Introduction: If the blood pressure of a pregnant woman is ≥140/90 mmHg at the clinic, but her ambulatory blood pressure is less <135/85 mmHg at daytime and <125/75 at night and her average ambulatory in 24 hours is <130/80 mmHg, her high blood pressure at clinic is considered white coat hypertension.Objectives: To evaluate the value of ambulatory blood pressure monitoring in pregnant women.Patients and Methods: This prospective cohort study was conducted in Imam-Khomeini hospital of Ahwaz, Iran between 2011 to 2012. A total of 105 pregnant women who had blood pressure of higher than 140/90 mmHg during the third trimester of pregnancy were monitored. Thirty five women with white coat hypertension, 35 women with gestational hypertension and 35 women with normal blood pressure were followed. The data were analyzed using the Kolmogorov-Smirnov test, Pearson correlation coefficient and Chi-square tests.Results: The prevalence of white coat hypertension was 31.3%. The maternal and neonatal outcomes and laboratory examinations in white coat hypertension were similar to the normal blood pressure, but the frequency of caesarean section was more than the other two groups.Conclusion: The findings of the study indicate the efficacy of 24 hour holter monitoring of blood pressure and using it more comprehensively , compared to the limited visits. Prospective cohort study indicated the efficacy of 24-hour holter monitoring of blood pressure and using it in a more comprehensive way compared to the limited visits.Hypertension (HTN) occurs in approximately 5-10% of all pregnancies. Among a wide variety of the causes of high blood pressure (BP) in pregnancy, preeclampsia syndrome, whether alone or in the form of added on the chronic hypertension, is considered as the most hazardous condition  and preterm delivery were compared between two groups of with white coat hypertension and those with gestational hypertension. Undesirable consequences were significantly more common in the gestational hypertension group . Holter monitoring device was comprised of a small and special pressure gauge, which at first was programmed and set by a computer and then it was connected to the patient. In the specified intervals while the patient was busy with everyday activities, every half hour during the day and every two hours during the night for 24 hours, the device was set to measure the blood pressure.Out of the 105 pregnant women, who were undergoing Holter monitoring device, 47 people had negative holter results and 103 people had positive Holter results. Out of the 47 people with negative Holter results, 35 women who had blood pressure less than 125/75, 135/85 and 130/80 mmHg during the day, night, and 24 hours, respectively, entered the study as group of white coat hypertension (negative Holter group). Also, out of 103 patients with positive results during the outpatient monitoring, 35 patients, who had blood pressure higher than the above mentioned values, entered the study as gestational hypertension (positive Holter group). Furthermore, 35 pregnant women who were diagnosed with normal blood pressure alone, entered the study as the control group.To compare the outcomes of pregnancy, up to the end of the pregnancy, these three groups were followed every two weeks and their blood pressure, complete blood count (CBC), liver enzymes, creatinine and proteinuria were assessed.Finally, duration of pregnancy, the rout of delivery , the incidence of preeclampsia and eclampsia, the preterm labor, duration of maternal and neonatal hospitalization, the weight of the their babies, intrauterine fetal death and laboratory examinations among three groups were studied and compared among the studied groups.Preeclampsia was defined as blood pressure of equal to or more than 140/90 mmHg after 20 weeks of gestation along with proteinuria equal to or more than 300 mg in 24 hours. Eclampsia was defined as having a seizure episode non-attributable to other causes in women with preeclampsia. Preterm labor was defined as the baby’s birth before 37 weeks of the pregnancy; intrauterine fetal death was defined as fetal death after 20 weeks of gestation; and low birth weight (LBW) was defined as birth weight between 500 and 2500 g.The research followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients. This study was approved by ethical committee of Ahvaz Jundishapur University of Medical Science.The Kolmogorov-Smirnov test was used to identify the normal distribution of variables and ANOVA test was used to compare the means of the three groups. Furthermore, Pearson correlation coefficient and Chi-square tests were used for comparing qualitative variables between the three groups. Data analysis was performed using SPSS version 19.0 software and the P-values ≤ 0.05 were considered statistically significant.In our study the prevalence of white coat hypertension was 31.3%. Among the variables investigated, the time of termination of pregnancy, the baby’s weight at birth, the number of babies and maternal hospitalization days . The meaThe average ratio of occurrence of reducing the number of platelets, increased creatinine, the incidence of abnormal liver function test and albumin in the random urine  in the get al., prevalence of white coat hypertension was more common than our study  in white coat hypertension were not observed . It was also necessary to educate pregnant women and encourage them to come for more follow up visits during pregnancy.Main draft write up and editing by MM. Important intellectual content and critical revision by NS, RM and HS.The authors declared no competing interests.Ethical issues  have been completely observed by the authors.This paper has been derived from the residential thesis of this study was granted by Ahvaz Jundishapur university of medical sciences and department of Gynecology and Obstetrics, fertility and perinatology research center, Ahvaz Jundishapur university of medical sciences and research consultation center.Hereby we would sincerely appreciate the Holter monitoring Center, Imam Khomeini Hospital, and patients participating in this study and all the ones who helped us in this study. The authors also, appreciate and thank the Research Deputy vice-chancellor for research affairs of the Ahvaz Jundishapur University of Medical Sciences, particularly the Research Consultation Center (RCC) for technical support.


Several studies have shown the relationship between lower urinary tract symptoms and autonomic imbalance. We investigated the relationship between detrusor overactivity (DO) or urgency, and transient increase in blood pressure as a type of hypertension related to sympathetic hyperactivity. Study 1: we enrolled 14 male patients with DO and 10 without DO. We measured the overactive bladder symptom score (OABSS) and blood pressure during cystometry. Study 2: we enrolled 14 men patients with overactive bladder (OAB) and 8 without OAB. We measured OABSS and blood pressure using a 24-h ambulatory device.Study 1: the mean systolic pressure was significantly higher at urgency or SDV than at the other measurement points in the DO group . Study 2: the mean systolic pressure was significantly higher at the measurement points before micturition than at the points unrelated to micturition in the OAB group (159.7 ± 24.9 vs. 124.9 ± 13.8 mmHg). In conclusion, DO or urgency induces a transient increase of blood pressure, suggesting that OAB induces a type of hypertension before micturition. Metabolic syndrome, in particular, diabetes and hypertension, are related to the clinical progression of benign prostatic hyperplasia . HyperteIn female patients, several studies on the relationship between OAB and sympathetic hyperactivity have been reported , 6. TakaWe conducted an exploratory study at two hospitals in Japan from July 2009 to March 2011. All patients provided written informed consent prior to enrollment. The study was performed in accordance with the Declaration of Helsinki, and approval was obtained from the institutional review board at Nara Medical University hospital.We enrolled male patients with any LUTS. Exclusion criteria were histories of lower urinary tract neoplasms, vesical stones, symptomatic urinary tract infection, and neurogenic bladder. We evaluated their storage symptoms using the overactive bladder symptom score (OABSS) and measured blood pressure with a sphygmomanometer during cystometry at first desire to void (FDV), normal desire to void (NDV), strong desire to void (SDV) or urgency, and after micturition. We performed cystometry with patients in sitting position and sphygmomanometry with a manchette placed on the left upper arm. We calculated the bladder outlet obstruction index (BOOI) using the formura: BOOI = Pdet at Qmax − 2 (Qmax) , and the®, Fukuda Denshi, Tokyo, Japan). Diagnosis of OAB was made using OABSS, which evaluates daytime frequency , nocturia , urgency , and urgency urinary incontinence  over a 1-week recall period. Patients were diagnosed as having OAB if the score for Question 3 regarding urgency yielded was ≥ 2 points and if the total score was ≥ 3 points [We enrolled male patients with any LUTS. Exclusion criteria were histories of lower urinary tract neoplasms, vesical stones, symptomatic urinary tract infection, and neurogenic bladder. We evaluated their storage symptoms using OABSS and measured blood pressure with a 24-hour ambulatory blood pressure monitoring device  in the group with DO and 3 patients (30.0%) in the group without DO . The number of patients with hypertension, who all received hypertensive drugs, was 6 43%) in the group with OAB and 4 (50%) in the group without OAB. Nobody had central nerve disease which may influence storage function  have been reported. These studies measured heart rate variability using electrocardiogram, which noninvasively detects autonomic imbalances , 12. TheWe demonstrated that DO or urgency, which usually coexists with DO, induces a transient steep increase in blood pressure in male patients. In general, sympathetic stimuli contract the arteries, and blood pressure and pulse increases. Thus, DO or urgency induces transient sympathetic hyperactivity. The reason for selecting male patients was that we needed to perform pressure flow study to check BOO before TURP. However, we believe that the same phenomenon would occur in female patients with OAB. Although “hypertension” is transient, the increase in blood pressure and the frequency of “hypertension” should be higher in patients with more severe OAB. The systolic pressure actually increases to more than 200 mmHg when a patient with severe BOO shows DO during a cystometrogram. Frequent occurrence of strong urgency and transient hypertension may cause patients stress and impair autonomic balance. Therefore, OAB is not just a local urinary continence and frequency issue, but sometimes it affects the global cardiovascular system.The mechanisms which increases blood pressure during DO or urgency remain unknown. We believe that autonomic dysreflexia (AD) in patients with spinal cord injury is a similar phenomenon. AD is an acute syndrome of excessive, uncontrolled, sympathetic output with potentially serious consequences that can occur in patients who have had an injury to the spinal cord  . From a In conclusion, DO or urgency induces a transient increase in blood pressure, suggesting that OAB induces a type of hypertension. Hypertension can be relieved after patients undergo transurethral resection of the prostate.The goal of this study was to estimate the influence of frequent transient hypertension due to OAB on the whole body. However, we did not measure autonomic imbalance directly or secretion of catecholamine. We did not check the symptoms of the hypertension, such as headache, sweating, and uneasiness. We also investigate whether DO or urgency- related hypertension could be relieved if OAB is treated well. We showed that a small number of patients (n = 4) for which TURP relieved OAB and hypertension. We do not think the numbers are sufficient. We need to perform further well-designed prospective studies based on the present study to confirm this phenomenon and global influence.For Table


