (p = 0.014). Increasing blood pressure (p = 0.005) and symptom count (p < 0.001), the presence of stroke (p = 0.008) and visual impairment (p = 0.015) were significant negative predictors of the overall HRQOL.This study provides evidence for a model that links patients' status with regard to biology (blood pressure), symptoms, and functionality (HRQOL) and may prove useful in guiding follow-up of patients who receive treatment for hypertension. Identification of patient's symptoms, blood pressure, complication/comorbidity and changes in functioning may help clinicians increase their effectiveness in helping patients maintain adherent behaviour with drug and non drug interventions in chronic diseases such as hypertension. Hypertension is a condition with tremendous financial and public health impact. The cost of inadequately controlled blood pressure can be measured financially and medically with financial impact in the United States being US$47.2 billion in direct and indirect cost in 2001[Although hypertension, especially in mild to moderate stages, is usually considered as an asymptomatic condition, its association with alterations in well-being and health-related quality of life (HRQOL) is still a controversial issue . The relThe profile and predictor of HRQOL of hypertensive patients has been documented in studies from non-black populations  receiving treatment at the medical outpatient clinic. The clinic runs four times a week with an average attendance of 200 patients weekly. All hypertensive patients seen at the clinic during the period of this study (three months) who met the inclusion criteria were invited to participate in this study. Sample size was determined using data from a previous study , where tClinical and disease characteristics included in this study were symptom counts, symptom prevalence, pattern of antihypertensive regimen, co morbidities/complications, body mass index (BMI), self reported duration of hypertension diagnosis, status of hypertension control, height & weight of patient, blood pressure (BP) and mean arterial blood pressure (MABP). Symptom counts  were meaThe Short Form-36 (SF-36) Health Survey, version 2.0  was usedp-value for addition to the model was p < 0.05 and for removal from model p > 0.1. A p < 0.05 was considered statistically significant; confidence interval was calculated for the β-estimate.Descriptive statistics was used in summarizing the demographic data and Hypertension related histories of the participants. The association between QOL scores, socio demographic and clinical variables were determined using stepwise multiple linear regression analyses with QOL score as the outcome variable, while socio demographic and clinical variables were predictor variables. Duration of hypertension diagnosis, age and MABP of respondents were used as continuous predictor variables while other non-linear categorical predictor variables were dichotomized for the purpose of the multiple linear regressions. The Three hundred hypertensive patients were invited to participate in this study out of which 265 participated thus giving a response rate of 85.3%. Twenty five (8.3%) patients declined to participate due to personal reasons while 10 (3.3%) patients did so due to lack of interest. The mean age of the 265 hypertensive patients who participated was 62.4 ± 10.7 years. Less than half of the respondents (43.4%) were male and 32.1% had tertiary education. About three-quarter (76.2%) of the respondents were married and 97.7% of them were of the Yoruba tribe. Few of them (8.3%) were blue collar workers and 66.4% of the respondents were Christians. Although 50.6% had no symptoms, the most prevalent symptom reported was frequent insomnia in 37% of respondents. Diabetes Mellitus was the most frequent co morbidities/complication in 23.6% of respondents. Anti-hypertensive medication prescribed was mainly combination therapy in 65.7% of respondents. The mean duration of hypertension diagnosis for respondents was 4.7 ± 6.1 years. Blood pressure was controlled in 52.1% of the respondents (that is systolic and diastolic blood pressure was less than 140/90 mmHg). Table Table Table Many studies ,5,9,10 hIn this study the Physical Functioning domain mean score was far below average (33.53 ± 29.65). Role Physical  and Role Emotional  domains were a little above average . Other domains were far above average. These domain scores are far lower than those presented by Bardage & Isacson -14 henceThe QOL of hypertensives who had controlled blood pressure and those with uncontrolled blood pressure was compared. The physical component summary (PCS) score of the QOL was not significantly different (p = 0.16) between the two groups of hypertensives but the mental component summary (MCS) score and the total T-QOL score were significantly different (p = 0.004 & 0.014 respectively) for the two groups of hypertensives. Shapiro et al, reporteResults from multiple regression analysis revealed that a hypertensive that has a low blood pressure (MABP less than 108), no symptom, any form of education, and does not have a stroke or visual impairment would have a better mental component of HRQOL than any hypertensive who does not have these characteristics. A hypertensive patient who has BMI less than 30 (not obese) and no symptom will have a better physical component of HRQOL than any hypertensive patient who does not have these characteristics. Also, a hypertensive patient who has blood pressure (MABP) less than108, no symptom and who does not a have stroke or visual impairment will have a better overall HRQOL than a hypertensive who does not have these characteristics. The adverse influence of increasing blood pressure on HRQOL has been well documented in literature,9,15,23 The data from this study may be subject to Berksonia's bias as the respondents were all hypertensives who presented in the hospital with specific complaint. In other to make generalizable conclusions, a population based study using a probability sampling technique will be recommended to survey the HRQOL of hypertensives at other meeting points apart from the hospital. This may give a more objective description of their HRQOL. Cross cultural content validity of the SF-36 questionnaire was assumed in this study. This presents a major limitation when comparing the concept of quality of life in different cultures as the respondents understanding of the questions might vary. This bias was minimized by ensuring that the interviewers were trained in the questionnaire administration and the questionnaire was translated into the local language of the study location with forward and backward translation.Nevertheless this study provides evidence for a model that links patients' status with regard to biology, symptoms, and functionality (HRQOL) and by implication may prove useful in guiding follow-up of patients who receive treatment for hypertension. Identification of patient's symptoms, complication/co morbidity and changes in HRQOL will help clinicians increase their effectiveness in helping patients maintain adherent behaviour with drug and non drug interventions in chronic diseases such as hypertension. Findings from this study shows that the predictors of HRQOL  in black hypertensive patients are not essentially different from those reported in non-black population although the co morbidities and complications in question are diverse.Results from this study revealed that none of the socio-demographic and clinical characteristics of the respondents significantly affected their control of blood pressure, but the HRQOL was significantly better in the group of hypertensives that had controlled blood pressure. Blood pressure and symptoms counts are major predictors of HRQOL in hypertensives. The presence of Stroke and Visual defect as a co morbidity or complication are also major determinant of the HRQOL of hypertensives.The authors declare that they have no competing interests.MOO participated in the acquisition of the data and conceptualisation of the study, performed statistical analysis, and drafted the manuscript; BA & MDD reviewed data analysis results and critically revised the manuscript. NAO participated in the conceptualisation of the study and critically revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


