Objectives: The objective of this study is to assess the association between hemoglobin (Hb) and blood pressure (BP) levels among community-dwelling older adults.Materials and Methods: This comparative cross-sectional study was conducted in April 2021 in West Bengal, India. Individuals who are receiving treatment for hypertension, or had a history of blood transfusion, or had a history of intake of iron and vitamins were excluded from the study. A total of 81 and 106 individuals were recruited in “Group 1” (no self-reported comorbidity) and “Group 2” (self-reported comorbidity present), respectively.Results: The mean (SD) age of the participants (n = 187) was 67.4 (7.4) years; 54% (n = 101) were males; and 45.4% (n = 85) were obese. We found a significant association of Hb level with systolic blood pressure (SBP)  and mean arterial pressure (MAP)  in “Group 1”. The quantum of increases in SBP, diastolic blood pressure (DBP), pulse pressure (PP), and MAP with one gram/dl change in Hb level were 3.24 (95% CI: -0.75 to 7.24) mmHg, 1.17 (95% CI: -0.84 to 3.20) mmHg, 2.06 (95% CI: -0.67 to 4.81) mmHg, and 1.87 (95% CI: -0.65 to 4.39) mmHg, respectively, in “Group 1” after adjustment for age, gender, and body mass index. The findings were inconsistent in “Group 2”, and the changes in Hb level were 0.5 (95% CI: -3.77 to 2.77) mmHg, 0.92 (95% CI: -0.72 to 2.75) mmHg, -1.42 (95% CI: -4.09 to 1.24) mmHg, and 0.45 (95% CI: -1.05 to 2.40) mmHg, respectively.Conclusion: Hb level has a positive correlation with SBP and MAP only in those without comorbidities. The world is experiencing rapid growth in the older adult (aged ≥ 60 years) population. Older adults acquire multiple functional limitations due to the accumulation of degenerative changes with aging. This mandates the quality of life (QoL) to be considered as a better indicator of health than the overall increase in life expectancy among older adults . Blood hA large number of older adults suffer from high blood pressure (BP) (hypertension), which contributes to significant mortality and morbidity ,3. AnemiOlder adults generally acquire multiple other chronic diseases with the advancement of age . The preStudy design and settingA comparative cross-sectional study was conducted during April 2021 in the urban field practice area of a medical college in Kalyani. Kalyani is one of the earliest planned cities of India and is located around 50 kilometers away from the metropolitan city of Kolkata, West Bengal. The municipality area is divided into 21 ward/block areas - all similar in sociodemographic and economic characteristics and caters to a population of around one lakh.Study participantsAll older adults (aged ≥ 60 years) residing in the ward/block areas of Kalyani municipality for at least the past one year were eligible to participate in the study. Individuals with a present history of receiving an anti-hypertensive group of medication, history of blood transfusion in the last six months, and history of intake of iron and folic acid and/or vitamin B12 in the last six months were excluded from the study as these parameters can influence the primary outcome variables.Sample size and sampling methodA list of households was obtained from Kalyani municipality. There was a total of 22,100 households/families  in the study area, and all were having a unique number provided by the municipality. A total of 1,112 households were listed, which had at least one eligible participant, and this had served as the sampling frame. Study households were selected from the sampling frame through simple random sampling using a computer-generated sequence. Assuming a correlation coefficient (r) of 0.27 , 80% powStudy toolAn interview was conducted using a structured questionnaire; the first part was used to collect information regarding demography and comorbidities. Individuals taking medicines for the last six months for conditions like diabetes, body or back pain, chronic obstructive pulmonary disease (COPD), osteoarthritis, or hypothyroidism were considered to suffer from chronic disease conditions. The second part comprised Hb estimation, anthropometry, and BP measurements.Data collectionData were collected using trained medical social workers (MSWs) under the supervision of resident doctors of the Department of Community Medicine and Family Medicine. The initial screening and data collection from the recruited individuals were done in house-to-house visits using the standard infection control precautions, and if any house was locked, then the next eligible household was approached. Initially, the age eligibility of the individual was assessed. If the individual was found to be eligible, she/he was asked “Do you have any disease for which you are taking medicine for the last six months?” If the answer was “No”, she/he was included in “Individuals with no reported chronic morbidity” (Group 1). If the answer was “Yes”, the exclusion criteria were applied and they were identified as “Individuals with reported chronic morbidity” (Group 2). The participants were contacted only once for the study, and data collection happened three times a week. Only one individual from each household was selected for the study. If any house had more than one eligible participant, then one of them was selected using the lottery method.Anthropometry measurements such as weight and half-arm span were taken with height being estimated from arm span for calculating body mass index (BMI) . Hb levePulse pressure (PP) and mean arterial pressure (MAP) were calculated from systolic blood pressure (SBP) and diastolic blood pressure (DBP) using the standard formula .Ethical approvalEthical approval was obtained from Institute Ethics Committee (IEC) . Informed consent was taken before the questionnaire was administered to the study participants.Statistical analysisData were collected using EpiCollect version 5.0 and analyzed using Stata version 14 . Descriptive statistics were presented as mean and standard deviation (SD) for continuous variables and frequencies with proportions for categorical variables. Pearson’s correlation coefficient (r) was used to measure the association between Hb level (considering it as exposure) and SBP, DBP, PP, and MAP (considering these as outcome variables), and the strength of correlation was graded accordingly . The quaAn initial screening was done among 220 individuals, out of whom 33 individuals refused to participate citing prior commitments. Finally, a total of 81 individuals were recruited in “Group 1”, i.e., with no self-reported comorbidity, and 106 were recruited in “Group 2”, which comprised of individuals taking treatment for diabetes , hypothyroidism , osteoarthritis , backache/chronic pain , and COPD  with multiple conditions coexisting.The mean (SD) age of the participants was 67.4 (7.4) years, and 54% n = 101) of the study participants were males. Of total, 45.4% (n = 85) were obese . As comorbidities are common with aging, we also have separately compared the association between Hb and BP in individuals with no comorbidity (Group 1) and individuals with one or more than one comorbidity (Group 2). We have found a consistent trend of increase in SBP, DBP, PP, and MAP with an increase in Hb among individuals with no comorbidity (Group 1). However, the correlation was not consistent in Group 2. Previously done two studies in China and Netherlands reported a similar positive correlation of Hb with SBP and DBP ,17. PhysPeople with chronic morbidities usually manifest with a high level of circulatory inflammatory cytokines like tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). Both of these have a direct inhibitory action on iron absorption from the gut and the release of iron from store cells via the hepcidin-mediated pathway, thereby causing anemia . As a reThe quantum of increase in SBP and PP with per gram/dL increase of Hb was 3.24 mmHg and 2.06 mmHg among individuals in Group 1 after adjusting for age, gender, and BMI. The observation was in consonance with an earlier study . It has This was a comparative cross-sectional study, so temporality cannot be established. The chance of random dilution bias could not be canceled as BP was measured in a single visit using a digital sphygmomanometer. We grouped the individuals based on self-reporting of chronic morbidity. Assessment of serum inflammatory bio-marker would have confirmed the disease activity and further strengthened the relationship. No earlier study from developing nations differentially assessed the correlation of Hb with SBP, DBP, PP, and MAP among individuals with or without comorbidity. Our study findings provide this important information.Hb level has a positive correlation with SBP and MAP only among the older adults without apparent comorbidity. Further research is required to assess the above relationship among the people with comorbidities as the prevalence of anemia and hypertension is high in older adults in the developing countries.