Dental consultation may provoke stress to the patient, especially when a dental surgery is going to be performed, stressful situations can cause a reaction in the sympathetic nervous system that could lead to cardiovascular alterations. Blood pressure and cardiac frequency are used often as an indirect measurement and this parameters combined can serve as good indicators of stress. Objective: Analyze the changes in vital signs and analytical parameters induced by a dental extraction.24 healthy patients who required a simple dental extraction underwent to a blood test and motorization of their pre- and post-extraction vital signs before, at 2 and 48 hours after the procedure. Data analysis was performed by means of repeated measures one way ANOVA followed by multiple comparisons Bonferroni’s Post-hoc test.The evaluated patients were 13 women and 11 men with an average age of 35.1. Thirteen patients (54.17% of the sample) were smokers and five were regular drinkers (20.8%). No significant differences were observed in the vital signs with the exception of diastolic blood pressure and cardiac rate that were slightly lower after extraction. Only two analytical parameters showed statistical significant changes. Total bilirubin was significantly higher at 48 hours after extraction and leukocyte count was significantly lower at this time. In any case, the magnitude of the changes observed was very low. The analytical parameters and the vital signs did not show any relevant change.Eventual alterations found after simple tooth extraction should not be attributed to the procedure. Key words:Blood pressure, heart rate, monitoring physiologic, oxygen saturation, tooth extraction. One of the objectives of dentistry is to preserve the teeth, but in determined situations dental extraction is necessary ,2. Thus,Excessive bleeding after a dental extraction is a relevant complication that can occur even after a routine tooth extraction, especially if the patient presents hemostatic alterations ,6. HowevAside of bleeding and pain, another frequent complication of dental treatments are the occurrence of cardiovascular changes, which are usually harmless in healthy subjects, but can be harmful in those with previous pathology, especially in the case of heart disease . The merOur objective in the present study was to examine the changes in the vital signs and analytical parameters induced by a simple dental extraction.The data of this research were obtained during the realization of the TETIS study (NCT01595360), whose main objective was to evaluate the safety and tolerability of the product TT-173 when it was applied to the bleeding alveolus after dental extraction . Since treatment did not induce significant changes in vital signs or analytical parameters, the data of both groups were pooled and analyzed in order to determine the changes induced by tooth extraction.-Patients and parameters evaluatedTwenty four adult volunteers of both sexes were recruited in this study. Vital signs and analytical determinations were obtained before extraction and after 2 and 48 hours. The parameters evaluated include cardiac frequency, systolic and diastolic blood pressure, temperature, oxygen saturation, complete hemogram, aPTT, PT, thrombin time, fibrinogen concentration, D-dimer, AST, ALT, total bilirubin, Ca, Cl, alkaline phosphatase, GGT, LDH, K, Na, urea, creatinine, urate, total proteins and albumin.-Protocol for the Dental ExtractionThe simple dental extraction was performed with anesthesia without vasoconstrictor (Mepivacaine 3%) applied periapically in the upper jaw or blocking the nerve in the mandible. After the extraction the integrity of the tooth was assessed and the alveolus was checked by curettage, of its four walls, as well as the apex area.-Statistical Analysisp < 0.05.Data analysis was performed by means of repeated measures One way ANOVA followed by multiple comparisons Bonferroni’s Post-hoc test. The significance level for all of the statistical tests was established at a value of -Ethical Considerations All data used for this study were obtained during the realization of TETIS study and according with the protocol of this trial . TETIS s-Demographic data and characteristics of subjects included in the studyOf the 24 patients 13 were women and 11 were men. The mean age of the participants was 35.2 (rank 18 to 54). Fifteen subjects (62.5%) presented previous concomitant diseases, 54.17% (13 patients) were regular smokers and five patients were regular drinkers (20.8%). An additional total of eight patients were considered occasional drinkers. The main cause of dental extraction was caries (58.3%) followed by radicular remains (33%). None of the patients showed increased risk of bleeding based on the questionnaire carried out, with a score of below 10 for all patients. Seven subjects (29.2%) had some clinically relevant alterations in the oral mucous membrane .-Vital Signsp<0.05) at 2 and 48 hours after extraction (71.8±15.9 and 71.8±16.9 respectively). In the same way, the heart rate was significantly lower at 2 hours after extraction  (The average pre-extraction systolic blood pressure was 121.4±15.1 mmHg (mean±SD) and that of the diastolic blood pressure was 76.9±13.4 mmHg. The body temperature was 36.18±0.5 ºC and the oxygen saturation level was of 97.07±2.13 %. Diastolic pressure was significantly lower (-Blood Test parameters p<0.001) (p<0.01) , or the proportion reported by others . Due to P <0.05). There were minor changes in the cardiac frequency that were not significant in the music group.In regard to vital signs, we have not found significant variations between the systolic blood pressure, body temperature and SatO2 obtained before and after the dental extraction. In contrast, diastolic blood pressure was significantly lower at 2 and 48 hours after the procedure. In the same way, we observed a significantly lower heart rate at 2 hours . HoweverMore clear changes were reported by other authors that monitored the cardiovascular signs in a group of 25 healthy patients who underwent a simple extraction. The evaluation took place in four phases: baseline situation, post-anesthesia , post-extraction and upon finishing. The authors observed an increase in systolic and diastolic blood pressure as well in heart rate during the procedure .In contrast with these studies, the average blood pressure observed in our study was lower . This coLikewise, an interesting paper evaluated the changes in blood pressure related to local anesthesia with various epinephrine concentrations . They weOur results indicate that a simple dental extraction does not induce physiologically relevant changes in vital signs and analytical parameters at 2 and 48 hours after procedure.


Shinrin-yoku (experiencing the forest atmosphere or forest bathing) has received increasing attention from the perspective of preventive medicine in recent years. Some studies have reported that the forest environment decreases blood pressure. However, little is known about the possibility of anti-hypertensive applications of Shinrin-yoku. This study aimed to evaluate preventive or therapeutic effects of the forest environment on blood pressure.We systematically reviewed the medical literature and performed a meta-analysis.Four electronic databases were systematically searched for the period before May 2016 with language restriction of English and Japanese. The review considered all published, randomized, controlled trials, cohort studies, and comparative studies that evaluated the effects of the forest environment on changes in systolic blood pressure. A subsequent meta-analysis was performed.Twenty trials involving 732 participants were reviewed. Systolic blood pressure of the forest environment was significantly lower than that of the non-forest environment. Additionally, diastolic blood pressure of the forest environment was significantly lower than that of the non-forest environment.Shinrin-yoku on reduction of blood pressure.This systematic review shows a significant effect of The online version of this article (doi:10.1186/s12906-017-1912-z) contains supplementary material, which is available to authorized users. Shinrin-yoku (experiencing the forest atmosphere or forest bathing) has received increasing attention from the perspective of preventive medicine in recent years [Shinrin-yoku.nt years –4. Obsernt years . Some exnt years –11, bloont years , 12–14, nt years , 16, andnt years , 10, 12 This study aimed to evaluate preventive or therapeutic effects of the forest environment on blood pressure. We systematically reviewed the medical literature and performed a meta-analysis. Further, we examined if there were differences in effects according to the characteristics of participants, such as age, sex, and blood pressure, before intervention.This review considered all published, randomized, controlled trials (RCTs), cohort studies, and comparative studies that evaluated the effects of the forest environment on changes in systolic blood pressure (SBP). Participants included adults.The primary outcome was SBP. Provided there were sufficient included trials, sensitivity analyses were performed to explore the influence of the characteristics of participants, such as age, sex, and blood pressure, before intervention on effect size.The secondary outcomes included diastolic blood pressure (DBP) and HR or pulse rate (PR). In this review, we assumed that HR and PR were indices of autonomic nervous activity, and conducted the meta-analysis without distinguishing between them.We searched electronic databases  from their inception to May 2016 with language restriction of English and Japanese. We also searched the references of relevant studies. The search terms were as follows: (1) forest environment, OR forest area, OR shinrin, OR shinrin-yoku, OR shinrinyoku, OR forest walking, OR forest treatment, OR forest healing, OR forest remedy, OR forest