After neck surgery, we usually apply a pressure dressing with a non-woven, adhesive fabric to reduce bleeding and fluid collection at the operative bed. We conducted a prospective, randomized, controlled study to evaluate a pressure We studied 108 patients who underwent 116 thyroid surgeries at Srinagarind Hospital, Khon Kaen University, between December 2006 and September 2007. The patients were randomized to either the pressure dressing or non-pressure dressing group. Ultrasound of the neck was performed 24 ± 3 hours after surgery. The volume of fluid collection in the operative bed was calculated. All patients were observed for any post-operative respiratory distress, wound complications, tingling sensation or tetany.p = 0.150) and the collected drained content (p = 0.798). The average time a drain was retained was 3 days. One patient in the pressure dressing group suffered cutaneous bruising while one patient in the non-pressure dressing group developed immediate hemorrhage after the skin sutures.The distributions of age, sex, surgical indications and approaches were similar between the two groups. There was no statistically significant difference in the volume of fluid collection in the operative bed (Pressure dressing after thyroidectomy does not have any significant impact on decreasing fluid collection at the operative bed. The use of pressure dressing after thyroidectomy may not therefore be justified.NCT00400465, ISRCTN52660978 About 200 cases of thyroidectomy are performed per year at Srinagarind Hospital, Khon Kaen University. An acute complication of this operation can lead to a fatal hematoma due to an upper airway obstruction (in 1 to 2.5 percent of cases) , requiriAfter surgery, we usually apply a pressure dressing using a non-woven, adhesive, fabric to help reduce bleeding and collection of fluid on the basis that it may help to decrease dead space, compress bleeding vessels, decrease the slipping of ligature, the re-opening of cauterized veins, and the oozing area, all of which might precipitate a hematoma at the operative bed. The obvious external evidence of hematoma is a change in the neck contour or bulging skin flaps ,6. Thesevs. non-pressure dressing after thyroid surgery, by monitoring fluid accumulation in the operative bed by ultrasound and by collecting serum in suction drains.We conducted a prospective, randomized, controlled study to assess the role of a pressure Approval was sought from the Khon Kaen University Ethics Committee for Human Research before initiating the study and informed consent was given by the patients. The study was carried out on 108 patients who underwent 116 thyroid surgeries at Srinagarind Hospital, Khon Kaen University, between December 2006 and September 2007. The discrepancy between the number of patients and the number of surgeries was due to 8 patients having undergone completion thyroidectomies for well-differentiated thyroid carcinomas confirmed by histopathology. These 8 patients were randomized as fresh cases with no consideration given to any previous surgery.We excluded patients (1) with cervical lymph node metastases requiring neck dissection, (2) clinical or laboratory indicators of coagulation disorders or (3) whose bleeding cannot be stopped by ligation and/or cautery or (4) with anaplastic (undifferentiated) carcinoma, which is typically large and invades adjacent structures.®); in the non-pressure dressing group, gauze was placed on the incision site and held in place with permeable plastic tape (Transpore®).We stratified patients into two groups according to operation field extension. The first group comprised patients who underwent lobectomy or completion thyroidectomy and the second group patients who underwent subtotal or total thyroidectomy. The patients in each group were then randomized to either the pressure or non-pressure dressing group using a computer-generated randomization list with balanced blocks of unequal size. The treatment assignments were contained in sealed, opaque, sequentially-numbered, individual envelopes. After randomization, a nurse, not involved in the surgery, opened the envelope and independently prepared the dressing material. We used conventional knot-tying ligation for medium-sized vessels and the monopolar electrothermal vessel-sealing system for small-sized vessels to achieve vascular control. The operating surgeon was informed of the assignment group after having completed closure of the wound to avoid bias during operation. In the pressure dressing group, gauze was placed throughout the operative area and pressure applied with a non-woven, adhesive fabric (Hypafix®), was threaded through a separate wound. A single drain was used in patients who underwent lobectomy or completion thyroidectomy vs. two closed suction drains for patients who underwent subtotal or total thyroidectomy.The closed suction drain, with negative pressure (Radivac® 9) of the neck was performed after surgery 24 ± 3 hours by the same head and neck radiologist or under his/her supervision. The dressing material was removed at the ward before the patient was taken for ultrasound so as not to apprise the radiologist of the type of dressing. The volume of fluid collection in the operative bed was calculated by measuring the maximum diameter in three dimensions; on the assumption that collection would be in the form of an ellipse or sphere [Volume ultrasound . The normal distributions of data were tested by Kolmogorov-Smirnov test. The effectiveness between the pressure and non-pressure dressing groups were analyzed using the unpaired Of the 116 thyroid surgeries conducted, there were 15 (12.9%) males and 101 (87.1%) females. The average age of patients was 45.45 years . Pressure dressings were used for 57 patients and non-pressure dressings for 59. A protocol violation occurred in 2 patients assigned to the pressure dressing group as the surgeon used only one drain instead of two after a subtotal thyroidectomy.Of the operations performed 65.5% (in 76 patients) were lobectomy. Age and sex were statistically similar between the two groups. The reasons for surgery included: thyroid nodule in 65 (56%) patients, multinodular goiter in 23 19.8%), Graves' disease in 9 (7.8%) and thyroid carcinoma in 19 (16.4%). The distributions of the surgical indications and approaches were similar between the two groups . The average drained content from the pressure vs. the non-pressure dressing groups was 59.88 and 62.63 mL, respectively, which was not a statistically significant difference (p = 0.798) . One patient in the pressure dressing group suffered cutaneous bruising; while an immediate hemorrhage after skin suture developed in one patient from the non-pressure dressing group. In the latter case, we re-explored and found ligation material was dislodged from anterior jugular vein. No patient had any post-operative respiratory distress, tingling sensation or tetany . The etiology includes slipping of ligature on major vessels (which occurred in this study), reopening of cauterized veins, retching, vomiting, bucking during recovery, valsalva maneuver, increased blood pressure during recovery, large dead space and oozing from the cut area of the thyroid . In our Although many surgeons have gone beyond abandoning a pressure dressing to completely avoiding the use of a drain ,9, to ouOur average hospital stay was slightly longer (5 days) than that of other institutions (3–6 days),13, perhIn our study, when using a pressure dressing over against a non-pressure dressing, fluid collection at the operative bed and collected drained content was lower in the pressure dressing group. This matched our hypothesis but there was no significant difference. Considering theory on the late detection of hematoma in pressure dressing due to a widely closed area, we did not find either immediate or late hematoma in this group. We suggest that the pressure dressing may have a benefit for preventing hematoma but a larger, randomized, controlled trial is required to establish this practice.Pressure dressing after thyroidectomy does not provide any significant benefit vis-à-vis decreasing fluid collection at the operative bed. The use of a pressure dressing after thyroidectomy may, therefore, not be justified.The author(s) declare that they have no competing interests.PP designed and supervised the research; collected, analyzed, and interpreted the data; and drafted and revised the manuscript. PV contributed to the conceptual design of the study. WR contributed to the conceptual design and coordinated the project. WP did the ultrasonographic assessments. ST made substantial contributions to the design of the study and approved the final version of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