Hypertension has been shown to be an important risk factor in IgA nephropathy (IgAN). The 2021 the Kidney Disease Improving Global Outcomes (KDIGO) Guideline proposes a target systolic blood pressure (SBP) of less than 120 mmHg in patients with Chronic Kidney Disease (CKD) not receiving dialysis. However, whether lowering SBP from <140– <120 mm Hg is renoprotective is unknown. This study aims to evaluate the association of SBP and the progression of IgAN, then explore whether lowering SBP from <140– <120 mm Hg is renoprotective.Overall, 2,240 patients with IgAN were enrolled in this study. Cox proportional hazards models and restricted cubic splines were used to estimate the associations between SBP and kidney failure events which are defined as 50% estimated glomerular filtration rate (eGFR) decline or kidney failure.p = 0.010) for SBP <140 mm Hg after adjustment for traditional risk factors. The renoprotective benefits of therapy targeting SBP <120 mm Hg from SBP <140 mm Hg was detectable within the subgroup with proteinuria >1.0 g/d, CKD 1-3a stage, but not those with proteinuria ≤ 1.0 g/d and CKD 3b-4 stage.After a median follow-up of 30.05 months, 217 (9.69%) patients reached composite kidney failure events. The association of SBP and kidney failure events showed a linear relationship. The risk of kidney failure events was greater with higher SBP. Compared with SBP <120 mm Hg, the hazard ratio was 1.85 (1.16–2.97, In patients with IgAN, SBP was independently associated with composite kidney failure events. Lowering SBP from <140– <120 mm Hg was renoprotective. Immunoglobulin A nephropathy is one of the most common primary glomerular diseases worldwide, approximately 20–40% of patients progressed to end-stage kidney disease (ESKD) in 20 years –4. IgA nThe Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggested a systolic blood pressure (SBP) target of <120 mm Hg for adults with high blood pressure (BP) and chronic kidney disease (CKD) because of the cardiovascular and survival benefits rather than renal benefits , 14. In A total of 2,240 patients with IgA nephropathy diagnosed between 2002 and 2019 in the First Affiliated Hospital, Zhejiang University School of Medicine were selected. Patients mainly come from Southeast China. Secondary IgA nephropathy such as IgA vasculitis, rheumatic disease, and systemic lupus was excluded.All participants provided written informed consent for using pathological and clinical data, this study was approved by local ethics committees.In our study, both arms were used for BP measurement. Before measurement, the patient sat in a chair relaxing for >5 min, the patient could not speak during the measurement, the arm which gives the higher reading was used for subsequent readings. Repeated measurements were made after 1–2 min, the average of ≥2 readings obtained was used as the patient's BP.2 or the need for kidney replacement therapy (KRT) . In order to assess the graded effect of SBP on renal survival, SBP was divided into three levels . Participants were also divided into two groups according to age (<50 years and ≥ 50years), baseline proteinuria (>1 g/d and ≤ 1g/d), and CKD stage (G1-3a stage and G3b-4 stage).Clinical data including age, sex, serum creatine level, 24-h urine protein excretion, systolic/diastolic blood pressure at the time of kidney biopsy, and the use of antihypertension medications  were collected from the medical records. Pathologic elements were evaluated according to the Oxford classification , 22. Thet-test or ANOVA as required for normally distributed data and nonnormally distributed data were compared using the Mann–Whitney test. Restricted cubic splines were used to determine the association of SBP levels with composite kidney failure events, three knots were placed at the 25th, 50th, and 75th for the cubic splines. The relationship between parameters and renal survival was estimated using unadjusted and multivariable-adjusted Cox models. The traditional risk factors of IgA nephropathy including sex, age, proteinuria, eGFR, and Oxford classification scores were adopted in multivariable-adjusted Cox models. Kaplan-Meier analysis was used to derive the cumulative kidney survival curves, the difference between the curves was analyzed using a log-rank test. Data were analyzed using SPSS software version 24.0 and Stata software, version 14.0 . A two-sided p < 0.05 was considered statistically significant.Categorical data were expressed as proportion and frequency and were compared using the chi-squared test. Continuous variables were presented as mean ± standard deviation and were assessed with a 2. During a mean follow-up of 30.05  months, 217 (9.69%) cases developed composite kidney failure events, including 194 (8.66%) with 50% eGFR decline events and 163 (7.28%) with ESKD events.Clinical data are summarized in The patients were divided into three groups according to the SBP levels as shown in P = 0.004) after being adjusted for age, sex, initial proteinuria, eGFR, Oxford classificatio,n and the use of antihypertension agents . In patients with proteinuria ≤ 1 g/d, SBP 120–139 mm Hg did not increase the risk for the composite kidney failure events compared to SBP <120 mm Hg . In those with proteinuria >1 g/d, SBP120-139 mm Hg was a risk factor for composite kidney failure events in reference to SBP <120 mm Hg . As shown in P for interaction < 0.001).We further evaluated the graded effect of SBP on renal outcomes in patients with proteinuria >1 g/d and ≤ 1 g/d. A total of 135 (13.89%) patients in the proteinuria >1 g/d group and 33 (3.14%) patients in proteinuria ≤ 1 g/d group developed composite kidney failure events (P = 0.031) for SBP between 120 and 139, and 2.29  for SBP ≥140 mm Hg. For patients with CKD 3b-4 stage, higher levels of SBP were not associated with poor renal outcome, the hazard ratios were 0.72  for SBP between 120 and 139, and 0.96  for SBP ≥140 mm Hg. These results were similar in cumulative kidney survival curves  or age ≥50 years (P = 0.018) (P = 0.017) for SBP between 120 and 139 and 1.92  for SBP ≥ 140 mm Hg in patients with years in age <50. In the subgroup with years in age ≥ 50, the hazard ratios were 1.72  for SBP between 120 and 139, and 2.27  for SBP ≥140 mm Hg.Cumulative kidney survival curves demonstrated that patients with SBP <120 mm Hg had a favorable prognosis compared to SBP 120–139 mm Hg and SBP ≥140 