therapy, OR forest basking, OR forest bathing, OR forest viewing, OR phytoncide; (2) blood pressure OR hypertension; (3) random, OR (single-blind method OR double-blind method), OR , OR ; and (4) 1, AND 2, AND 3.Three investigators  extracted the literature, which were retrieved from the medical databases and manual searches. Two of three reviewers  evaluated the full text of the extracted literature independently and discrepancies were resolved by discussion. We extracted information on the following: study characteristics ; participants’ characteristics ; intervention (forest exposure and comparators); and outcomes (blood pressure and HR or PR). We extracted the mean change from baseline and standard deviation (SD) and/or before and after mean scores and corresponding SDs.Risk of bias was assessed using Cochrane’s risk of bias tool .2 statistics. Publication bias or small study effects were checked by the conventional funnel plot. Statistical analyses were performed by Cochrane Review Manager software (RevMan) ver5.1 . When we used the generic inverse variance method to incorporate cross-over studies into the meta-analysis, we used the formula listed in the Cochrane Handbook for Systematic Reviews of Interventions, section 16.4.6.1 [Treatment effect size was standardized by mean differences (MDs) that were obtained by dividing changes from baseline (or the difference between before and after treatment) by the pooled SD. Results for the comparative effect are shown by the mean difference estimates and 95% confidence intervals (CIs). We used a standard inverse variance random effects model for meta-analyses. Heterogeneity was assessed by I16.4.6.1 , to calcn = 1) or insufficient data (n = 6). Figure The initial search identified 33 records, of which 28 full papers were identified for further examination. We excluded five papers on the basis of their abstracts because they did not meet the selection criteria of the study design. After screening the full text of the 28 selected papers, 21 met the inclusion criteria; seven were excluded because of no control group , and sitting and viewing forest landscapes . These intervention methods were compared with the same activities in non-forest environment-like city areas , with sitting in a room , or with only measuring blood pressure in daily life . The duration of interventions in most trials was within 2 h , but the duration of two trials was longer than 1 day.Of the 20 trials that reported values of SBP, 17 reported values of DBP, five reported values of HR, and eight reported values of PR.Trials were conducted in three countries, with 17 trials conducted in Japan, two in Korea, and one in China.P < 0.001; I2 = 1%; 732 participants; 20 trials)    .Seventeen trials were suitable for meta-analysis. DBP of the forest environment was significantly lower than that of the non-forest environment .Five trials reported values of HR and eight trials reported values of PR. We conducted meta-analysis using these 13 trials. HR and PR of the forest environment were significantly lower than those of the non-forest environment , which is consistent with the possibility that some studies are missing from the right Fig. . But, thThis systematic review examined the evidence for effects of the forest environment on blood pressure. The review identified 20 trials (15 studies), involving 732 participants. The majority of trials were cross-over studies , and only five trials were parallel-group comparison studies, which had a separate control group from the experimental group. The results of meta-analysis showed that SBP and DBP of the forest environment were significantly lower than those of the non-forest environment. Taken together, these findings suggest that the forest environment may have anti-hypertensive effects.For analysis according to participants’ characteristics, we conducted sub-group analyses considering SBP levels before intervention and age. The trials were divided into the high SBP group (≥ 130 mmHg) and the low SBP group (< 130 mmHg) according to the value of SBP before intervention. Meta-analysis showed that SBP of the forest environment was significantly lower than that of the non-forest environment. When we compared the MD of both groups, the MD in the high SBP group was lower than that in the low SBP group. This finding suggests that the forest environment may have a larger effect on lowering SBP in hypertensive people than in normotensive people.We then divided subjects into the young male group, the middle-aged or older male group, and the middle-aged or older female group. Although all of the groups showed that SBP of the forest environment was lower than that of the non-forest environment, the MD of the older groups was lower than that of the younger group. This finding suggests that the forest environment has a larger effect on lowering SBP in older people than in younger people. However, all trials for male university students comprised the low SBP group and blood pressure rises with age. Therefore, rather than being affected by age, the forest environment might have a larger effect on lowering SBP in people with higher blood pressure than in those with lower blood pressure.An observational study showed a positive association of exposure to the forest environment with reduced blood pressure in children . HoweverWe also divided the trials into the walking group and the non-walking group to examine differences in intervention methods, and conducted sub-group meta-analyses. In both groups, SBP of the forest environment was significantly lower than that in the non-forest environment. There was not a large difference in the MD between these groups. This finding suggests that the effect of the forest environment on blood pressure is not due to physical activity. Some studies have shown that phytoncides  may have a beneficial effect on blood pressure , 37. Fur.This study has several limitations. First, because most trials investigated only immediate effects of the forest environment, we could not evaluate long-term effects. There were only two trials in which the intervention or observation period was longer than 1 day , 26, of The second term of the National Health Promotion Movement in the twenty-first century  estimates that lowering average systolic blood pressure by 4 mmHg will lead to a reduction in mortality rate of cerebrovascular disease  and in mortality rate of ischemic heart disease , among 40- to 89-year-old people whose prevalence of high blood pressure is high , 43. OurThis systematic review shows significant effects of the forest environments on a reduction in blood pressure. In particular, the forest environment has a larger effect on lowering SBP in people with high blood pressure and in middle-aged or older people compared with the non-forest environment.


The EndoPAT method has been used as a noninvasive method for assessing endothelial function in several non-pregnant populations. We investigated its possible use in assessing endothelial dysfunction in pre-eclampsia.Two hundred and fifteen participants were recruited and grouped as pre-eclamptic cases (105) and normotensive controls (110). Endothelial function and arterial stiffness were measured as reactive hyperaemia index and augmentation index, respectively, using the EndoPAT 2000 machine.The reactive hyperaemia index was significantly lower in the pre-eclamptic group compared to the normotensive group (p < 0.05). Augmentation index on the other hand was significantly higher in the pre-eclamptic group compared to the normotensive group (p < 0.0001).The EndoPAT method demonstrates endothelial dysfunction and arterial stiffness in pre-eclampsia. Pre-eclampsia is a pregnancy-specific multisystem disorder characterised by new-onset hypertension and proteinuria from 20 weeks’ gestation in a previously normotensive pregnant woman. It is one of the major causes of maternal and perinatal morbidity and mortality worldwide and more so in developing countries.2In the complex and intriguing pathogenesis and pathophysiology of pre-eclampsia, endothelial dysfunction remains the most agreed-upon central mechanism involved, leading to clinical manifestations of the syndrome.4The most commonly used (gold standard) non-invasive technique in assessing endothelial function in pregnancy is the ultrasonography method called flow-mediated dilatation (FMD) of the brachial artery. The technique measures endothelial function by inducing reactive hyperaemia (which is based on nitric oxide production and bioavailability) by temporary occlusion and measuring the resultant relative increase in blood vessel diameter.The EndoPAT method is non-invasive, easy to use, userindependent and immediate, and provides automatically calculated results for assessing endothelial function.This study set out to assess pulse-amplitude tonometry (PAT) using EndoPAT 2000 in normotensive and hypertensive pregnant women in rural Africa to determine whether it could demonstrate endothelial dysfunction associated with pre-eclampsia.The study was done with approval from the Bio-Ethics Committee of the Faculty of Health Sciences, Walter Sisulu University (bioethics clearance certificate No.045/010). It was a prospective case–control study conducted in Mthatha Hospital Complex, Eastern Cape, South Africa, between 2010 and 2013.A total of 215 participants with known HIV status were recruited into the study; 105 women had pre-eclampsia (cases) and 110 were normotensive pregnant women (controls). Selection of cases was based on persistent blood pressure of ≥ 140/90 mmHg on two occasions, at least four to six hours apart or a single reading of ≥ 160/110 mmHg, and proteinuria of ≥ 1+ on at least two random specimens collected at least four hours apart (or a 24-hour urine protein of ≥ 300 mg/l) from 20 weeks of gestation, as defined by the International Society for the Study of Hypertension in Pregnancy (ISSHP). Controls were age-matched (within two to three years) and gestational age-matched (within two weeks) normotensive pregnant women attending the antenatal clinic or admitted for other obstetric conditions other than hypertension or diabetes.Women with severe hypertension (blood pressure of ≥ 160/110 mmHg) not responding to treatment, imminent eclampsia, foetal distress, the HELLP syndrome or eclampsia and other complications requiring immediate intervention were excluded from the study. Women with known history of chronic hypertension or diabetes mellitus were also excluded from the study.Endothelial function was assessed using the EndoPAT 2000 technique, which measures PAT using the reactive hyperaemia index . Briefly, after 20 minutes’ rest in a chair inclined at an angle of about 45° at room temperature, a blood pressure cuff was placed on the non-dominant upper arm (study arm), while the other arm served as the control. The hands were placed on armchair supports with the palm side down, such that the fingers hung freely.The EndoPAT probes were then placed on the tip of each index finger of both hands. The probes were prevented