ALDH2 encodes a major enzyme involved in alcohol metabolism. Individuals homozygous for the null variant (*2*2) experience adverse symptoms when drinking alcohol and consequently drink considerably less alcohol than wild-type homozygotes (*1*1) or heterozygotes. We hypothesise that this polymorphism may influence the risk of hypertension by affecting alcohol drinking behaviour.Alcohol has been reported to be a common and modifiable risk factor for hypertension. However, observational studies are subject to confounding by other behavioural and sociodemographic factors, while clinical trials are difficult to implement and have limited follow-up time. Mendelian randomization can provide robust evidence on the nature of this association by use of a common polymorphism in ALDH2 genotype with blood pressure  and hypertension  using studies identified via systematic review. In males, we obtained an overall odds ratio of 2.42  for hypertension comparing *1*1 with *2*2 homozygotes and an odds ratio of 1.72  comparing heterozygotes (surrogate for moderate drinkers) with *2*2 homozygotes. Systolic blood pressure was 7.44 mmHg  greater among *1*1 than among *2*2 homozygotes, and 4.24 mmHg  greater among heterozygotes than among *2*2 homozygotes.We carried out fixed effect meta-analyses of the These findings support the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension. Using a mendelian randomization approach Sarah Lewis and colleagues find strong support for the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension. High blood pressure (hypertension) is a common medical condition that affects nearly a third of US and UK adults. Hypertension has no symptoms but can lead to heart attacks or strokes. It is diagnosed by measuring blood pressure—the force that blood moving around the body exerts on the inside of large blood vessels. Blood pressure is highest when the heart is pumping out blood (systolic pressure) and lowest when it is filling up with blood (diastolic pressure). Normal blood pressure is defined as a systolic pressure of less than 130 millimeters of mercury (mmHg) and a diastolic pressure of less than 85 mmHg (a blood pressure of 130/85). A reading of more than 140/90 indicates hypertension. Many factors affect blood pressure, but overweight people and individuals who eat too much salty or fatty foods are at high risk of developing hypertension. Mild hypertension can often be corrected by lifestyle changes, but many people also take antihypertensive drugs to reduce their blood pressure.ALDH2 *2*2 genotype (genetic makeup) and become flushed and nauseated after drinking. Consequently, they drink less than people with a *1*2 genotype and much less than those with a *1*1 genotype. Because inheritance of these genetic variants does not affect lifestyle factors other than alcohol intake, an association between ALDH2 genotypes and blood pressure would indicate that alcohol intake has an effect on blood pressure without any confounding.Another modifiable lifestyle factor thought to affect blood pressure is alcohol intake. Observational studies that ask people about their drinking habits and measure their blood pressure suggest that alcohol intake correlates with blood pressure, but they cannot prove a causal link because of “confounding”—other risk factors associated with alcohol drinking, such as diet, might also affect the study participant's blood pressures. A trial that randomly assigns people to different alcohol intakes could provide this proof of causality, but such a trial is impractical. In this study, therefore, the researchers have used “Mendelian randomization” to investigate whether alcohol intake affects blood pressure. An inactive variant of aldehyde dehydrogenase 2  has been identified. People who inherit the variant form of this gene from both parents have an ALDH2 gene variant is common) on associations between ALDH2 genotype and blood pressure or hypertension using a detailed search protocol (a “systematic review”). A meta-analysis  of the studies that had investigated the association between ALDH2 genotype and hypertension showed that men with the *1*1 genotype  and those with the *1*2 genotype  were 2.42 and 1.72 times more likely, respectively, to have hypertension than those with the *2*2 genotype . There was no association between ALDH2 genotype and hypertension among the women in these studies because they drank very little. Systolic and diastolic blood pressures showed a similar relationship to ALDH2 genotype in a second meta-analysis of relevant studies. Finally, the researchers estimated that for men the lifetime effect of drinking 1 g of alcohol a day  would be an increase in systolic blood pressure of 0.24 mmHg.The researchers identified ten published studies The MedlinePlus encyclopedia has a page on hypertensionThe American Heart Association provides information for patients and health professionals about all aspects of hypertension, including information about alcohol affects blood pressureThe UK Blood Pressure Association provides information for patients and health professionals on The Explore@Bristol science center (a UK charity) provides an alcohol unit calculator and information on the effects of alcoholThe International Center for Alcohol Policies provides drinking guidelines for countries around the world Observational epidemiological studies have generally reported that blood pressure is lower among individuals with a moderate alcohol intake than in nondrinkers, but that heavy alcohol intake is associated with an increase in blood pressure –4. HowevRandomized controlled trials in which individuals are randomized to drink different amounts of alcohol are problematic for ethical reasons and in terms of compliance, so trials have generally randomized individuals who drink at least moderate amounts of alcohol to receive interventions aimed at reducing drinking. It is difficult to know how successful such interventions are, and how taking part in a trial aimed at reducing alcohol intake influences reporting of  drinking behaviour. Furthermore, follow-up is generally short-term, whereas alcohol intake may have long-term effects on blood pressure.ALDH2 gene is polymorphic and an individual's genotype at this locus influences blood acetaldehyde concentrations after drinking [ALDH2 has resulted in the ALDH2*2 allele, which is common in some Asian populations. The resultant protein has an amino acid substitution from glutamic acid (glutamate) to lysine at residue 487, and an inactive subunit. This substitution leads to an inability to metabolize acetaldehyde and causes an accumulation of acetaldehyde after alcohol intake [ALDH2*2 allele have 18 times higher, and heterozygotes have five times higher, peak blood acetaldehyde levels compared with *1*1 homozygotes (wild type) [ALDH2*2*2 homozygotes are characterized by a facial flushing response after consumption of alcohol coupled with nausea, drowsiness, headache, and other unpleasant symptoms that normally prevent them from heavy drinking [ALDH2*2*2 homozygotes. Due to the above adverse symptoms when drinking alcohol, *2*2 homozygotes drink considerably less alcohol than people homozygous for the wild-type allele (*1), with heterozygotes drinking intermediate amounts [Mendelian randomization can provide robust evidence on such associations . Alcoholdrinking . A singl amounts . The gen amounts .ALDH2 genotype as an instrument for indexing alcohol intake at a group level, producing groups with relatively high (*1*1), moderate (*1*2), and very low alcohol consumption (*2*2). We undertook a systematic review and carried out meta-analyses of studies examining the association of ALDH2 with risk of hypertension and/or level of blood pressure.We have used a Mendelian randomization approach  to estabhttp://www.ncbi.nlm.nih.gov/PubMed) and ISI web of Knowledge (http://wok.mimas.ac.uk/) using the search terms: “Aldehyde dehydrogenase 2” and “ALDH2” in combination with “Hypertension”, “Blood pressure”, “Cardiovascular diseases”, “Coronary disease”, “Heart disease”, “Coronary artery disease”. The bibliographies of retrieved articles were also scanned for relevant publications. We searched for all papers published before October 2006. Screening of studies for inclusion was performed by two researchers  independently of each other to increase objectivity. We also searched for all studies of the ALDH2 genotype regardless of outcome for use in separate analyses, and we scanned the abstracts of these studies to determine whether they may include any of the outcomes we were interested in. If we were uncertain we scanned the paper and then contacted the authors. There was no exclusion on the basis of language. For multiple publications based on the same study, the latest publication was included. For inclusion we required, as a minimum, data on systolic or diastolic blood pressure