mm Hg either in the subgroup with age <50 years (= 0.018) . In the P = 0.004) after being adjusted for traditional risk factors, treatment with antihypertension was significantly associated with reduced risk for the composite event . Kidney cumulative survival analysis demonstrated that patients with antihypertension treatment had a favorable renal survival compared to those without antihypertension treatment  cases that received antihypertension treatment. Treatment with antihypertension was a protective factor in the unadjusted Cox model  during follow-up, and the treatment was similar in three groups, therefore, we did not include the use of RAASi and immunosuppressives into the analysis.In conclusion, in this large cohort study, we demonstrated that in patients with IgA nephropathy, SBP was independently associated with kidney failure events, lowering SBP from <140– <120 mm Hg could improve the renal prognosis, the effect was greater in those with baseline proteinuria > 1.0 g/d, CKD 1-3a stage and age <50 years, for those with proteinuria ≤ 1.0 g/d and CKD 3b-4 stage, the renoprotective was not significant.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All procedures performed in this study protocol were reviewed and approved by the Ethics Committee of the institute of the First Affiliated Hospital, College of Medicine, Zhejiang University.GY and JC: research idea and study design. GY, JC, and YJ: data acquisition. GY: data analysis, interpretation, and statistical analysis. HL, XL, and JC: supervision or mentorship. All authors approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by grants LQ19H050009 and LY19H050007 from the Zhejiang Provincial Natural Science Foundation of China and grant 2016KYA087 from the Zhejiang Medical and Health Science and Technology Project.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In conclusion, according to our preliminary study, low-pressure laparoscopy represents a valid alternative to standard laparoscopy and could facilitate the development of outpatient surgery.The aim of our study was to evaluate the benefits of a low-pressure insufflation system  vs. a standard insufflation system in terms of anesthesiologists’ parameters and postoperative pain in patients undergoing laparoscopic surgery for early-stage endometrial cancer. This retrospective study involved five tertiary centers and included 152 patients with apparent early-stage disease who underwent laparoscopic surgical staging with either the low-pressure AirSeal system  or standard laparoscopic insufflation . All the intraoperative anesthesia variables evaluated  were significantly lower in the AirSeal group. We recorded a statistically significant difference between the two groups in the median NRS scores for global pain recorded at 4, 8, and 24 h, and for overall shoulder pain after surgery. Significantly more women in the AirSeal group were also discharged on day one compared to the standard group. All such results were confirmed when analyzing the subgroup of women with a BMI >30 kg/m This system provides a more stable pneumoperitoneum by responding to the slightest changes in IAP and is associated with a reduced rate of CO2 use, absorption, and elimination [Over the last two decades, laparoscopy has become the favorite approach for the surgical treatment of apparent early-stage endometrial cancer worldwide ,2,3,4. Mmination ,11. Furtmination ,13,14. Tmination ,16. HoweThis was a multicenter, two-arm, retrospective pilot study conducted at the Michele e Pietro Ferrero Hospital, Verduno ; San Gerardo Hospital, University of Milano-Bicocca, Monza ; Ospedale Santa Croce e Carle, Cuneo ; Division of Obstetrics and Gynecology, University Hospital of Udine; and at the Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome . The ethics committee of the principal investigator has declared that it was not necessary to obtain informed consent from patients for this retrospective study specifically, since all patients had given informed consent before surgery.One hundred and fifty-two women with apparent early-stage endometrial cancer who had undergone laparoscopic surgical staging with the AirSeal System between January 2019 and December 2021 were retrospectively included in this study and were compared to a subgroup of women operated with the standard insufflation system.The primary objective was to compare and evaluate the impact of the low-insufflation system in terms of anesthesiology parameters and postoperative shoulder pain at 4, 8 and 24 h after surgery. Intra-operatively, the following were evaluated: systolic blood pressure, end-tidal CO2, peak airway pressure, volume of CO2 used, duration of surgery, and blood loss. Pain was evaluated with the Numeric Rating Scale (NRS) with a range between 0 and 10.2. Considering the retrospective nature of the study, which did not involve any direct patient contact or diagnostic or therapeutic intervention, a waiver of informed consent and a waiver of authorization were requested. All patient information was guaranteed to be confidential. The study was conducted according to the guidelines of the Declaration of Helsinki.Secondarily, we investigated the impact of low-pressure insufflation in the subgroup of women with a BMI > 30 mg/mAfter the induction of standard general anesthesia, the induction of pneumoperitoneum was achieved by using either the Veres needle technique or the open technique at the standard flow of 12 mmHg. After primary port placement, the intra-abdominal pressure was decreased to 8–10 mmHg in the AirSeal system group, while it was maintained at 12–14 mmHg in the standard insufflation group.The AirSeal insufflation system, once activated, works with three essential components, the iFS AirSeal control, the Tri-Lumen Filtered Tube Set, and the Access Port, which together allow the creation of a stable pneumoperitoneum and of continuous smoke evacuation. The access port is available in two sizes: 5 or 10 mm. The 5 mm port was usually placed on the right side of the iliac quadrant, whereas the 10 mm port was placed on the camera site, i.e., on the umbilicus scar. In order to prevent smoke evacuation from impairing visualization, the 5 mm trocar was placed away from the camera. Two more accessory 5 mm diameter trocars that do not require fascial closure were placed, as shown in The general anesthesia induction protocol included