from touching any other finger or object, and were then electronically inflated. The PAT signal was continuously recorded on a personal computer during the test. Baseline pulse amplitude was measured from each fingertip for five minutes. After baseline recording of five minutes on each arm, arterial flow was then interrupted in the experimental arm by rapidly inflating the cuff to occlusion pressure of 200 mmHg or 60 mmHg plus systolic blood pressure (whichever was higher). After exactly five minutes’ occlusion, the cuff pressure was rapidly deflated, and post-occlusion recording continued for another five minutes in the experimental arm as well as the control arm.h/Ah, with A representing pulse amplitude, h denoting hyperaemic finger). This result was divided by the corresponding ratio from the contralateral, control hand  to obtain the RH–PAT ratio or PAT ratio.Pulse amplitude response to hyperaemia was automatically calculated from the hyperaemia in the finger of the experimental arm as a ratio of post-deflation average pulse amplitude to the baseline average pulse amplitude (i.e. A2–P1/P1), expressed as a percentage.The EndoPAT 2000 not only measured endothelial function with the RHI but also assessed arterial stiffness by measuring the peripheral augmentation index (PAIx) from the radial pulsewave analysis. PAIx was automatically calculated as the ratio of the difference between the early and late systolic peaks of the waveform relative to the early peak  software was used for data analysis. Normality of the data distribution was evaluated by the Shapiro–Wilk and Kolmogorov and Smirnov normality tests. Data are summarised as means ± standard error of the mean (SEM) for normally distributed data and medians  for non-normally distributed data. The two-sample Student’s t-test was used to compare means, while the Mann–Whitney U-test was used to compare medians. Spearman’s correlation and multiple regression analyses were used to determine relationships between RHI, PAlx, baseline pulse-wave amplitude (BPWA) and maternal blood pressure.Secondary analysis was carried out based on whether the cases had early- or late-onset pre-eclampsia and whether cases and controls were HIV positive or negative. Kruskal–Wallis and one-way ANOVA were used to compare means between the cases and controls. Statistical significance was set at p < 0.05.The general characteristics of the participants are as laid out in Women with pre-eclampsia were found to have significantly lower RHI  and log-transformed RHI  and BPWA  were found to be higher among women with pre-eclampsia compared to the normotensive controls, as shown in On bivariate correlation analysis, there was a significant inverse relationship between RHI and diastolic blood pressure, parity and mean arterial pressure, and no relationship with maternal age, body mass index (BMI), systolic blood pressure, or total number of risk factors for pre-eclampsia, as seen in BPWA was positively related to maternal age, BMI, parity, pulse pressure, weight and systolic blood pressure on univariate correlation, as seen in The participants were divided into four groups, namely, (1) HIV-negative normotensive (A) (n = 83); (2) HIV-positive normotensive (B): (n = 27); (3) HIV-positive pre-eclamptic (C): (n = 38); and (4) HIV-negative pre-eclamptic (D) (n = 67) . The KruFor mean arterial pressure, significant differences were evident between HIV-positive normotensive and HIV-positive pre-eclamptic pregnant mothers (p < 0.001), HIV-positive normotensive and HIV-negative pre-eclamptic pregnant mothers (p < 0.001), HIV-negative normotensive and HIV-positive pre-eclamptic pregnant women (p < 0.0001), and between HIV-negative normotensive and the HIV-positive pre-eclamptic pregnant women (p < 0.001), respectively. Significant differences were observed for BPWA (p < 0.01) and augmentation index at 75 bpm (p < 0.0001) between the four groups.For BPWA, Dunn’s multiple comparison test revealed a significant difference only between HIV-negative normotensive and HIV-negative pre-eclamptic pregnant women (p < 0.01). For augmentation index, significant differences were observed between HIV-negative normotensive and HIV-positive pre-eclamptic pregnant women (p < 0.001) and between HIV-negative normotensive and HIV-negative pre-eclamptic pregnant women (p < 0.001), as shown in In this study, we set out to assess whether PAT (through RHI) demonstrates endothelial dysfunction in pre-eclampsia. The RHI was found to be significantly lower in patients with pre-eclampsia compared to normotensive controls. Since RHI is endothelium dependent, these results indicate that there is indeed endothelial dysfunction in rural African women with pre-eclampsia, therefore confirming what has been reported in other populations. To our knowledge, this is the first report involving rural black African women.Endothelial dysfunction is known to be the central mechanism in the pathophysiology of pre-eclampsia.We have shown in this study that the EndoPAT 2000 can be used successfully to assess endothelial function in pregnant subjects by measuring the RHI. Although the EndoPAT 2000 itself is a fairly expensive machine, it is less invasive, much easier to use, does not require extensive training and it can be used to assess large numbers of patients rapidly and reliably, even in a clinic setting.Although not many studies have tested endothelial function in pregnancy using EndoPAT 2000, our results are in agreement with the study done by Yinon et al. in 2006, who examined 17 women at the time of diagnosis of pre-eclampsia (mean gestation 32 weeks) and compared them with 25 women with normotensive pregnancies. They found that women with pre-eclampsia had significantly lower RHI values (1.5 ± 0.1 vs 1.8 ± 0.1) compared to uncomplicated pregnancies.The results of this study with much larger number of subjects clearly indicate that RHI, as measured using the EndoPAT, can be used as an adjunct to blood pressure measurement in assessing endothelial dysfunction in pre-eclampsia. However, as endothelial dysfunction is known to precede clinical pre-eclampsia, the important question is, can the EndoPAT 2000 be used for screening and identifying patients before the onset of clinical pre-eclampsia? CartyIf it were demonstrated that RHI, as measured by the EndoPAT 2000, can be used as a predictor of pre-eclampsia, then the test would become much more cost-effective and cheaper. A prospective cohort study of normotensive pregnant women recruited in the first or early second trimester and followed until delivery is planned to determine whether RHI measurement can be used as a predictor of pre-eclampsia.When participants with early-onset pre-eclampsia were compared with those with late-onset pre-eclampsia, there was no statistically significant difference in RHI between patients with early- and late-onset pre-eclampsia (p > 0.05). Although the numbers are small, this finding suggests that endothelial dysfunction is indeed present in both early- and late-onset pre-eclampsia, and that this may be the central mechanism involved in the pathophysiology of both early- and late-onset pre-eclampsia.Although some authors have suggested that early-onset pre-eclampsia is a result of impaired placentation,An inverse relationship observed between FMD and baseline vascular dimension has been reported from previous studies, where peak arterial dilation is a function of baseline vessel diameter and smaller vessels dilate more than larger ones.It has been suggested that in individuals with variable brachial geometry, adjusting RHI for brachial artery diameter may be needed to accurately examine microvascular endothelial function using PAT.An inverse relationship was found between RHI, mean arterial pressure and diastolic blood pressure in the entire study population. No relationship was observed between RHI and systolic blood pressure. Other studies have reported conflicting relationships between RHI and mean arterial pressure, diastolic and systolic blood pressure. Truschel et al.Hamburg et al. suggested that systolic blood pressure may have a limited effect on the distal microcirculation, whereas it had a predominant effect on BPWA without additional modification of the hyperaemic response, when presented as a ratio.30In pregnancy, a similar correlation between RHI and mean arterial pressure was found in a study done in Israel assessing the relationship of pre-eclampsia with sleep-disordered breathing.36Traditionally, PAlx is obtained from pressure waveforms via applanation tonometry of the carotid or radial arteries. Recently, it has been demonstrated that PAlx measured from digital pulse-wave volumes by peripheral PAT correlated with that from applanation tonometryPatvardhan et al.45Normal pregnancy is a profoundly vasodilated state.48The reactive hyperaemia index, as a measure of endothelial dysfunction, was lowest in HIV-positive pre-eclamptics (1.67) and highest in HIV-negative normotensive controls (1.84). In HIV-positive normotensive controls, the RHI was 1.79 and it was 1.70 in HIV-negative pre-eclamptic cases. Although these differences did not achieve statistical significance, a trend towards a lower reactive hyperaemia index can be seen in the HIV-positive patients, indicating increasing levels of endothelial dysfunction. Arterial stiffness, as measured by the augmentation index was significantly worse (p < 0.000) in the HIV-positive pre-eclamptic and normotensive women than in the HIV-negative pre-eclamptic and normotensive women. Arterial stiffness is also a measure of endothelial dysfunction, therefore indicating that HIV infection is indeed associated with endothelial dysfunction in both normotensive and pre-eclamptic patients.Considering that vasodilation, upon which the EndoPAT depends, is influenced by temperature, efforts were made to conduct the measurements in temperature-controlled rooms for all participants. Due to insufficient funds, we were not able to compare EndoPAT results with a blood marker of endothelial dysfunction, but such a study is planned.This study has shown that there is impaired endothelial function in rural African women with pre-eclampsia, based on the low RHI and increased arterial stiffness, as measured by the BPWA and augmentation index, compared to normotensive pregnancies. This clearly indicates that RHI, BPWA and Alx@75, as measured using the EndoPAT, can be used for assessing endothelial dysfunction in pre-eclampsia. Although PAT could be used as an adjunct to blood pressure measurement in assessing patients with pre-eclampsia, the EndoPAT is a relatively expensive piece of equipment.The EndoPAT 2000 may earn its worth if it could detect endothelial dysfunction and hence be used for screening patients before the onset of hypertension and proteinuria. This will need to be assessed in a prospective, cohort study of pregnant women from the first or early second trimester until delivery, in order to determine whether a reduced RHI can be detected before the onset of pre-eclampsia. Such a study is planned.