by genotype or prevalence of hypertension by genotype. Where insufficient data for inclusion were available in the paper we contacted authors directly, and if sufficient information could still not be obtained the study was excluded. A flow diagram showing the number of studies found in our search strategy, and reasons for exclusion is given in Papers included in the systematic review were retrieved from Medline  and 95% confidence intervals (CIs) for ALDH2 genotype and hypertension risk. Data extraction was carried out by two researchers  independently of each other.We followed a standard protocol for data extraction. For each study, the following data were recorded (where available): first author's name, year of publication, country and city in which the study was performed, name of the study, study design, number and source of participants, sex, method of assessment of drinking status, categories of alcohol drinking, mean alcohol drinking and standard deviation by Data on alcohol intake were converted to a uniform measure of grams per day for comparison across all studies with 1 unit = 10 ml = 7.9 g [*1*2 and *1*1 to *2*2 genotypes. In the analyses of hypertension, fixed-effects meta-analysis was used to calculate summary odds ratio estimates, and in the analyses of diastolic and systolic blood pressure, mean differences between genotype groups were obtained. We carried out fixed-effects meta-analyses separately for men and women, excluding two very small studies  that did not provide data separately by sex, and two further small studies [*1*2 and *2*2 genotypes. All statistical analyses were carried out with the use of Stata statistical software . All statistical tests were two-sided. We assessed evidence of small-study effects (which may include publication bias) for studies of ALDH2 polymorphism and hypertension risk, and for ALDH2 and blood pressure by computing both the Egger [We calculated the unadjusted mean difference in blood pressure or the odds ratio of hypertension by comparing ishimura , n = 36,ackenzie , n = 28) studies ,14 for whe Egger  and Begghe Egger  tests.F-statistic; values considerably above 10 are generally taken to show sufficient instrument strength to ensure the validity of two-stage least-squares [For the studies that reported both blood pressure and mean alcohol intake by genotype, we calculated estimates of the causal effect of alcohol on blood pressure, using the method of instrumental variables with genotype as the instrument assuming the effect is linear. In order to use standard instrumental variable estimation methods (‘two-stage least squares')  the corr-squares . The resALDH2 and hypertension or blood pressure, the majority of which were cross sectional studies; five of these studies focused on male populations only  for *1*1 versus *2*2 and 1.72   . No assoALDH2 genotype being observed in males only , while among heterozygotes mean DBP was 1.58 mmHg higher than among *2*2 homozygotes . A similar result was obtained for SBP, with a mean difference of 7.44 mmHg  between *1*1 and *2*2 homozygotes, and a mean difference of 4.24 mmHg  between heterozygotes and *2*2 homozygotes.Meta-analyses of diastolic blood pressure (DBP) and systolic blood pressure (SBP) were performed on 7,658 participants from five publications. Results were similar to the meta-analysis of hypertension, with mean differences in blood pressure by les only . Mean DB1*2 heterozygotes and *1*1 homozygotes there was some evidence that effect sizes were greater in smaller studies . A small-study effect was also detected in the analysis of male DBP differences between ALDH2 genotypes , no other associations showed evidence of small study bias. Sensitivity analysis including only studies with more than 500 individuals gave the following results: hypertension *1*1 versus *2*2 OR = 2.23 , *1*2 versus *2*2 OR= 1.62 ; DBP *1*1 versus *2*2 mean difference = 3.48 mmHg , *1*2 versus *2*2 mean difference = 1.33 mmHg  and SBP *1*1 versus *2*2 mean difference = 6.73 mmHg , *1*2 versus *2*2 mean difference = 3.78 mmHg .There was no strong evidence of heterogeneity between the studies. In the meta-analysis of hypertension comparing *F-statistics ranged from 42 [ from 42  to 1,962 from 42 , indicatALDH2 genotype and blood pressure, in which we used ALDH2 genotype as a marker of differing alcohol intake levels. We found that individuals with the ALDH2 *1*1 genotype, with average alcohol intakes of 20–30 g/d, had strikingly higher systolic and diastolic blood pressure than those with the ALDH*2*2 genotype, who tend to drink only small amounts of alcohol. In addition, the risk of hypertension among *1*1 homozygotes was around 2.5-fold above that among *2*2 homozgotes. Even heterozygotes who tended to be quite modest drinkers had elevated blood pressure and a 70% increased risk of hypertension compared with individuals with the *2*2 genotype. Exploratory analyses using an instrumental variable approach in which the association between genotype and alcohol intake and the association between genotype and blood pressure was triangulated to give an estimate of the effect of alcohol on blood pressure, we obtained estimates of a 0.24 mmHg increase in SBP per gram of alcohol per day over the course of a lifetime .We carried out a meta-analysis of the association between the n = 10) randomized crossover trial published in 1986 found that among healthy male volunteers, 7 d abstaining from alcohol was associated with an decrease in SBP of 3.00 mmHg relative to when drinking 60 g/d [It is difficult to compare these effects with those seen in randomized controlled trials, because very few trials have managed to include a control group drinking little or no alcohol, and randomized controlled trials look at the effect of changes in alcohol consumption over a short time period, whereas genetic variants will influence alcohol intake over a lifetime. One very small . Analyses of this genotype in relation to oesophageal cancer are complicated by dual effects of the ALDH2 *2*2 genotype in reducing alcohol intake but dramatically increasing acetaldehyde, a potent carcinogen, among those who do drink [ALDH2 *2*2 homozygotes [*2*2 homozygotes in this study, particularly as they tend not to drink. In fact, heterozygotes tend to have higher levels of acetaldehyde than either *1*1 or *2*2 homozygotes, because although they drink alcohol in moderation, they clear acetaldehyde at a much slower rate and consequently have greater elevations of acetaldehyde per unit of alcohol consumed than do *1*1 homozygotes, which is illustrated by their high oesophageal cancer risk relative to other genotypes [ALDH2 or linkage disequilibrium, is provided by the data on women, who tended not to drink and among whom there were no differences in blood pressure by genotype. If either pleiotropic effects or confounding by linkage disequilibrium were operating, an effect on blood pressure would be seen in both sexes.It is possible that the do drink . Elevatiozygotes . The lowenotypes . TherefoALDH2 genotype after adjustment or stratification for amount of alcohol consumed there was no difference in blood pressure by genotype [ALDH2 and blood pressure in a multiple logistic regression analysis including age, BMI, genotype, and alcohol consumption, but the association with genotype in this analysis was considerably weaker than in the univariate analysis, and the authors concluded that this difference could be due to differences in past drinking habits between genotype groups, which were not controlled for in the analysis [Additional evidence that argues against linkage disequilibrium and pleiotropic effects and an effect of acetaldehyde on blood pressure, is that among studies that looked at the effect of genotype ,20,28,29analysis . The finThere was some evidence of small-study effects in our review, which suggests that publication bias may have occurred. This bias may have led to an overestimation of the effects in the meta-analyses. However, only three of the largest studies were included in our instrumental variable analysis, as these were the only studies that presented mean alcohol intake by genotype, and so we do not expect this estimate to be influenced to a great extent by small-study bias; in addition a sensitivity analysis including only studies with at least 500 participants showed only minor changes in effect estimates.In summary, observational epidemiological studies have proved to be a misleading source of knowledge regarding the cardioprotective effects of several dietary factors . InadequAlternative Language Abstract S1(20 KB DOC)Click here for additional data file.