Propofol as a hypnotic, Fentanyl or Remifentanyl as an analgesic, and Rocuronium as a muscle relaxant, followed by intubation, and maintenance with Desflurane or Sevoflurane and Remifentanil. Nausea and vomiting prevention were obtained with Dexamethasone administered at 4 or 8 milligrams intravenously.In the absence of contraindications, postoperative pain was controlled with the intravenous administration of Paracetamol at 1 g and Ketoprofene at 160 milligrams (Artrosilene) 3 times daily. In the presence of a Numeric Rating Scale of pain (NRS) higher than 4, Ketoprofene 160 mg was given intravenously and, eventually, subcutaneous morphine 10 mg was given if NRS was still higher than 4 after administration of Ketoprofene.p-values with p < 0.05 were considered statistically significant. We performed a multivariate analysis to adjust for potential confounding factors. We used logistic regression to perform the analysis because of the binary endpoint. Stata software 9.0  was used for performing the statistical analysis.Descriptive statistics are presented as frequencies and proportions for categorical variables and mean/median with a standard deviation/interquartile range for continuous variables. These descriptive characteristics are reported in tables so that readers can inspect the distribution of these variables in the two study groups (ultrastaging protocol A vs. B) and for the lymph node status (positive node disease vs. negative node disease). Continuous variables were compared using Wilcoxon rank-sum tests. Proportions were compared using Chi-Square tests or Fisher’s exact tests. All 2-sided One hundred and fifty-two patients were included in this retrospective study. A total of 84 patients (55.3%) underwent laparoscopic surgery with the AirSeal system at 8–10 mmHg, whereas 68 (44.7%) were treated with conventional laparoscopic surgery and the standard insufflation system. The baseline characteristics of the study population are shown in 2 (range 23.7–36.4) and 27.9 kg/m2 (range 22.6–33.2) for the AirSeal and the standard group, respectively. No differences in terms of the presence of previous surgery, smoking habits, pulmonary disease and ASA score were observed between the groups. Surgical outcomes such as duration of surgery, blood loss, and number of lymph nodes removed were similar between the two groups.Surgical procedures, including simple hysterectomy, bilateral salpingo-oophorectomy and sentinel node biopsy, were performed with a traditional laparoscopic tower. The median age of patients was 63 years (IQR 52–73) for the AirSeal group, and 65 years (IQR 54–75) for the standard group. The median BMI was 30.0 kg/mp = 0.224). However, patients in the AirSeal group recovered significantly faster compared to the standard group. In the AirSeal group, 98% (80/81) of women were discharged within 2 days, compared to 75% (51/68) of patients in the standard group (p < 0.0001). The complication rate did not differ between the two groups.Median length of hospital stay was 2 days in both groups (p < 0.0001). In the subgroup of 67 women with a BMI greater than 30 mg/m2, the differences were maintained  were significantly lower in the AirSeal group . Furtherintained .p = 0.023). This difference was maintained at 8 and 24 h after surgery, when the median reported global pain was 0.8 (IQR range 0–1.6) and 0.2 (IQR range 0–0.8), respectively, for the AirSeal arm compared to 1.4 (IQR range 0.7–2.1) and 1.1 (IQR range 0.2–2.0) for the control arm (p < 0.0001). The administration of morphine was statistically different across the two groups, with 4.8% and 27.9% in the AirSeal and the standard group, respectively (p < 0.0001). The analysis of women with a BMI greater than 30 mg/m2 showed that the differences between the Airseal and standard groups were maintained  for endometrial cancer patients have been widely demonstrated in the last decade ,18. Womep = 0.0001).Pneumoperitoneum with CO2 increases the risks of respiratory, cardiovascular and metabolic complications, mainly caused by the increase in the intra-abdominal pressure that triggers the increase in median systolic pressure. In obese women, this phenomenon is accentuated and with the activation of the kidney-angiotensin renin system, a further increase in blood pressure can occur. Furthermore, elevation of the intra-abdominal pressure with pneumoperitoneum causes an upward elevation of the diaphragm, resulting in increased intra-thoracic pressure, thus decreasing pulmonary compliance and augmenting peak airway pressure, which results in an increased risk of barotrauma. In this study, the use of low-pressure insufflation with the AirSeal system allowed for a significant limitation of the increase in et-CO2, peak airway pressure and maximum systolic blood pressure during surgery. The overall consumption of CO2 was also reduced with AirSeal  compared with traditional insufflation . Moreover, as already shown by Sroussi et al., the pain control was lower overall in the AirSeal group compared to the standard insufflation group, in both the general population and the obese subgroup , which dp = 0.0001). Even if outpatient surgery is not widespread in Italy, the development and increased adoption of low-pressure laparoscopy associated with 3 mm trocars [In our opinion, our results should further encourage the adoption of this technology in patients with a higher risk of complications such as obesity and older age with malignancies, as demonstrated by the LAP2 study, where laparoscopy did not increase with age and analysis showed that a higher percentage of patients had undergone the open approach [ trocars , togethe trocars , may furOur results have some drawbacks, including the retrospective design and the relatively small sample size, and should be interpreted with caution. However, the differences highlighted between groups are significant and further multicentric studies should evaluate and further confirm our preliminary results in the oncologic population.In conclusion, the use of low-pressure laparoscopy should be encouraged mainly in the subgroup of obese women with endometrial cancer, as well as to promote the development of outpatient surgery. Low-pressure laparoscopy with the valveless platform in our experience represents a valid and innovative alternative to the standard insufflation system during minimally invasive surgery in gynecologic oncology.