Surgery causes a stress response, a physiologic response to trauma. The intraoperative surgical stress response in dogs diagnosed with pyometra has not previously been described. The aim of this study was to investigate the intraoperative surgical stress response, assessed by blood pressure and heart rate measurements, in dogs diagnosed with pyometra and healthy controls. All dogs were premedicated with acepromazine and methadone, anaesthesia was induced with propofol and maintained with isoflurane, where after the dogs were subjected to ovariohysterectomy.P = 0.37). In both groups, systolic blood pressure increased between phase 1 and 2, from 87 ± 15 to 114 ± 19 mmHg in dogs with pyometra, and from 88 ± 18 to 106 ± 20 mmHg in healthy controls, (both P < 0.0001). Systolic blood pressure did not differ significantly between groups in any of the phases. Heart rate and end-tidal concentration of isoflurane did not differ significantly between phases or between groups.Eight dogs diagnosed with pyometra and eight healthy controls were used. Systolic blood pressure and heart rate were measured to assess the surgical stress response. Additionally propofol dosage at induction of anaesthesia and the end-tidal isoflurane concentration were investigated. The surgery was split into four phases. Phase 0 was the period 10 min before the skin incision, phase 1 was skin incision and opening of abdomen, phase 2 was manipulation of uterine horns, lifting of the ovary with stretching of the mesovarium, ligation and transection of mesovarium and phase 3 was ligation and transection of cervix, removal of organs and closing of the abdomen. Dosage of propofol at induction of anaesthesia was 3.6 ± 1 mg/kg in dogs with pyometra and 4.1 ± 1 in healthy controls (The increased blood pressure at removal of ovaries during ovariohysterectomy suggests a pronounced noxious stimulus at this part of the procedure. In principle, the study parameters and response to surgery did not differ significantly between dogs with pyometra and healthy controls. Pyometra is a common disease in intact bitches. In a study of insured dogs in Sweden approximately 25% of females were affected by pyometra before 10 years of age –8 which The study population consisted of female privately owned dogs admitted to the University animal hospital for surgical treatment, OHE, due to pyometra. Dogs of different breeds and ages were included Table . All dogAcepromazine and methadone were used for sedative premedication Table . CarprofAnaesthesia was induced by intravenous administration of propofol  given to effect at approximately 4 mg/kg and maintained with inhalation of isoflurane mixed in air at 2–3%. Oxygen and air mixture at approximately 50% was used at a flow of approximately 20–40 ml/kg/min in a circle breathing system. The dosage of isoflurane was controlled by an experienced and qualified veterinary nurse who monitored the anaesthesia. All dogs breathed spontaneously. The setting of the vaporizer was aimed at maintaining the dog anesthetized at surgical plane of anaesthesia . Depth of anaesthesia was judged by subjective assessment of the muscular tonus of the jaw, position of the eyeballs, dilation of the pupils, and the response to surgery.The end-tidal isoflurane concentration heart rate and blood pressure were recorded using a multi-parameter anaesthetic monitoring device . Non-invasive arterial blood pressure and heart rate were monitored by use of an oscillometric method. An automatic pneumatic cuff, with a width to circumference ratio of approximately 0.4, was wrapped around the distal forelimb and connected to the monitoring device. Data were registered once per minute following induction of anaesthesia until completion of surgery. Data was transferred to an Excel file (Microsoft Office) and all data points were included in the analysis.linea alba, subcutaneous tissue and skin).The dog was placed in dorsal recumbency and the animal´s abdomen was clipped and scrubbed. A ventral midline incision 2–3 cm cranial to the umbilicus was made and extended caudally and the abdomen was opened. The uterus was located, the ovaries were identified and a hole was made in the mesovarium. Haemostat forceps were placed across the ovarian pedicle. Forceps were repositioned distally (closer to the ovary) to expose the compressed mesovarial tissue and one or two ligatures were placed and tied. An absorbable suture size 2–0 or 3–0 was used for ligation. The ovarian pedicle was cut between the distal ligature and the forceps. A ligature was also placed over the broad ligament. The procedure was repeated on the contralateral side. The uterine body was ligated at the cranial tip of the cervix, the tissue was transected and the uterus was removed. The ligated tissue was observed and verified for hemostasis. The abdominal wall was closed in three layers , skin incision and opening of abdomen (phase 1), manipulation of uterine horns, ligation and transection of mesovarium (phase 2), ligation of cervix, removal of organs and closing (phase 3). Other actions by the surgeon that could affect the surgical stress response were noted in the protocol, i.e. application of forceps or diathermy. The exact time when all parts of the surgical procedures that represented each phase were performed were noted in the protocol. The recorded data was thus labelled by phase.t test  was used  for comparison of age, body weight, dosage of propofol and duration of phases between the groups . There were no significant differences between the groups’ corresponding phases in systolic blood pressure, heart rate or concentration of anaesthetic gas. Duration of phases 0–3 for pyometra and control dogs did not differ significantly between groups . Neither heart rate, nor end-tidal concentration of isoflurane, changed significantly during the procedures in any of the groups  inhibitor and the mechanism behind its main anti-inflammatory effect is unknown. No perioperative adverse effects on the cardiovascular system have been reported at recommended dosages , 54. TheIn a previous study where markers of surgical stress in dogs subjected to OHE were measured, the heart rate increased at ligation of mesovarium and removal of the ovary . The samIn one dog an intraoperative haemorrhage was observed after single ligation of the ovarian pedicle. In addition one dog was re-operated due to haemorrhage from a single ligated ovarian pedicle. The complications described in this study confirm the current recommendation that the ovarian pedicle should be double ligated .There were study limitations. One limitation was the use of non-invasive blood pressure measurements. An invasive technique is considered gold standard, but with repeated measurements a reliable average of a series of systolic blood pressure readings can be obtained. Systolic blood pressure values are given as the non-invasive method may be less accurate at lower pressures –58. The In principle, the study parameters and the response to surgery did not differ significantly between corresponding phases of the groups. Blood pressure increased at removal of the ovaries, both in dogs diagnosed with pyometra and healthy controls that were subjected to OHE under isoflurane anaesthesia and premedicated with acepromazine and methadone. Blood pressure did not differ significantly between the groups’ corresponding phases. Heart rate and end-tidal concentration of isoflurane did not change significantly during the procedure and did not differ significantly between groups.


Hypertension is known as the “silent killer,” driving the global public health burden of cardiovascular and renal disease. Blood pressure homeostasis is intimately associated with sodium balance and the distribution of sodium between fluid compartments and within tissues. On a population level, most societies consume 10 times more salt that the 0.5 g required by physiological need. This high salt intake is strongly linked to hypertension and to the World Health Organization targeting a ∼30% relative reduction in mean population salt intake to arrest the global mortality due to cardiovascular disease. But how does a habitually high-salt diet cause blood pressure to rise? In this focused review, we discuss 2 “evolutionary medicine” concepts, presented at the ISN Forefront Meeting “Immunomodulation of Cardio-renal Function.” We first examine how ancestral variants in genes that conferred a selection advantage during early human development are now maladaptive. We then discuss the conservation of “renal” sodium transport processes across multiple organ systems, including the brain. These systems influence sodium appetite and can exert an often-overlooked effect on long-term blood pressure control. Hypertension is known as the “silent killer”: it rarely causes symptoms and is the chief modifiable risk factor driving a global health crisis of cardiovascular and renal disease.et al., which placed renal function at the center of long-term blood pressure homeostasis.What is the relationship between salt intake that is habitually high and long-term blood pressure? This is difficult to gauge, as most clinical studies estimate salt intake from measurement of 24-hour urinary sodium excretion and recent research clearly shows that this is not an effective index of intake.It is certain that chronically elevated blood pressure reflects interactions between multiple systems , but thiAGT promotor that increase circulating angiotensinogen encoding gene are found at higher frequency in African populationsAs recently reviewed,How should these data be interpreted? One possible inference is that hypertension arises from a mismatch between environment and ancestral salt-conserving variants. Indeed, the gain-of-function variants would impair the pressure natriuresis response, promoting sodium retention. Indeed, such variants in angiotensinogen, for example, are associated with hypertension in the general population.APOL1 gene, which encodes apolipoprotein-L1, is observed in higher frequency in African Americans, contributing to higher rates of cardiovascular and renal disease.Trypanosoma brucei, which causes sleeping sickness, rather than a beneficial effect on blood pressure homeostasis.However, to contextualize hypertension as a misalignment of ancestrally favorable “blood pressure” variants is too narrow a view. Recent studies suggest that hypertension is a modern bystander effect of selective pressure imposed to conserve other desirable traits. For example, an ancestral variant in the UMOD, the gene encoding uromodulin  protein. Common gain-of-function SNPs in UMOD associate with hypertension, low glomerular filtration rate, and risk of renal disease.A similar picture is emerging for gain-of-function variants in What does Evolutionary Medicine tell us about hypertension? First, these studies underscore the necessity to return to a more “primitive” diet, low in sodium and high in potassium. Second, they can provide new mechanistic insights into blood pressure control: the study of ancestral variants is identifying new loci associated with hypertension, including kinases that regulate ENaC and sodium chloride co-transporter (NCC).Early terrestrial animals evolved highly effective strategies to conserve sodium, and it is evident that both afferent  and efferent  arms of salt homeostasis engage a conserved molecular framework of sodium transport proteins and regulatory kinases . MutatioThis framework is exemplified in the principal cell of the distal nephron . AldosteThe same molecular machinery contributes to sodium absorption in the GI tract, activation of salt-taste receptors on the tongue,nucleus tractus solitarius; NTS) are selectively activated by sodium depletion and rapidly inactivated when salt appetite is satiated.Salt appetite is often overlooked as a factor for hypertension and, despite evidence of benefit, compliance with restricted salt intake is poor.It is not certain whether MR activation in the CNS is determined by aldosterone penetrating the blood−brain barrier or whether aldosterone is also produced in the brain.Post hoc analysis of Symplicity-HTN3 found benefit of denervation in hypertensive patients with obstructive sleep apnea,Dysregulation of central salt-regulating pathways can compromise long-term adherence to restricted sodium intake and promote hypertension. Can these processes be targeted to improve cardiovascular outcome? Certainly the brain and the kidney “talk” to each other, and bilateral renal denervation has gained considerable traction as a device-based approach to manage blood pressure in patients with resistant hypertension.For most of mankind’s existence, sodium chloride was a scarce nutrient. This scarcity gave great economic value to salt and shaped the formation and customs of our societies, both ancient and modern. It is also reflected in our DNA, encoding the multiple interlocking pathways that efficiently control salt balance. However, our salt intake is now habitually high, and these genes no longer fit: blood pressure rises, and cardiovascular disease is the leading cause of global mortality. It is clear that BP homeostasis is intimately associated with sodium homeostasis and the distribution of sodium between fluid compartments and within tissues. Research has given us a more sophisticated understanding of blood pressure control, revealing a dynamic interplay among hormonal, neuronal, and immune systems. Our habitually high salt intake promotes abnormal interactions and causes hypertension. This improved understanding may help us to develop therapeutic and lifestyle interventions to tame the “silent killer.”All the authors declared no conflict of interest.