Body composition is an important parameter for patients with chronic obstructive pulmonary disease (COPD) whereas the association between asthma and obesity is not fully understood. The impact of severe refractory asthma (SRA) on fat free mass (FFM) has not been investigated.213 subjects  without significant comorbidities were included in the study. In all patients, body composition assessment  and spirometry were performed. Differences in fat free mass index (FFMI) between groups were assessed and determinants of FFMI in asthma were evaluated. Patients with SRA had lower values of FFMI compared to patients with mild-to-moderate asthma , despite the fact that they were more obese. The levels of FFMI in SRA were lower than those of GOLD stage I–III COPD and comparable to those of stage IV COPD patients . These differences were present even after proper adjustments for sex, age, smoking status, daily dose of inhaled corticosteroids (ICS) and daily use of oral corticosteroids (OCS). In multivariate analysis, independent predictors of FFMI in asthmatic patients were age, use of OCS and the presence of SRA, but not smoking, sex or cumulative dose of ICS used.SRA is related to the presence of low FFMI that is comparable to that of GOLD stage IV COPD. The impact of this observation on asthma mechanisms and outcomes should be further investigated in large prospective studies. Body composition is an important parameter for humans as it has been shown that either malnutrition or obesity, both expressed as body mass index (BMI), are correlated with overall morbidity and mortality Body composition represents a risk factor for the development of both chronic obstructive pulmonary disease (COPD) and asthma On the other hand, smoking, COPD and asthma affect body composition. There is evidence that smoking induces loss of body weight, whereas smoking cessation provokes weight gain. Moreover, smoking contributes in the accumulation of visceral fat and in the development of insulin resistance, metabolic syndrome and type 2 diabetes The aim of the present study was to assess body composition in patients with asthma and compare it to COPD patients and healthy smokers. We tested the hypothesis that patients with severe refractory asthma (SRA) might have lower FFMI than those with mild-to-moderate asthma. Predictors of FFMI in patients with asthma were further evaluated.Study participants were asthmatic patients, COPD patients and healthy smokers, without significant comorbidities that might affect body composition, including history of cardiovascular disease (CVD), diabetes mellitus, history of cancer, other lung disease or any other chronic systemic disease. COPD and asthma patients were recruited from the outpatients clinics of a tertiary hospital and had stable disease for the previous 8 weeks. Diagnosis of COPD and asthma has set at least one year before the inclusion in the study by an expert respiratory physician (K.K.) with specific interest in COPD and asthma, according to the existing guidelines A structured questionnaire was completed for all study participants, including demographic data, as well as data regarding their disease (for asthmatic and COPD patients) e.g. duration of treatment, use of inhaled corticosteroids (ICS), total ICS dose per day expressed in equivalent mcg of beclomethasone, number of exacerbations during the past year which were treated with short courses of oral corticosteroids (OCS), and daily dose of OCS for some patients with SRA.All subjects additionally completed a food frequency questionnaire (FFQ), which has been used in the Greek population, for the assessment of their nutritional status Body composition was assessed by bioelectrical impendance analysis (BIA), with a commercially available body analyzer  according to current recommendations All patients were submitted to spirometry by the same experienced technician, using a commercially available system  according to American thoracic society (ATS) guidelines st second (FEV1), as it is referred in the global initiative for chronic obstructive pulmonary disease (GOLD) guidelines  Patients with asthma were classified as mild-to-moderate asthma patients and patients with SRA according to the ATS and global initiative for asthma (GINA) guidelines Normally distributed data are presented as mean±SD whereas skewed data are presented as median (interquartile range). Normality of distribution of the variables was assessed using the D'Agostino-Pearson normality test. Comparisons of variables between two groups was performed using unpaired Student's t-tests or Mann-Whitney U tests for normally distributed and skewed variables, respectively whereas comparisons of variables between three or more groups was performed using one way ANOVA or Kruskal Wallis test for normally distributed and skewed variables, respectively, with suitable post hoc analyses  for all pairs of data. For the comparison of FFMI among all groups of subjects a univariate general linear model with appropriate adjustment for confounding factors  was used; the equality of variances was assessed with Levere's test and post hoc analysis was performed with Dunnett's T3 test. Pearson and Spearman's rank correlation coefficients were used for the correlation between normally distributed and skewed variables, respectively. Multiple regression analysis was performed for the evaluation of FFMI predictors, using FFMI as dependent variable and sex, age, smoking habit, cumulative ICS dose, daily use of OCS and asthma classification (mild-to-moderate vs. SRA) as independent variables. Stepwise multiple regression analysis was additionally used for the development of a prediction equation for FFM in patients with asthma, using anthropometric parameters. P values<0.05 were considered statistically significant. Analyses were performed using GraphPad Prism 5  and SPSS 16 .In total, 213 patients were included in the study. Of these 70 were healthy smokers, 71 were COPD patients and 72 were asthma patients. Demographic data for each group are presented in Regarding the group of healthy smokers, ex smokers had higher values of body weight, BMI and FFMI compared to current smokers . PatientDifferences in FFMI in all subgroups of healthy smokers, COPD and asthma patients are presented in After proper adjustments for sex, age, smoking habit, ICS dose and daily use of OCS, patients with SRA still presented significantly lower FFMI compared to healthy current (p<0.001) and ex smokers (p<0.001), as well as to patients with COPD stage I (p = 0.007), II (p<0.001), III (p = 0.005), and patients with mild-to-moderate asthma (p = 0.002). Again, there was no difference between patients with SRA and COPD stage IV (p = 0.826). Moreover, after the adjustments, ex smokers differed significantly with COPD stage III (p = 0.02), whereas there was no statistically significant difference between COPD stage I and patients with mild to moderate asthma (p = 0.087). All the other differences presented in 2: 0.960, Adjusted R2: 0.956).Predictors of FFMI in patients with asthma, provided by multiple regression analysis, are presented in 2: 0.999, Adjusted R2: 0.998; FFMI in patients with asthma was correlated with subscapular skinfold , midaxillary skinfold , neck circumference , waist circumference , iliac diameter  and knee circumference . Stepwise multiple regression analysis using anthropometric parameters as independent variables showed that FFM values can be predicted based on weight, height, abdominal and calf skinfold and iliac diameter  In conclusion, in the present study we have shown that in a population of healthy smokers and patients with COPD and asthma without comorbidities, SRA is related to the presence of decreased FFMI that is comparable to that of GOLD stage IV COPD. The impact of this observation on asthma outcomes should be further investigated in large prospective studies.