In this prospective interventional study in a neurosurgical ICU the arterial partial pressure of carbon dioxide (PaCO2) was increased to a target range of 55 mmHg for 120 min by modification of the respiratory minute volume (RMV) one time a day between day 4 and 14 in 12 mechanically ventilated poor-grade SAH-patients. Arterial blood gases were measured every 15 min. CBF and brain tissue oxygen saturation (StiO2) were the primary and secondary end points. Intracranial pressure (ICP) was controlled by an external ventricular drainage. Under continuous hypercapnia (PaCO2 of 53.17 ± 5.07), CBF was significantly elevated between 15 and 120 min after the start of hypercapnia. During the course of the trial intervention, cardiac output also increased significantly. To assess the direct effect of hypercapnia on brain perfusion, the increase of CBF was corrected by the parallel increase of cardiac output. The maximum direct CBF enhancing effect of hypercapnia of 32% was noted at 45 min after the start of hypercapnia. Thereafter, the CBF enhancing slowly declined. No relevant adverse effects were observed. CBF and StiO2 reproducibly increased by controlled hypercapnia in all patients. After 45 min, the curve of CBF enhancement showed an inflection point when corrected by cardiac output. It is concluded that 45 min might be the optimum duration for a therapeutic use and may provide an optimal balance between the benefits of hypercapnia and risks of a negative rebound effect after return to normal ventilation parameters.Temporary hypercapnia has been shown to increase cerebral blood flow (CBF) and might be used as a therapeutical tool in patients with severe subarachnoid hemorrhage (SAH). It was the aim of this study was to investigate the optimum duration of hypercapnia. This point is assumed to be the time at which buffer systems become active, cause an adaptation to changes of the arterial partial pressure of carbon dioxide  and registered at ClinicalTrials.gov . Registered 01/01/2015. While autoregulation is deranged and the balance of paracrine factors shift towards vessel contraction, the PaCO2 reactivity may be altered but is, in principle, intact after aneurysmal SAH2. Elevated PaCO2 can cause vasodilation of cerebral vessels via the carboanhydrase pathway, which, as a result of increasing pCO2, leads to a lowered pH in the CSF, which in turn leads to relaxation of the vascular smooth muscle cells. Another way is through direct interaction of PaCO2 with the endothelium of the cerebral vascular system3. The degree of reactivity of CBF after SAH has been shown to be an indicator for the course of the disease after SAH with poor reactivity indicating a high risk for delayed cerebral ischemia and poor prognosis. During delayed vasospasm of proximal intracranial vessel trunks, hyperventilation induces ischemia and infarction due to an additional constriction of small distal blood vessels and is associated with poor outcome after SAH5. However, previous trials investigated only minor PaCO2 variations around the normal range. Petridis and co-workers have demonstrated that permissive hypercapnia is not hazardous to patients after SAH if they have an external ventricular drainage (EVD) continuously draining cerebrospinal fluid (CSF) during the period of hypercapnia6. In a previous trial, it was demonstrated that more pronounced changes of PaCO2 can reproducibly affect CBF even after severe SAH suggesting a therapeutic potential of temporary hypercapnia7. However, it is well known that alterations of arterial blood gases are followed by adaptation mechanisms. Research data on high altitude adaptation showed that the effect of increased CBF due to hypercapnia is timely limited9.Cerebral vasospasm and delayed cerebral ischemia (DCI) are much-feared complications and the main reason for prolonged hospitalization and persistent disabilities after aneurysmal subarachnoid hemorrhage (SAH). Cerebral blood flow (CBF) is—under physiological conditions—regulated by autoregulation as reactivity to changes of transmural wall tension, by equilibrium of vessel relaxing and constricting factors and by changes of the arterial partial pressure of carbon dioxide (PaCO2) as a therapeutic tool against DCI are not clarified. In a previous proof-of-principle study7, the CBF reactivity was demonstrated in patients with poor-grade SAH. A stepwise increase of PaCO2 in 15 min intervals up to 60 mmHg resulted in a concordant increase of CBF, which did not result in a negative rebound effect, but a sustained increase of CBF after resetting the respiration volume to baseline parameters. The questions addressed in the present work were at what point the beneficial effects of long-term hypercapnia would be exhausted or reverse to possible negative effects. The measurements of CBF and StiO2 as the primary and secondary endpoints were performed invasively with an intracerebral thermodilution probe and noninvasively by bifrontal near-infrared spectroscopy, respectively. In this prospective trial we aimed to investigate the course of CBF during longer-term hypercapnia and determine the time-point at which physiologic adaptation mechanisms start to mitigate the CBF-increasing effect in order to locate the optimum duration of controlled hypercapnia in poor-grade SAH patients.The optimum duration of controlled hypercapnia and its effects on CBF and brain tissue oxygen saturation  and registered at ClinicalTrials.gov . All methods were performed in accordance with the guidelines and regulations of the institutional ethics committee. Also, the study has been conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written consent of a legal guardian was obtained for each patient prior to inclusion into the study.Patients were eligible for recruitment if they had suffered severe aneurysmal SAH  no longer than 96 h ago, had received external ventricular drainage (EVD) due to occlusive hydrocephalus and early treatment of the ruptured aneurysm (coiling or clipping) after a 4-vessel angiography of the cerebral vessels. If no other condition like pulmonary complications after aspiration or elevated intracranial pressure prohibited a reduction of analgosedation after occlusion of the aneurysm, an attempt was made to reduce analgosedation. If the patient did not show appropriate reactions, anaesthetics were reapplied and the patient was included in the study.2 in the target range of this study is unclear. Patients eligible for inclusion who had an ICP over 20 mmHg were not included and were re-evaluated later for a possible start of the study intervention.Age under 18 years, pregnancy, non-aneurysmal SAH and the presence of a not occluded aneurysm were exclusion criteria. Furthermore, patients suffering from chronic obstructive lung disease (COLD) were excluded because their cerebrovascular reactivity to changes of PaCOStudy interventions were performed in 24-h intervals (24 ± 1 h). Prior to the daily study intervention, cardiovascular parameters, blood gases and ICP were assessed. For documentation of ICP, the EVD was closed for 5–6 monitor lengths until a steady plateau was reached, then opened again for continuous drainage. If resting ICP was over 20 mmHg at the desired timepoint, the study intervention was not conducted and the patient re-assessed 2 h later. If ICP was still elevated over 20 mmHg, the study intervention was not performed on that day. Criteria to interrupt the trial intervention were predefined as an increase of ICP over 25 mmHg for more than two minutes, hypoxemia (PaO2 < 70 mmHg or sO2 < 90 mmHg) and severe arterial acidosis with an arterial pH-value under 7.25.Study interventions were terminated on day 14. Predefined criteria to terminate the study procedures in an individual patient before day 14 were the cessation of therapy due to a poor prognosis of whatever reason according to the treating physicians’ estimation and if a reduction of analgosedation was possible