Intracerebral hemorrhage (ICH) remains a prevalent and severe cause of death and disability worldwide. Control of the hypertensive response in acute ICH has been a mainstay of ICH management, yet the optimal approaches and the yield of recommended strategies have been difficult to establish despite a large body of literature. Over the years, theoretical and observed risks and benefits of intensive blood pressure reduction in ICH have been studied in the form of animal models, radiographic studies, and two recent large, randomized patient trials. In this article, we review the historical and developing data and discuss remaining questions surrounding blood pressure management in acute ICH. The pathophysiologic mechanisms underlying the acute hypertensive response observed in stroke are not clearly understood, although proposed theories have included autoregulation to improve cerebral perfusion, Cushing reflex in patients with elevated intracranial pressure (ICP), damage to brain areas regulating BP3, and a sympathetic response to discomfort or illness4. It is also reasonable to attribute at least a proportion of hypertension in patients with acute stroke to chronic hypertension, although this explanation would be inconsistent with the observed patterns of spontaneous reduction in BPs over the several days following stroke1. Of stroke subtypes, there is a higher prevalence of severe hypertension among patients with acute intracerebral hemorrhage (ICH)2. Interestingly, the Oxford Vascular Study found that the mean first systolic blood pressure (SBP) after ICH onset was much higher than the most recent pre-ICH reading, and this difference was greater than that seen in patients with acute ischemic stroke despite similar rates of premorbid hypertension 5. Additionally, BPs decreased more rapidly in the first 24 hours after ICH than after ischemic stroke , even after excluding patients who received antihypertensives and who died prior to 24 hours after onset. This suggests that the hypertensive response to ICH is different from other types of brain injury, perhaps due to the mass effect of the hemorrhage or responses to blood vessel rupture or blood products.Elevated blood pressure (BP) is prevalent in an estimated 60–84%7 and in particular among patients with ICH8. A relationship between uncontrolled BP and hematoma volume expansion has been reported in several studies11; however, others have failed to find a clear association13. These conflicting data cast doubt on whether it is a simple linear relationship between pressure and hemorrhage growth. There are more consistent data on the association between hematoma growth and poor outcome14, so that any potential decrease in the risk of expansion attributable to aggressive BP control has therapeutic interest. The management of elevated BP in acute ICH confronts two conflicting pathophysiologic processes. First, BP reduction lowers hydrostatic pressure and therefore may attenuate hematoma expansion and theoretically perihematoma edema as well. Second, there is the potential risk of worsening ischemia in the perihematomal region or precipitating renal injury by aggressively lowering perfusion pressures. In the following paragraphs, we describe the main concerns that have surrounded BP management in acute ICH in recent years, and we summarize the data that have influenced various perspectives on this controversial topic.The clinical significance of hypertension in acute stroke and the optimal strategies for managing it have been topics of extensive study for many decades. Elevated admission BP has been associated with increased mortality and disability among certain groups of stroke patients15. Magnetic resonance imaging (MRI) diffusion and perfusion studies also found hemispheric hypoperfusion and, in some patients, perihematomal areas of decreased apparent diffusion coefficients, which were correlated with poor outcome. If these areas represented risk for secondary ischemia, BP reduction could lead to further neurological injury16.Recently, a number of clinical trials have demonstrated the relative safety of BP reduction in acute ICH. However, evidence of therapeutic benefit has remained elusive or variable, and optimal strategies to lower BP are poorly defined. Prior to large clinical trials, caution against aggressive BP treatment came in the form of retrospective data suggesting that rapid BP reduction, as reflected by steeper slopes of the change in mean arterial pressure (MAP) over time, was associated with increased mortality17. Additionally, human radiographic studies of the posited “penumbra” suggested that early BP control in acute ICH could be safe. Positron emission tomography (PET) was used to demonstrate that perihematomal areas of hypoperfusion were characterized by matched reduction in demand, with reduced oxygen metabolism and extraction rather than the increased oxygen extraction seen in ischemia18. PET was also used to show that the use of antihypertensive medications to lower MAP in the acute period led to no further changes in global or perihematomal blood flow, suggesting preservation of autoregulation despite antihypertensive treatment19. More recently, similar findings were confirmed by using computed tomography (CT) perfusion imaging in the Intracerebral Hemorrhage Acutely Decreasing Blood Pressure Trial (ICH-ADAPT)20. Patients presenting with SBP of more than 150 mm Hg and moderately sized ICH within 24 hours of onset were randomly assigned to a target SBP of less than 150 mm Hg or less than 180 mm Hg. There was no difference in perihematomal CBF between groups and no association between magnitude of SBP reduction and perihematomal CBF. In addition, maximum oxygen extraction fraction (OEF[max]) and maximum cerebral metabolic rate of oxygen (CMRO2[max]) were not affected by aggressive SBP treatment21. Cerebral perfusion pressure was also maintained in the perihematomal region, and the perfusion pressure did not differ by BP treatment arms or BP22. Information from these studies offered to quiet the theoretical risk of major ischemia in the perihematomal area. However, substantial prospective data were not available at the time.Despite this concern, early animal studies showed that controlled antihypertensive treatment in the acute period had no adverse effect on ICP or regional cerebral blood flow (CBF), as measured by radiolabeled microspheres23, a prospective trial of 27 patients found a low rate of neurological deterioration and hematoma expansion in patients who received treatment to reduce BP below 160 systolic and 90 diastolic within 24 hours24. Two clinical trials—the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage (INTERACT)25 and the Antihypertensive Treatment in Acute Cerebral Hemorrhage (ATACH) study26—had just begun. In the absence of clinical trial data, guideline recommendations were hesitant, suggesting treatment for BPs over 200 mm Hg systolic or MAP over 150 mm Hg, and discretion to treat BPs over 180 mm Hg systolic or MAP over 130 mm Hg, either to a goal cerebral perfusion pressure of 60–80 mm Hg in patients with elevated ICP or to a target BP 160/90 mm Hg or MAP 110 mm Hg in those not suspected to have elevated ICP23.The American Heart Association/American Stroke Association guidelines for management of spontaneous ICH have evolved over the last few iterations, reflecting conclusions drawn from sequential studies on intensive BP treatment. Prior to publication of the 2007 guidelines27. A few years later, a prospective Chinese study of 1,760 patients with ICH reported a direct linear association between elevations in SBP and death and major disability28. Another retrospective study, of 122 patients with ICH, found an association between BP control and neurological deterioration over the course of 24 hours29. The risk of neurological deterioration—defined by comparing baseline and 24-hour Glasgow Coma Scale (GCS) scores—was significantly lower in the quartile of patients with maximum SBP drop over the course of 24 hours. These studies further highlighted the need to determine whether intervening in elevated BP could mitigate the poor outcomes seen after acute ICH, and trials ensued  to be maintained for 24 hours. The 3-month mortality was lower than expected in all tiers, and frequencies of neurological deterioration and serious adverse events were below pre-specified safety thresholds26. Overall, the pilot demonstrated feasibility and safety of early BP lowering. In a post-hoc analysis, patients who had more aggressive SBP reduction over the course of 24 hours (based on area under the curve of hourly SBP and baseline SBP) showed trends toward reduced hematoma expansion and better 3-month outcomes.32. Based on this emerging available evidence, guidelines were updated to suggest that lowering SBP to 140 mm Hg in those patients presenting with SBP between 150 and 220 mm Hg was probably safe but underscored the uncertainty of efficacy until larger trials were completed33.In 2008, a prospective trial which randomly assigned 21 patients each to groups with target MAP of less than 110 mm Hg versus 110–130 mm Hg found no significant differences between the groups in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days34. On average, BPs among the 88 participants dropped from 175.4 ± 33.7 mm Hg systolic to 127.4 ± 16.7 mm Hg systolic over 6 hours of infusion. Only three (3.4%) patients had hematoma expansion, and two (2.2%) had neurological deterioration. In 2015, another study found an inverse association between relative SBP reduction (24-hour SBP compared with that on admission) and neurological deterioration , hematoma expansion (>33% increase), and unfavorable outcome at 3 months  score >3)35.The pilot clinical trial data were accompanied by additional retrospective and prospective observational studies. In 2012, a multicenter prospective study to evaluate the feasibility of intravenous nicardipine to treat hypertension in acute ICH was reportedP = 0.06) for the primary outcome of death or major disability, defined as an mRS score of more than 2 at 90 days. Although effect on the primary outcome just missed statistical significance, secondary analyses indicated that the intensive treatment group had significantly better functional recovery on an ordinal analysis of mRS scores and better physical and mental health-related quality of life on the European Quality of Life 5 Dimension (EQ-5D) scale36. There were no safety concerns identified. A post-hoc analysis of INTERACT2 did find that greater reduction in SBP was associated with reduced hematoma growth . In addition, the lowest mean hematoma growth was in patients in the intensive treatment arm who achieved a target SBP at less than 1 hour compared with those patients who achieved target SBP at later time points37.The phase III INTERACT2 trial, which studied 2,794 patients presenting with SBP between 150 and 220 mm Hg within 6 hours of symptom onset, provided the largest body of evidence on SBP treatment to date. Those randomly assigned to the intensive treatment group had a target SBP of less than 140 mm Hg within 1 hour of randomization and for a duration of 7 days. Intravenous medications were administered per local protocols, and outcomes were assessed blinded to treatment arm. The standard treatment group had a target SBP of