Hypertensive patients with reduced blood pressure fall (BPF) at night are at higher risk of cardiovascular events (CVE).We evaluated in hypertensive diabetic patients, if a reduced nocturnal BPF can precedes the development of diabetic nephropathy (DN). We followed 70 patients with normal urinary albumin excretion (UAE) for two years. We performed 24-hours ambulatory BP monitoring in baseline and at the end of the study.Fourteen (20%) patients (GI) developed DN (N = 11) and/or CVE (n = 4). Compared to the remaining 56 patients (GII) in baseline, GI had similar diurnal systolic (SBP) and diastolic BP (DBP), but higher nocturnal SBP  and DBP . Basal nocturnal SBP correlated with occurrence of DN and CVE  and with UAE at the end of the study . Basal BPF (%) correlated with final UAE . In patients who developed DN, reductions occurred in nocturnal systolic BPF  and diastolic BPF  while no changes were observed in diurnal SBP  and DBP . Patients with final UAE < 20 μg/min, had no changes in nocturnal and diurnal BP.Our results suggests that elevations in nocturnal BP precedes DN and increases the risk to develop CVE in hypertensive patients with T2DM. Cardiac disease is a common cause of death in patients with DM ,2. PrediWe have demonstrated that nocturnal systolic blood pressure fall (BPF) is lower in T2DM when compared with essential hypertensives and it is related to left ventricular hypertrophy  and diabIts well known that 24-hours ambulatory BP monitoring (24-h ABPM) has previously identified variations in blood pressure profile in patients with essential hypertension and diabetes and it is related to cardiac events -15. The The inclusion criteria were: age between 30-70 years, hypertensives with T2DM not treated with insulin before, normal values of urinary protein excretion, creatinine and urinary albumin excretion. The exclusion criteria were: history of congestive heart failure and angina pectoris; cardiac valvulopathy evaluated by echocardiography (ECHO) and history of previous cardiovascular events. Myocardial infarction, stroke, angina pectoris were considered as cardiovascular events. This study was approved by Ethics Committee.We followed 70 T2DM hypertensive patients  with both normal urinary protein excretion (UPE), urinary albumin excretion (UAE), excretion glomerular filtration rate (eGFR) and serum Cr (Cr), submitted to 24 h-ABPM, during a period of two years. Those patients were recruited from Diabetes and Hipertension ambulatory of Federal University of São Paulo.At baseline all patients were submitted to 24 h-ABPM, ECHO, UPE, UAE, Cr, fasting blood glucose (FBG), cholesterol (TC), triglycerides (TG) and office BP. Every three months Cr, FBG, TC and fractions, and office BP were repeated. UPE was performed every six months. All patients who developed abnormal proteinuria during the study also had performed UAE. And at the end of the study (2 years follow-up), patients repeated ABPM, UEA and UPE. The development of CVE, and DN, defined as abnormal UPE  were considered as end points.Criteria for established hypertension were systolic and diastolic blood pressure ≥ 140/90 mmHg on repeated measurements . All T2DThe average of FBG, chosen in this study, has been commonly used to monitor glycemic control in type 2 diabetics treated with diet alone or oral hypoglycemic agents. According to several studies, the retrospective average of FBG values is considered a good index to establish a previous long-term glycemic control on those patients .Diabetic Nephropathy was established by microalbuminuria, according to the Gentoften-Montecatini convention . It was 24-h ABPM was performed using a Spacelabs - 90207 automatic cuff-oscillometric devices  after 15 days washout of all antihypertensive drugs, after that all subjects restarted on their antihypertensive medications. The monitor was installed in the morning period and it was drop out after 24 hours. The individuals were oriented to keep their regular activities and make a report discriminating the hours of each activity. The device was programmed to perform four measures during each hour. It was established an average systolic and diastolic pressure, during diurnal period, nocturnal period and in 24 hours.For the purpose of ambulatory blood-pressure monitoring, two different periods were defined. The daytime period included all readings obtained from 8 a.m. until 8 p.m., and the night time period included all readings from 8 pm until 8 a.m. Measures of systolic BP higher than 260 mmHg and diastolic BP higher than 150 mmHg were excluded. The limit to detection of heart rate was between 200 and 20 bpm. The exam was accepted if at least 75% of the measures in 24 hours were successfully executed.Moreover, it was calculated the nocturnal BPF . It was considered normal values of nocturnal systolic BPF greater than 10% (dippers). Patients that showed BPF lower than this value were called "non-dippers".M-mode, two-dimensional echocardiographic and cardiac Doppler studies were performed using a commercially available echo-Doppler unit  equipped with a 2, 5 MHz mechanical transducer. It was performed with patients in the partial left lateral supine position. M-mode measurements were performed according to the recommendations of American Society of Echocardiography. Left ventricular mass (LVM) was calculated as previously recommended by Devereaux et al . The LVMUPE was performed through Kingsbury sulfosalicilic method adapted by Morales and Merino that has normal values below 150 mg in 24 hours. The Cr was determined through Jaffé technique modified by Bartels et al .UAE was determined by a turbidimetric immunoassay kit. Microalbuminuria was defined by the presence of a UAE rate consistently between 20 and 200 mg/min, as assessed by three 24-h urine samples collected at least 6 weeks after any urinary tract infections or acute hyperglycemic events, and after exclusion of all other causes of albuminuria .To create a measure of the previous long-term glycemic control, the average of all FG values available before the study was calculated. If several FG values were recorded during a month, only the first value of the month was used. The same procedure was used to calculate previous indexes of office BP, TC and fractions, and TG. These indices were referred to as the basal average of FG, office BP, TC and fractions, and TG values; and did not differ between the groups.All normally distributed values were given as mean ± SD and all other values were given as median (range). In comparison of the non-normally distributed variables, the Mann-Whitney test was used to test the differences between two groups and Wilcoxon test was used to compare the same groups before and after the follow up period. For all normally distributed variables, the unpaired student's test was used for comparison between two groups and paired student's test was used to compare the same groups before and after. For correlation analysis, correlation coefficients (Pearson or Spearman) were calculated. A P value (two tailed) less than 0.05 was considered statistically significant. All calculations were made with a commercially available program, SigmaStat 1.0 .Fourteen (20%) patients (GI) developed DN N = 11) and/or CVE (n = 4). One patient who presented CVE also had DN. Initially, when compared with group of the remaining 56 patients (GII). Group I had similar values of Cr and mean diurnal systolic (SBP) and diastolic blood pressure (DBP) but higher basal levels of both nocturnal SBP  and DBP   and with UAE, determined at the end of the study .The basal BPF (%) also showed correlation with final UAE . In patients who developed DN an elevation of nocturnal BP was observed during the study period. In this group, significant reductions were detected in both nocturnal systolic BPF  and diastolic BPF  while no changes were observed in diurnal SBP  and DBP   could be a via through hyperglycemia would elevate nocturnal SBP levels. Some studies have related AN to an increase of left ventricular mass and to the loss of nocturnal BP decrease . Other cThere are a few limitations of 24-h ABPM technique in diabetic patients. One of the main problems is the necessity of validation studies of each oscillometric device. We recently tested and retested the Spacelabs - 90207 automatic cuff-oscillometric devices  in hypertensive type 2 diabetic patients  and we fper se in diabetic patients must be an indication to perform 24 h-ABPM. The cost must be reduced to that approach be possible.According to Parati et al , a noninIt has been pointed out the importance of cardiometabolic risk factors in hypertensive patients . BellettIn summary, our study suggests that an elevation of nocturnal systolic blood pressure and a loss of nocturnal blood pressure fall might precede the development of diabetic nephropathy and cardiovascular events in hypertensive normoalbuminuric patients with type 2 diabetes. Other studies are necessary to confirm these findings.The authors declare that they have no competing interests.JF conceived the study, participated in its design and coordination and performed the statistical analysis. AS, NK and OK participated in the sequence algnment. AR and MZ participated in the designed of the study. All authors read and approved the final manuscript.


Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT. A 41-year-old pregnant woman with no other past medical history presented to a community hospital with pre-eclampsia at 36-week gestation. She had a systolic blood pressure (SBP) of 160 mmHg with proteinuria but no neurologic signs or symptoms. Twins were delivered by emergent Cesarean section under spinal anesthesia without apparent complications. She was discharged home on hospital day 5.  The following day she developed a severe headache, blurred vision, and SBP >160 mmHg. She had a generalized tonic-clonic seizure in the emergency department. She was orotracheally intubated for airway protection, treated with magnesium sulfate, levetiracetam, and labetalol. She had no further clinical seizures. A noncontrast CT of the head was normal. After extubation the following day, she became lethargic, and her mental status rapidly declined. MRI of the brain showed several areas of acute infarction in the posterior circulation. She was transferred to our neurological intensive care unit (NeuroICU) for further evaluation on the third day of hospitalization.  On presentation to our facility, she was lethargic and opened her eyes only to repeated tactile stimulation. She was oriented to name, could follow simple commands, and was severely dysarthric with incomprehensible speech. She had a right homonymous hemianopia, disconjugate gaze, and was quadriparetic. She was treated with a magnesium infusion, intravenous levetiracetam, aspirin 325 mg daily, and a nicardipine infusion which was titrated to maintain a goal SBP less than 120 mmHg. On the third day of hospitalization at our institution she became comatose, and her SBP was persistently >130 mmHg despite aggressive medical therapy. Continuous EEG showed diffuse slowing but no epileptiform activity. MRI of the brain redemonstrated multiple acute infarcts isolated to the posterior circulation . There was a small area of hemorrhagic transformation of the left occipital lobe infarct seen on gradient echo images (not shown). MRA of the head and neck revealed patent cervical arteries with an apparent dissection flap visualized throughout the basilar artery . A conventional angiogram confirmed a “double lumen” within the basilar artery with possible involvement of both intradural vertebral arteries, a finding specific for a vertebrobasilar dissection , 2. In aGiven the radiographic findings there was uncertainty whether the patient's elevated blood pressure was contributing to her clinical deterioration or whether it was a compensatory mechanism to improve perfusion of ischemic tissue. To better direct management of her blood pressure, a Xenon enhanced CT (Xe-CT) was performed to quantify cerebral blood flow (CBF) at different blood pressures. This study showed areas of decreased relative cerebral blood volume in the bilateral posterior cerebral, right middle cerebral, and left anterior cerebral vascular territories at an SBP of 120 mmHg which improved by allowing the SBP to rise above 130 mmHg .The Mg infusion was discontinued at that time, and her blood pressure target was changed to an SBP of 130 mmHg. Her neurological examination improved slowly over the next several weeks. She was discharged to an acute rehabilitation facility on hospital day 30. At the time of discharge, she was awake, alert, and oriented to person, place, and year. She had a dense right homonymous hemianopia and a moderate right hemiparesis. She required intermittent enteral feeding through a percutaneous gastrostomy tube.  Three months after hospital discharge, she remained in an acute rehabilitation facility. She continued to clinically improve. The gastrostomy tube had been removed, and she could walk with assistance. She continued to have significant memory difficulties and vision loss.Cervicocephalic arterial dissection (CCAD) is a rare postpartum complication only previously described in case reports and one recent small case series, involving a total of 6 patients –7. The g The relationship between CCAD and the postpartum period remains unclear. A traumatic mechanism from strenuous labor is unlikely to be the mechanism in most cases. All 6 of the patients reported by Arnold et al. had uneventful deliveries with symptomatic dissection occurring at least 5 days postpartum, as did our patient who delivered via C-section and did not become symptomatic until day 6. A more likely association exists between CCAD and an acquired vasculopathy. In the prior series of spontaneous CCAD, 4/6 67%) of patients who were postpartum had neuroimaging characteristics consistent with reversible cerebral vasoconstriction syndrome (RCVS), reversible posterior leukoencephalopathy (RPLS), or cortical subarachnoid hemorrhage (cSAH) without associated intradural dissection, while only 3/96 (3%) patients in the age and sex matched controls had similar findings % of pati. A commo Aggressive blood pressure reduction is accepted as the treatment of hypertension in the RCVS syndromes including PPA and eclampsia , 17. The This is the first reported case of an intracranial vertebrobasilar dissection causing ischemic stroke in a patient with PPA and eclampsia. This is significant because of the uniqueness of the case and the uncertainty about blood pressure management. A flow-limiting intracranial dissection may alter the optimal target blood pressure. Blood pressure management tailored to the individual patient's cerebral hemodynamic needs is likely the best solution to optimizing CBF to areas of relative ischemia while avoiding excessive elevations in perfusion pressure which can exacerbate RCVS. Xe-CT has been utilized to determine CBF in acute stroke, differentiate between normal, ischemic, and irreversibly infarcted tissue, and optimize hemodynamic treatment parameters –22. It hIntracranial vertebrobasilar dissection is a rare postpartum complication and likely occurs in vessels with endothelial damage from associated underlying conditions such as eclampsia and PPA. Antihypertensive therapy to treat these diseases may exacerbate ischemia in patients with concurrent cerebral infarction. Individualized therapy, utilizing methods to quantify CBF, may allow clinicians to optimize treatment of their patients and warrants further study.