and the study intervention was no longer feasible due to spontaneous breathing.2 within the normal range (36–44 mmHg). This was confirmed by another blood gas analysis. The respiratory rate was then reduced to lower the RMV by 40% in every patient. This value was adopted from a previous study assessing the feasibility and risk profile of the study intervention7 and served as a guide value for further respirator adjustments to reach the target PaCO2 of 55 mmHg. Arterial blood gases were then measured in 5-min intervals and fine adjustment of the respirator settings made until a steady PaCO2 between 50 and 55 mmHg was reached. Thereafter, arterial blood gases were measured in 15-min intervals and further respirator adjustments made in order to maintain a stable PaCO2 of 55 mmHg for 120 min. All other respiratory settings  remained unchanged. Respirator settings were returned to pre-trial settings to obtain normal PaCO2 levels after 2 h.All patients were intubated and mechanically ventilated as defined by the inclusion criteria. If not indicated for ventilatory reasons anyway, the respirator was brought into a volume-controlled ventilation mode for the daily study intervention  maintaining the same respiratory minute volume (RMV). After a first arterial blood gas analysis , respirator settings were adjusted to reach a PaCOParameters measuring CBF and brain tissue oxygenation were the predefined study endpoints.10.Direct measurement of CBF (primary endpoint): The course of CBF, was measured by an intracerebral thermodilution probe (Q-Flow 500®) located in the right frontal cortex. The probe was placed 1.5 cm anterior to the external ventricular drainage and was monitored by a Bowman Perfusion Monitor® . To obtain a continuous measurement and avoid recalibration during the study intervention, the automatic calibration was paused during the time of the study interventionTranscranial Doppler sonography (TCD): Prior to the beginning of each study intervention, baseline measurements of TCD were made. At each time-point during the study intervention, TCD measurements were repeated. Measurements were conducted by a well-trained medical technician otherwise not involved in the study procedures with an experience of over 15 years of TCD measurements.tiO2) (secondary endpoint): StiO2 was measured by bilateral near-infrared spectroscopy (NIRS) electrodes , which were attached on both sides of the forehead. A baseline value was set prior to the intervention to which the following measurements (every 15 min for 2 h) were compared.Cerebral tissue oxygen saturation . In patients included into the study, a pulse contour-based measurement of cardiac output (CO) was added to the invasive blood pressure monitoring  in order to follow changes of CO during hypercapnia.tiO2, ICP, arterial blood gases, pH and hemodynamic parameters were measured at baseline and at 0, 15, 30, 45, 60, 75, 90, 105 and 120 min of the intervention and documented in a paper-based examination protocol. Acquired data was transferred to Excel®-Worksheets . A Kolmogorov–Smirnov test for data rows was used to decide if a normal distribution can be assumed or has to be rejected. Dynamic changes over time were analysed using a one-way ANOVA for repeated measures. In case of statistical significance, time-points were compared to baseline values using a Dunnett’s post hoc test. Statistical significance was defined if p < 0.05. Statistical analysis was performed using GraphPad Prism 4.0 Statistical Software .CBF, SThe study was approved by the institutional ethics committee (AZ 230/14) and registered at ClinicalTrials.gov . Written consent of a legal guardian was obtained for each patient prior to inclusion into the study.All 12 patients included in this trial suffered from severe aneurysmal SAH. The average and median Hunt/Hess grade was 4 with four patients classified as Hunt/Hess grade 3, four patients as Hunt/Hess grade 4, and four patients as Hunt/Hess grade 5. All patients had thick subarachnoid blood layers and clots according to grade 3 of the Fisher scale, in ten patients additional intracerebral and/or intraventricular blood was detected in the initial CT scan. Cerebral angiogram at admission revealed a total of 15 aneurysms (3 patients with two aneurysms), of which 13 were occluded within 96 h after ictus, 6 by surgical clipping, and 7 by endovascular coiling. The remaining two aneurysms were not considered to be the origin of SAH in patients with more than one aneurysm. Mean age at admission was 48 ± 7.93 years, 9 were female and 3 were male. Patient characteristics, hemorrhage-related features and location and treatment of the ruptured aneurysms are depicted in Table Mean initial Glasgow Coma Score (GCS) was 8 with deterioration to a GCS of 6 prior to intubation. All patients had developed occlusive hydrocephalus and received an external ventricular drainage (EVD). After occlusion of the aneurysm anesthetics were withdrawn and the patients were allowed to wake up. If regain of consciousness was not appropriate and extubation not possible, anesthetics were readministered and the patients were included in the study after written informed consent was given by a legal guardian. 11 of 12 patients showed a significant increase in daily transcranial Doppler sonography (TCD) and/or Perfusion-CT and underwent follow-up angiography.2 of 55 mmHg, the baseline RMV was reduced by 40% in every patient. After the first arterial blood gas control, the respirator settings were further adjusted  was not influenced by the alterations of the respirator settings with a mean PaO2 of 112.55 mmHg (± 24.00 mmHg) before trial intervention and a mean PaO2 of 111.67 mmHg (± 13.67 mmHg) after 120 min of hypercapnia. Prolonged hypercapnia led to a decrease in pH as a sign of respiratory acidosis. Nevertheless, no patient reached a pH under 7.25 as a criterion for trial interruption. Mean pH was 7.44 with normocapnia before trial interventions and decreased to 7.28 after 75 min with a slight increase to 7.29 after 90 min, reaching a steady state of 7.29 at 90 to 120 min of hypercapnia  increased slightly but significantly within the first 45 min. Baseline ICP before the start of the study intervention was 11.7 ± 2.4 mmHg at a PaCOtiO2 measured over the right forebrain increased to a maximum of 109 ± 8.8% of baseline 60 min after induction of hypercapnia at a PaCO2 of 54.22 ± 5.27 mmHg. Over the left forehead, StiO2 increased to a maximum 109 ± 7.9% of baseline after 60 min into the trial intervention, respectively. The course of StiO2 during hypercapnia is depicted in Fig. SMean flow velocities (MFV) in TCD increased in both middle cerebral arteries during the trial intervention. In the right middle cerebral artery (MCA), MFV increased from a baseline of 112 ± 35 cm/s to a steady level of 140–145 cm/s between 45 and 120 min into the trial intervention. In the left MCA, MFV increased from a baseline of 106 ± 51 cm/s to values between 135 and 140 cm/s from 45 to 120 min after induction of hypercapnia. The increase was significant throughout the entire period of monitoring  increased from a baseline of 6.3 ± 2.0 l to 6.6 ± 2.0 l (106%) after induction of hypercapnia, 7.1 ± 2.3 l (114%) after 45 min and 7.5 ± 2.5 l (120%) after 120 min. This increase was caused by an equal 10% increase of stroke volume and heart rate.2 from a baseline value of 38.77 ± 3.75 mmHg to 53.18 ± 7.16 mmHg after 120 min resulted in a final increase of cerebral blood flow (CBF) to149 ± 93% of baseline. After 30, 45, 60, 75 and 90 min CBF increased to 141 ± 92%, 146 ± 99%, 140 ± 80%, 144 ± 80%, 151 ± 86%, and 147 ± 93% of baseline values, respectively. The peak value was recorded after 75 min . Even the evidence for nimodipine, the most widely used pharmacological attempt to prevent DCI is based on a single trial which was conducted more than 30 years ago before endovascular aneurysm and vasospasm therapy was invented and without