less than 180 mm Hg. The intensive treatment group had an odds ratio (OR) of 0.87  0.75–1.01,38.Interestingly, INTERACT2 did not show a clear relationship between outcome and time from onset to initiation of BP treatment. Of note, only one third of patients achieved the target SBP within 1 hour; half achieved the target in 6 hours. This raises the possibility that the duration of BP control, rather than the rapidity of treatment, contributed to the outcomes. There are also important populations for whom INTERACT2 did not provide data, including patients presenting with SBP of more than 220, larger hematomas, and more severe neurological deficits and patients undergoing decompressive craniectomy. Nevertheless, the trial offered strong evidence that early intensive BP lowering in the studied population did not lead to increased risk of death or serious adverse events. It demonstrated an effect of intensive treatment target on better functional recovery  as well as a trend toward decreased mortality and major disability (primary endpoint). Based on these data, the current American Heart Association guidelines were revised to state that for “ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe  and can be effective for improving functional outcome ”39. This randomized controlled trial enrolled 1,000 patients in the USA, Europe, and Asia who presented with primary supratentorial ICH and initial SBP of more than 180 mm Hg. Patients were initially enrolled within a 3-hour window from symptom onset, but later the window was expanded to 4.5 hours after an analysis found similar prevalence of hematoma expansion within the 3- to 4.5-hour window40. Patients 18 years or older with a GCS score of 5 or more and hematoma volumes of less than 60 mL on CT scan were eligible. They were randomly assigned to either the intensive treatment group with a goal SBP of 110–139 mm Hg for 24 hours or the standard treatment group with a goal SBP of 140–179 mm Hg. Intravenous nicardipine was used according to a standard protocol: initiation at 5 mg per hour and then an increase by 2.5 mg per hour every 15 minutes as needed to a maximum of 15 mg per hour. After this, if the SBP was still above target, then intravenous labetalol was used .The most recent data reported are from the ATACH-2 trialP = 0.05).The primary outcome in ATACH-2 was death or moderately severe to severe disability (mRS score >3) at 3 months. The trial was terminated for futility before reaching the proposed enrollment target of 1,280 subjects, which was calculated to identify a 10% difference between groups. Analysis of the first 1,000 subjects recruited showed that the absolute difference in the rate of death and disability was similar between the two treatment groups . There was also no difference between groups on the ordinal analysis of the mRS score. The rate of hematoma expansion was slightly lower in the intensive treatment group ; however, quality-of-life assessment using EQ-5D also did not demonstrate significant difference between the two groups. There was no difference in the rate of serious adverse events within 72 hours between the two groups; however, the rate of non-serious renal adverse events within 7 days was higher in the intensive treatment group (9% versus 4%). In addition, there were higher rates of serious adverse events within 3 months in the intensive treatment group , and only 30% of patients in the intensive arm of the trial achieved the target SBP level of less than 140 mm Hg within 1 hour36. Thus, the INTERACT2 trial in effect tested a more moderate approach to control of hypertension than ATACH-2 and showed more promising results on clinical outcomes. Neither trial was designed to inform whether SBP of 140–160 mm Hg would have different outcomes from SBP of 160–180 mm Hg, assuming that target BPs can be achieved and maintained. Subgroup analyses to address outcome differences between groups as defined by their achieved BPs within the range of SBP of 140–180 mm Hg could be informative. In addition, SBP goals were maintained for 7 days in INTERACT2 but for only 24 hours in ATACH-2, raising important questions about optimal timing and duration of BP control and the effects of these variables on patient outcomes.The two largest clinical trials—INTERACT2 and ATACH-2—used SBP of less than 180 mm Hg as the standard treatment target, yet the intensity in the intervention arm and the time to achievement of SBP goals differed between the trials. In ATACH-2, the mean minimum SBP values during the first two hours were 128.9 ± 16 mm Hg in the intensive treatment group and 141.1 ± 14.8 mm Hg in the standard treatment group, and 88% of patients met the SBP goal within 2 hours43, 14 patients with suspected acute stroke and hypertension were recruited and randomly assigned to a first dose of lisinopril versus placebo; four patients completed 7 days of study treatment. In the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT)44, 41 of 80 screened patients were enrolled and successfully randomly assigned to transdermal glyceryl trinitrate versus placebo. SBP between the groups was significantly different at 2 hours (P = 0.03), and there was no difference in rates of serious adverse events or death. Pre-hospital identification of definitive ICH, if achievable, could allow further study on the effects of pre-hospital initiation of antihypertensive treatment specifically in this population.With consideration to the timing of initiation of BP treatment, pre-hospital screening, assessment, and initiation of treatment are of great interest. Two trials have demonstrated the feasibility of executing an ambulance-based, paramedic-initiated randomized controlled trial. In Paramedic Initiated Lisinopril For Acute Stroke Treatment (PIL-FAST)The challenges that exist in applying the available data to individual clinical situations are universal. For BP management in ICH, conclusions from the trials must be extrapolated when patients do not fall within the description of the study patient populations. Patients comprising the majority of subjects in the aforementioned studies had small to moderate-sized hematomas, leaving those with large and more severe hemorrhages an understudied population. Over half of participants in both INTERACT2 and ATACH-2 were recruited from Asian countries. However, there were no differences found in treatment effect among Asian versus non-Asian subjects in either study. In terms of intervention, BP parameters and choice of intervention varied among the studies and depended on the resources available to practicing clinicians; thus, conclusions from the different trials may or may not be generalizable.46 and mortality47. Other studies have highlighted additional radiographic predictors of hematoma growth, including spot sign number48; the presence of fluid levels, density heterogeneity, and margin irregularity49; the black hole sign50; and the blend sign51. If radiographic predictive features for hematoma expansion prove robust, they may offer a selection tool for early intensive BP treatment. One such study (SCORE-IT) is testing this hypothesis by using the spot sign in the ATACH-2 study52.The decision to pursue more aggressive treatment may be informed by methods useful for identifying patients most likely to benefit. Identifying those who may be at particular risk of hematoma expansion could sway the approach to treating hypertension. An interesting body of research has focused on the “spot sign”, or the appearance of contrast extravasation on CT angiography, which is thought to represent an area of active bleeding. This effect has been found to be independently associated with hematoma expansion53. Such DWI lesions have been found to be more prevalent in patients with acute SBP lowering54 and patients with cerebral amyloid angiopathy56 and have been associated with poor functional outcomes57. In an effort to prospectively study the relationship between BP management and DWI lesions after ICH, the ongoing randomized trial ICH ADAPT II will study patients randomly assigned to an SBP target of less than 140 versus less than 180, with MRI performed on days 2, 7, and 30 to assess the impact of hypertensive therapy on DWI lesions, both at 48 hours and cumulatively over 30 and 90 days. Secondary outcomes will include absolute hematoma growth and prediction of DWI lesion incidence as well as mortality, functional outcome, and cognitive status58. Factors besides acute BP lowering may be associated with DWI lesions, however. A study of 600 patients with primary ICH found DWI lesions in 26.5% of cases, and associated variables after controlling for race/ethnicity, leukocyte count, and acute in-hospital antihypertensive treatment included higher first recorded SBP as well as greater change in MAP, microbleeds, white matter hyperintensity score, and lower age59. The association of such imaging markers with different pathologies underlying hemorrhage  raises an important distinction for patient selection that has been unaddressed thus far. If the risks and benefits of aggressive BP control vary depending on the underlying pathology, that patients with decidedly different etiologies for spontaneous ICH have been studied as one population may account for some of the difficulties finding evidence of therapeutic benefit. Systematic studies using neuroimaging may assist in delineating optimal selection strategies for SBP target in individual patients.Alternatively, neuroimaging may identify patients at risk of cerebral ischemic events with aggressive BP control. There is a growing literature on the occurrence of diffusion-weighted imaging (DWI) lesions, remote from the primary site of injury and delayed from hemorrhage onset, on the MRIs of an estimated 25% of patients with ICH. Mechanistic theories suggest a “stroke-prone” state after hemorrhagic or ischemic stroke, composed of an enhanced thrombotic milieu or impaired hemodynamic regulation (or both) amidst pre-existing vascular pathology, making distant brain regions potentially susceptible to secondary injury in the setting of rapid BP lowering60. However, a small study of nine patients who received nicardipine and were monitored with transcranial Doppler found evidence of paradoxical intracranial vasoconstriction, as characterized by prominent systolic peak and dicrotic notch, pronounced systolic deceleration, and elevated pulsatility index during nicardipine infusion, thus contradicting the expected autoregulatory response to decreasing BP61. Without a large body of evidence for one agent over another, the most recent guidelines suggest that an agent be chosen on the basis of practicability, pharmacological profile, potential side effects, and cost38. Relevant to this question are animal studies that have shown that inflammation contributes to secondary injury in ICH, making the various factors involved in promoting inflammatory pathways attractive potential treatment targets62. There are data to suggest that activation of the sympathetic nervous system leads to increased inflammation63. Motivated by this concept, an analysis of the placebo-arm patients in a randomized trial testing a potential neuroprotective agent found that the use of anti-adrenergic medications  was shown to be associated with less edema on 72-hour imaging after hemorrhage volume and BP were controlled