The present prospective comparison study was designed to determine the effects of variations in arterial blood pressure on the reliability of the FTV system in patients undergoing coronary artery bypass grafting (CABG).The reliability of autocalibrated pressure waveform analysis by the FloTrac-VigileoComparative measurements of cardiac output by FTV  and IPATD were performed in 16 patients undergoing elective CABG in the period before institution of cardiopulmonary bypass. Measurements were performed after induction of anesthesia, after sternotomy, and during five time points during graft preparation. During graft preparation, arterial blood pressure was increased stepwise in intervals of 10 to 15 minutes by infusion of noradrenaline and lowered thereafter to baseline levels.P < 0.0001) while no correlation between MAP and IPATD cardiac output was observed. Bland-Altman analyses for FTV versus IPATD cardiac output measurements revealed a bias of 0.4 l/min (8.5%) and limits of agreement from 2.1 to -1.3 l/min (42.2 to -25.3%).Mean arterial blood pressure was varied between 85 mmHg and 115 mmHg. IPATD cardiac output did not show significant changes during periods with increased arterial pressure either during sternotomy or after pharmacological manipulation. In contrast, FTV cardiac output paralleled changes in arterial blood pressure; i.e. increased significantly if blood pressure was raised and decreased upon return to baseline levels. Mean arterial blood pressure (MAP) and FTV cardiac output were closely correlated , ® device with the second-generation software. This finding may help to explain the variable results of studies comparing the FTV system with other cardiac output monitoring techniques, questions the usefulness of this device for hemodynamic monitoring of patients undergoing rapid changes in arterial blood pressure, and should be kept in mind when using vasopressors during FTV-guided hemodynamic optimization.Acute variations in arterial blood pressure alter the reliability of the FlowTrac/Vigileo Controversy exists about the reliability of this technique in comparison with intermittent pulmonary arterial thermodilution (IPATD), especially during cardiac surgery [® operating systems with software version 1.07 or later show acceptable agreement with ITD (intermittent thermodilution), both clinically and statistically" [®-system.Autocalibrated pressure waveform analysis by the FlowTrac/Vigileo surgery ,2. A rectically" . This cotically"  and obsetically"  showing When using the FTV-system in patients undergoing non-cardiac surgery and critically ill patients in the intensive care unit (ICU) we have frequently observed increases in CO following a bolus of a vasopressor titrated to achieve a normal mean arterial blood pressure (MAP). This is a unique finding and is in contrast to what is to be expected from physiology, because the normal CO response during an increase in afterload in a patient with preserved cardiac function would be a short-lasting decrease in stroke volume followed by restoration of stroke volume and CO to the previous level, but not an increase in CO .The present study was thus designed to determine the effects of variations in arterial pressure on the reliability of CO measurements by autocalibrated pulse wave analysis with the FTV system in comparison with IPATD. With respect to the fact that pulmonary artery catheters are routinely used in the cardiac anesthesia department but not in the noncardiac surgery population, the study was performed in cardiac surgery patients undergoing coronary artery bypass grafting (CABG) in the period before cardiopulmonary bypass.Following approval by the local ethical committee  and written informed consent, 16 consecutive patients  scheduled for standard on-pump CABG with moderate hypothermia were enrolled  for this prospective comparison study. All patients had a three-vessel coronary artery disease, a history of arterial hypertension, and hyperlipidemia. Three patients had diabetes and one had a history of stroke.Following premedication with oral diazepam, general anesthesia was induced with fentanyl and etomidate and maintained with propofol and remifentanyl, as appropiate. Endotracheal intubation was facilitated with cisatracurium. All patients were equipped with a five lead electrocardiogram, a femoral arterial line, a triple lumen central venous catheter and a pulmonary artery catheter connected to a Vigilance I monitor .® system  was connected to the femoral arterial line, the transducer was adjusted to the level of left atrium and the system was started according to the instructions of the manufacturer .After induction of anesthesia the pulmonary artery catheter was floated into the pulmonary artery until a typical pressure profile was obtained. Thereafter, a FloTrac/VigileoIn the further course, comparative measurements of CO by IPATD and the FTV system were performed. MAP was recorded concomitantly. Bolus thermodilution CO measurements were performed in triplicate to quadruplicate with 4°C cold saline and averaged for respective time points. In general, three thermodilution measurements were performed. If the difference between these measurements was greater than 0.5 l/min, an additional measurement was performed and the three most contiguous results were averaged.Autocalibrated CO measurements from the FTV system were recorded immediately after a bolus of saline was given for thermodilution (resulting in three to four measurements each that were again averaged). To assure adequate pressure recordings the arterial line was repeatedly flushed with 5 ml saline throughout the observation period and observed for tracing quality.Comparative measurements were performed after induction, after sternotomy, and in the period of graft preparation (GP1 to GP5) before cardiopulmonary bypass. During graft harvesting, arterial blood pressure was titrated in periods of 10 to 15 minutes from a stable baseline around 80 mmHg (GP1 and GP2) to 100 mmHg (GP3) and further to higher than 110 mmHg (GP4) by a continuous infusion of noradrenaline (2.6 μg/min to 6.6 μg/min). Thereafter blood pressure was allowed to decrease back to levels around 80 mmHg (GP5).P < 0.05 was considered statistically significant.Data analyses were performed by MedCalc 10.4 . Following Kolmogoronov-Smirnov test for normal distribution, data were analyzed parametrically. Between group differences were analyzed by analysis of variance. Intraindividual changes were analyzed by paired Student's t-test with Bonferoni-adjustment. Correlation analyses were performed by linear regression. Comparisons between methods were performed by Bland-Altman statistics. A The course of CO measurements and MAP is given in Figure P < 0.0001) and between MAP and FTV-CO  but no correlation between MAP and IPATD-CO. Bland-Altman analyses for FTV-CO versus IPATD-CO revealed a bias 0.4 l/min and limits of agreement from 2.1 to -1.3 l/min for the pooled data : 0.35 to 0.64, Bland-Altman analyses at the individual data acquisition points are shown in Table Adequate monitoring of CO and stroke volume is a pivotal part of any hemodynamic optimization protocol and has traditionally been accomplished by using a pulmonary artery-catheter. And although it is now clearly established that the use of a pulmonary artery catheter is not associated with an increase in mortality, its use should be restricted to units with specialized knowledge and experience in using this technology . Within One of the most recent developments is autocalibrated pressure waveform analysis by the FTV system . The sys® need repeated recalibration if such changes occur [It is well known that changes in arterial resistance either by a vasodilating or a vasoconstricting agent may change pulse wave velocity and thereby influence peripheral as well as central aortic pulse contour . In linees occur ,12. The Our results clearly show that the autocalibration algorithm of the FTV system was not capable to adapt to changes in MAP between 80 to 110 mmHg (that were maintained for 10 to 15 minutes) although the software generation used calculates arterial compliance every minute: results in a percentage error between both methods that is clinically not acceptable. This is highly suggestive that the algorithm fails to detect short-term changes in systemic vascular resistance and may help to explain why the FTV-system has repeatedly been shown to underestimate CO in the immediate period after cardiopulmonary bypass or in patients with liver cirrhosis  but per se did not reliably measure CO in comparison with IPATD, even if arterial blood pressure was in the normal range. This further questions the clinical usefulness of this device, at least with the software version used in this study.It is of note, that the percentage error at most measurement time points was higher than 30% and that the FTV system The results of the present study show that changes in systemic arterial resistance alter the reliability of the FTV-system; even if using the modified second-generation software (version 1.14). This may help to explain the variable results of studies comparing the FTV-system with other CO monitoring techniques, questions the usefulness of this device for hemodynamic monitoring of patients undergoing rapid changes in arterial blood pressure, and should be kept in mind when using vasopressors during FTV-guided hemodynamic optimization. Further studies are needed to reveal if the most recent modification of the FTV-system software (the third generation) improves the reliability of this technology.• Variations in arterial blood pressure lead to parallel changes in CO measurements by the second generation of the FTV system.® - guided hemodynamic optimization.• This questions the usefulness of this device for hemodynamic monitoring of patients undergoing rapid changes in arterial blood pressure and should be kept in mind when using vasopressors during Flowtrac/Vigileo®; GP: graft preparation; ICU: intensive care unit; IPATD: intermittent pulmonary arterial thermodilution; MAP: mean arterial blood pressure.CABG: coronary artery bypass grafting; CI: confidence interval; CO: cardiac output; FTV: FlowTrac-Vigileo® - system, Osypka Medical, Germany, and Covidien, Germany.The authors SE, ZG, VD, IB, JS, HH, and KUB declare that they have no competing interests. MH received scientific support and/or honoraria for lectures from Edwards Lifesciences, Irvine, CA, USA, the manufacturer of the FloTrac/VigileoSE, JS, and MH designed the study, performed the statistical analyses and drafted the manuscript. SE, ZG, VD, and IB coordinated the study, were responsible for patient recruitment and data acquisition. HH and KUB were involved in the interpretation of the data and manuscript drafting. All authors read and approved the final manuscript.