intensive care therapy with contemporary standards16.Aneurysmal SAH is still a life-threatening incident with poor over-all prognosis. Its course is characterized by serially occurring ischemic events. Immediately after the rupture of the aneurysm, cerebral perfusion pressure (CPP) decreases due to a sudden increase of ICP resulting in a reduction of CBF and global ischemia. Simultaneously or shortly thereafter, diffuse early arterial vasoconstriction has been observed and contributes to the persistent perfusion deficit in the early stage of SAH18. A variety of clinical and experimental studies have investigated various approaches to prevent vasospasm21. But even initially promising trials, e.g. with endothelin A receptor antagonists, successful in treating vasospasm, did not prevent DCI or improve clinical outcome22.Delayed vasospasm after a few days, caused by endothelial dysfunction, structural changes of the vessel wall, and inflammatory processes is a decisive factor for delayed ischemic neurological deficits (DIND) and delayed cerebral ischemia (DCI)24.Most likely, DCI is a multifactorial phenomenon with delayed cerebral vasospasm, cortical electrical hyperactivity with enhanced energy expenditure, disturbed equilibrium of local vasodilatory and vasoconstrictive paracrine factors and a possible primary metabolic derangement contributing to ischemic damage. However, these factors finally turn into a common finish line, the mismatch of oxygen supply and demand of brain tissue resulting in a breakdown of aerobic metabolism, depletion of energy stores and terminal depolarization of neurons and glial cells26. Energy depletion, therefore, is also likely to be gradual. Thus, the rationale behind intermittent controlled hypercapnia is to temporarily increase a critically reduced CBF so that energy stores can recover.From a pathophysiological point of view, delayed ischemia after SAH is a multifactorially conditioned slowly arising perfusion deficit rather than a sudden and complete ischemia due to severe vasospasm2 remains vital28. Increased PaCO2 may not have an effect on CBF and vessel diameter in the early stage of SAH as recently published by Friedrich and co-workers29. For the chronic phase, however, previous work has shown a highly reproducible increase of StiO2 and CBF under staged hypercapnia. Since this effect was still reproducible during angiographically proven vasospasm7 the concept of maximum peripheral vessel dilation downstream of large-trunk vasospasm may have to be rethought. At the same time, it gives space for a therapeutic intervention. A previous phase 1 study has not only shown the proof of principle without noteworthy negative side effects, but also a surprising reduction of the incidence of DCI and relatively favorable outcome as compared to historical controls and data published in literature11.It has long been shown that cerebral autoregulation of arterial blood pressure is disturbed after severe aneurysmal SAH and that the equilibrium of local factors are shifted towards constriction. However, the reactivity to changes of PaCO230.To the best of our knowledge, there is no literature about the long-term effects of hypercarbia upon CBF and the course of its adaptation. From high altitude research it is known that mountaineers start to hyperventilate during ascent, which results in a decrease of CBF. After several hours or days, depending on the altitude, acclimatization processes are leading to a normalization of ventilation and physiological parameters9. However, this is not the timeframe of interest for the particular needs of our patient collective. In contrast to our study protocol the effects in high altitude and its impact on CBF do not occur in a range of seconds or minutes but rather within hours and days during or after an ascent. An additional factor is the lower partial pressure of O2 in high altitude leading to hypoxia; therefore, this data is not comparable with normoxic conditions on an intensive care unit. Adaptation mechanisms to long-term hypercapnia, e.g. buffer in the cerebrospinal fluid or blood via carboanhydrase are neither well known nor investigated in trials up to now. Alterations of the pH of the brains’ extracellular space as a regulator of the cerebrovascular response to CO2 were discussed by Lassen et al.31. Yoon et al. suggest that CBF is regulated by pH-changes of the CSF and that possibly both, PaCO2 and CSF-pH “independently and concomitantly regulate cerebrovascular contractility”. According to their findings, an increase of PaCO2 (or a decrease in pH) might directly lead to vasodilatation by hyperpolarization of smooth muscle cells via potassium channels. Indirectly, vasodilatation could occur through endothelium-dependent mechanisms3. Raichle and co-workers examined the effects of transient hyperventilation for several hours on CBF in healthy volunteers covering the period that is of interest for our particular study setting. They showed that CBF decreased with the onset of hyperventilation, but gradually recovered again under continuous hyperventilation and finally exceeded baseline levels in terms of a rebound effect when ventilation was returned to normal. PaCO2 also decreased initially but remained constantly low under hyperventilation and returned to baseline parameters after ending of hyperventilation32.The previous results make it seem worthwhile to evaluate this procedure regarding its therapeutic effect. However, to date no data about the ideal duration of hypercapnia on CBF and cerebral tissue oxygenation exists. From a physiological point of view these positive effects must be temporary since buffer mechanisms in blood and CSF, connected via the carboanhydrase enzyme, trigger an adaptation to long-term changes of COhypercapnia is approximately the same as the adaptation to hyperventilation as reported by Raichle et al.32. This implies that in patients with SAH, whose CBF is critically reduced, there is the danger that a negative rebound effect may carry CBF below ischemic thresholds even if there is a beneficial effect during the study intervention. Therefore, the duration of CBF hypercapnia must not exceed a safe time-frame. The additional measurement of StiO2 as a secondary endpoint was therefore mainly because the CBF measurement only covers the right frontal lobe and is therefore more or less a punctual measurement. Bilateral NIRS, on the other hand, covers both MCA and ACA territories, albeit only as a relative indicator for an increase in CBF. NIRS, as well as TCD, however, showed a very good correlation with the right frontal CBF values. Thus, we can conclude that the effect of hypercapnia on CBF is 1. not only selective, and 2. not a steal effect from critically perfused areas into “healthy” territories.We assume that the time-course, extent and reaction upon adaptation to tiO2 and no rebound effects or adverse events7. In this present trial, under continuous hypercapnia of 50–55 PaCO2 for 120 min, CBF and StiO2 reached peak values after 75 min and 60 min, respectively. Hence, at first glance 60 to 75 min seem to be the ideal duration for the highest treatment benefit. Regarding the parallel increase of cardiac output under prolonged hypercapnia the results have to be corrected in order to calculate the maximum intrinsic effect upon cerebral vessels. As a result of disturbed cerebral autoregulation after severe SAH, systematic increase of cardiac output alone, e.g. via application of catecholamines, could lead to an increase in CBF. In the face of disrupted autoregulation, changes of blood pressure and cardiac output are transferred into brain circulation as well as into other parts of systemic circulation33. Accordingly, we found that blood flow in the high cervical extracranial carotid artery increased during study intervention (Fig. 2 challenge severely interferes with fundamental physiological regulation mechanism it may potentially cause other unwanted