for63. In a retrospective study investigating the association of beta-blocker use with mortality among patients in a prospectively collected ICH database, in-patient beta-blocker use was independently associated with reduced rates of in-hospital and 3-month mortality. However, univariate and multivariate analyses comparing outcomes among patients who received beta-blocker therapy versus other antihypertensive classes of medications failed to show any class-specific difference64. Potential benefits of different classes of medications on other mechanisms of injury have not been extensively studied. Differences in medication classes used in INTERACT2—primarily alpha(1)-antagonist (urapidil), calcium channel antagonists (nicardipine and nimodipine), and mixed alpha- and beta-antagonists  and ATACH-2 (nicardipine)—may also have contributed to outcomes, although this remains speculative.Data are even sparser on specific medication selection; one study has compared nitroprusside and nicardipine and found lower rates of mortality among those who received nicardipineP = 0.0167 for the first 24 hours and OR 1.57, 95% CI 1.14–2.17;P = 0.0124 for days 2–7). Similar associations were seen for the secondary outcome of an ordinal shift in mRS score at 90 days65. The findings were also reported in a retrospective cohort study66. Another cohort study measured parameters, including diastolic BPs, pulse pressures, and MAPs, and found that higher mean pulse pressures were significantly associated with in-hospital mortality67. Secondary analyses addressing this same topic in the ATACH-2 population will be of great interest. It may emerge that avoidance of SBP spikes and acute BP troughs is as important as the specific target chosen if not more so. Furthermore, the use of SBP versus MAP in the different trials raises uncertainty as to which would be the better physiologic marker of the biological effects of BP variability in ICH. Further study to characterize not only the optimal measurement target but also the biological correlates of changes in MAP versus SBP could be important to understanding the physiologic mechanisms underlying outcome effects of different approaches to intensive BP management.Control of BP variability did emerge from a secondary analysis of INTERACT2 as a priority in management. When serial BP measurements in two phases of treatment (first 24 hours and days 2–7) were analyzed for variability defined as the standard deviation of SBP, categorized into quintiles, a significant linear association was found between variability and the primary outcome of death or major disability at 90 days (OR 1.41, 95% CI 1.05–1.90;Research on BP management in acute ICH over years of study has focused on the mechanics of hematoma expansion, perihematomal physiology, mechanisms of secondary injury, and the relationship between BP targets and patient outcomes. Recent trials have offered the needed data on the safety and potential efficacy of moderately aggressive SBP control in acute ICH. However, the precise interactions between patient selection and the timing and duration of different interventions and outcomes remain intriguing and require further definition.ATACH, Antihypertensive Treatment in Acute Cerebral Hemorrhage; BP, blood pressure; CBF, cerebral blood flow; CI, confidence interval; CT, computed tomography; DWI, diffusion-weighted imaging; EQ-5D, European Quality of Life 5 Dimension; GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage; ICP, intracranial pressure; INTERACT, Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage; MAP, mean arterial pressure; MRI, magnetic resonance imaging; mRS, modified Rankin Scale; OR, odds ratio; PET, positron emission tomography; SBP, systolic blood pressure.


Chronic kidney disease (CKD) is a syndrome characterized by progressive and irreversible deterioration of renal function linked to slow destruction of renal parenchyma, eventually terminating in death when sufficient number of nephrons are damaged. Oxidative stress is commonly observed in CKD patients resulting from an imbalance between overproduction of reactive oxygen species (ROS) and impairment of defence mechanisms. Grape seed extract (GSE) is a polyphenolic mixture exhibiting antioxidant and anti-inflammatory properties. We conducted an interventional pilot study of supplementation with GSE capsules  or placebo  on CKD patients. Blood and urine samples were collected at baseline and after a six-month-long supplementation period to determine some renal function biomarkers, as well as antioxidant, anti-inflammatory and haematological parameters. GSE improved glomerular filtration rate (GFR) and proteinuria, increased the anti-oxidant status as assessed by high plasma catalase and superoxide dismutase and also lowered lipoperoxidation and carbonylation. GSE ameliorated inflammation by decreasing CRP, triglyceridemia and counteracted anemia and thrombocytopenia. Supplementation with 2 g GSE/day for six months improved some kidney function parameters of CKD patients and this beneficial effect of GSE seems to be mediated at least partly by its antioxidant and anti-inflammatory properties. Chronic kidney disease (CKD) is a slow and progressive decline of kidney function that is often linked to long standing diseases such as diabetes and hypertension . It is Grape seed extract (GSE) is a complex polyphenolics mixture containing flavonoïds, non flavonoïds, proanthocyanidins exhibiting multi-organ protection in various experimental settings . For inThe present work aims to test the ability of GSE to improve kidney dysfunction of CKD patients from various renal stages i.e stage 2, 3, 4. Data mainly show that although used at a low dosage, GSE improves several kidney function parameters as well as the anti-oxidative status of CKD patients after a 6-month-supplementation period.CKD patients with renal failure  were recruited as volunteers at the haemodialysis unit of the Regional Hospital of Menzel Bourguiba for a randomized double blind and placebo control pilot study. All patients suffered from diabetic nephropathy and hypertension. They were treated with insulin (two doses per day), received captopril 50 mg (2 tablets/day) for hypertension, furosemide 40 mg (asylix 2 tablets/day) for nephropathy, folic acid (foldine 2 tablets/ day) and iron (2 tablets/day) for anemia. Key exclusion criteria included smokers and haemodialysis patients receiving antioxidant supplements in the previous six months. All patients were asked to keep their habits and medication as usual and were dispatched into two groups: experimental and placebo. Patients in the placebo group (n = 10) were distributed as follows:2)3 patients were from stage 2 (GFR ≤ 90 ml/min/1.73m2)4 patients were from stage 3 (GFR ≤ 60 ml/min/1.73m2)3 patients were from stage 4 (GFR ≤ 30 ml/min/1.73mPatients in the GSE group (n = 23) were distributed as follows:6 patients were from stage 2 11 patients were from stage 36 patients were from stage 4The GSE group was daily supplemented with six capsules of GSE, each capsule containing 350 mg of grape seed powder. Two bottles of 90 capsules each were provided to each patient for one month during the entire six months long study which lasted from May to October 2011. The placebo group received starch containing capsules in the same conditions. Blood samples were withdrawn after an overnight fasting at the beginning of the study and after 6 months of supplementation with either GSE or placebo. Urines were also collected at baseline and at the end of the experimentation for proteinuria determination. The study protocol was approved by the ethics committee on clinical research of the Regional Hospital of Menzel Bourguiba and informed consent was obtained for all participants. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2000 and 2008.Vitis vinifera from northern Tunisia. Seeds were carefully separated from skin, washed, dried and grounded with an electric grounder until a fine powder was obtained. After mixing with 3 % colloïdal silica as excipient, the powder was conditioned into capsules weighting approximately 350 mg. Total polyphenolics content as well as polyphenol composition were determined previously  of al., 2014).2O2  method. Plasma was processed by centrifugation at 3000 rpm for 10 min and used for the determination of renal function biomarkers as urea and uric acid using commercial kits from Biomaghreb, Tunisia. Urine urea and uric acid were also determined and proteinuria evaluated using the biuret method . Oxidatal., 1979), free ial., 1979) as wellal., 1979) and glual., 1979).Inflammation was evaluated using plasma CRP and LDH. Triglyceridemia and cholesterolemia were measured using commercial kits from Biomaghreb . P value less than 0.05 was considered signiﬁcant.We reported in Figure 1GSE also affected several plasma biomarkers of the antioxidant status. GSE slightly decreased plasma MDA by -14.96 % Figure 2A. We reported in Table 1Table 2We reported in Table 3The present work is a preliminary and pilot study dealing with the effect of GSE treatment on CKD patients of various renal failure stages. Data mainly show that even when used at a low dosage, GSE exerts a clear beneficial effect on some renal function biomarkers as well as on the antioxidant status of CKD patients. To our knowledge, our work is the first one to describe such relevant and hopeful clinical trials data for million CKD patients worldwide. First of all GSE improves some kidney function parameters as it enhances GFR and clearly lowers proteinuria. This result is of utmost importance as reduction in proteinuria to the lowest achievable level is an important predictor of long term renal protection , as it The beneficial effect of GSE on renal function seems to be mediated, at least partially, by its antioxidant and anti-inflammatory properties. After a six-month-period of treatment, GSE counteracts both plasma lipoperoxidation and carbonylation as well as CRP and LDH, and clearly increases plasma CAT and SOD . MoreovRemarkably that in our present case, GSE improvement in kidney function of CKD patients has been obtained at a low GSE dosage of 35 mg/kg if we consider the weight of the starting grape seed powder, and highly lower if we consider the polyphenol content. Our laboratory has recently demonstrated the efficiency of high dosage GSE till 4 g/kg) in multi-organ protection against various insults as obesity , stro g/kg in Nevertheless the current interventional pilot study suffers from several limitations. First the sample size is too small to be of robust statistical significance. Although GSE was used at low dosage, a significant improvement in the decline of some kidney function biomarkers after a six-month-treatment period was obtained. Duration of the study should be extended to increase blood and urine sampling and a ten fold higher GSE dosage (350 mg/kg) should be tested to reach improvement of statistical significance. Owing to its tremendous safety, GSE is increasingly used at high dosage (more than 500 mg/kg) according to our own data  or to cIn conclusion, due to the multi-organ safety and beneficial health effects of grape polyphenols, clinical trials using high GSE dosage should be urgently planned to confirm these preliminary and hopeful data.The authors declare no conflict of interest.