side effects. In this particular kind of intervention safety aspects are of utmost priority. Hence, it is the auxiliary concept that the optimum duration of hypercapnia is the time-span before buffer mechanisms cause a secondary decline of CBF under hypercapnia after a primary increase. Graphically this is the inflection point of the CBF-curve. Since it was the purpose to find the optimum intrinsic effect on brain vessels, the increase of cardiac output has to be subtracted from the gross increase of CBF in the face of deranged autoregulation.Previous data on the effect of graded hypercapnia after aneurysmal SAH showed a sustained effect on CBF and Sion Fig. . Therefo2-intervention at higher frequency, e.g. 2 or 3 times a day, although this has not been explicitly tested in the current trial. A randomized, controlled trial with 45 min of controlled hypercapnia at 12-h intervals is planned for further evaluation of the therapeutic efficacy of this method in poor-grade aneurysmal SAH.As a result of this study we conclude that 45 min of controlled hypercapnia might be the most suitable duration regarding the CBF-increasing effect, the patients’ safety and the feasibility in an intensive care setting. Considering that a complete normalization of cardiac and physiologic parameters is achieved several hours after returning to baseline ventilation parameters it might be even more beneficial to repeat the CO


P < 0.001, Shannon P < 0.001, Chao P < 0.001). The beta-diversity difference demonstrated a significant difference among AAV patients with kidney injury, patients with lupus nephritis (LN), and health controls . Among these AAV patients, the Deltaproteobacteria, unclassified_o_Bacteroidales, Prevotellaceae, Desulfovibrionaceae Paraprevotella, and Lachnospiraceae_NK4A136_group were correlated negatively with serum creatinine, and the proportion of Deltaproteobacteria, unclassified_o_Bacteroidales, Desulfovibrionaceae, Paraprevotella, and Lachnospiraceae_NK4A136_group had a positive correlation with eGFR. In conclusion, the richness and diversity of gut microbiota were reduced in AAV patients with kidney injury, and the alteration of gut microbiota might be related with the severity of kidney injury of AAV patients. Targeted regulation of gut microbiota disorder might be a potential treatment for AAV patients with kidney injury.Increasing evidence suggested that gut microbiota played critical roles in developing autoimmune diseases. This study investigated the correlation between gut microbiota and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) with kidney injury. We analyzed the fecal samples of 23 AAV patients with kidney injury using a 16s RNA microbial profiling approach. The alpha-diversity indexes were significantly lower in AAV patients with kidney injury than healthy controls (Sobs  Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of systemic diseases characterized by pauci-immune necrotizing inflammation of the small blood vessels, which includes microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA). ANCAs, mainly targeting at myeloperoxidase (MPO) and proteinase 3 (PR3), were usually the serological markers of AAV. Usually, AAV involves multiple organs, predominantly the lungs and the kidneys . The oveS. aureus in the respiratory tract, which was associated with the increased relapse risk , and 27 healthy controls in West China Hospital of Sichuan University. Participants with AAV were eligible if they met the modified American College of Rheumatology classification criteria . Patient® soil DNA Kit  according to the manufacturer’s protocols. The V3-V4 regions of the bacterial 16S rRNA gene sequences were amplified from the diluted DNA extracts with the primers 338F (5′- ACTCCTACGGGAGGCAGCAG-3′) and 806R (5′-GGACTACHVGGGTWTCTAA T-3′). Polymerase Chain Reaction (PCR) amplification was performed in a 20 μL mixture containing 4 μL of 5 × FastPfu Buffer, 2 μL of 2.5 mM dNTPs, 0.8 μL of each primer (5 μM), 0.4 μL of FastPfu Polymerase and 10 ng of template DNA. The reactions were hot-started at 95°C for 3 min, followed by 27 cycles of 95°C for 30 s, 55 °C for 30 s, and 72°C for 45 s, with a final extension step at 72°C for 10 min. The resulted PCR products were extracted by a 2% agarose gel and further purified using the AxyPrep DNA Gel Extraction Kit  and quantified using QuantiFluor™-ST  according to the manufacturer’s protocol.Microbial DNA was extracted from 65 fecal samples using the E.Z.N.A.http://drive5.com/uparse/) and chimeric sequences were identified and removed using UCHIME. The taxonomy of each 16S rRNA gene sequence was analyzed by the RDP Classifier algorithm (http://rdp.cme.msu.edu/) against the Silva (SSU123) 16S rRNA database using a confidence threshold of 70%.Purified amplicons were conducted using Illumina MiSeq platforms  according to the standard protocols by Majorbio Bio-Pharm Technology Co. Ltd. . Before assembly, sequences were firstly filtered to remove low-quality or ambiguous reads, including reads with an average quality score <20 over a 50 bp sliding window, reads lacking exact matching with the primer, and reads containing ambiguous character. Operational taxonomic units (OTUs) were clustered with 97% similarity cut off using UPARSE  and the Adonis test were used. We also compared alpha diversity indices across these three groups, such as Sobs, Chao, Shannon, and Simpson., Linear discriminant analysis Effect Size (LEfSe) analysis was used to identify differentially abundant bacteria among the three groups with a cutoff of 2.0. Microbial phylum and genera concentrations among AAV patients with kidney injury, patients with LN, and healthy controls were compared using a Mann-Whitney test. Using a normalized relative abundance matrix, LEfSe performs the Kruskal-Wallis rank sum test to determine the features with significantly different abundances between assigned taxa and uses LDA to assess the effect size of each feature . Spearma2 and 349 μmol/L, respectively. The clinical characteristics of the AAV patients with kidney injury, the patients with LN, and the healthy controls were summarized in We continuously enrolled 23 AAV patients with kidney injury, including 15 females and 8 males with a median age of 62 years in this study. Among the 23 AAV patients, two were PR3-ANCA positive, twenty were MPO-ANCA positive, and one was both PR3-ANCA and MPO-ANCA positive. The median estimated glomerular filtration rate (eGFR) and serum creatinine were 12.5 ml/min/1.73 mp = 0.001).As shown in As exhibited in the Venn diagram , the numFirmicutes was the most predominant bacteria of gut microbiota, followed by Bacteroidetes and Proteobacteria in all groups. Firmicutes and Bacteroidetes had a lower proportion in feces of AAV patients with kidney injury and those of LN patients, compared to those of healthy controls. Whereas the abundance of Proteobacteria was higher in the feces of AAV patients with kidney injury and LN than that of healthy controls , blood urea nitrogen (BUN), eGFR, and hemoglobin (Hb), the Spearman’s correlation analysis was employed . Among tp = 0.653, Pseudomonadales was significantly higher in samples of AAV patients with kidney injury patients than that of patients with LN  generated in the gut contributed to the renal inflammation via the circulation , which induced overt inflammation via NLRP3 inflammasome, and Enterobacteriaceae could promote inflammation through stimulating newly recruited monocytes to induce NLRP3-dependent IL-1β release (Bacilli and Enterobacteriaceae are involved in the inflammation of AAV with kidney injury through NLRP3 needs further study.In the present study, we further explored an increased abundance of  obesity . Bacilli release . Interes release . TherefoAkkermansia and Ruminococcaceae was increased in AAV patients with kidney injury. A previous study by Ren et al. (_NK4A136_group was lower in AAV patients with kidney injury than healthy controls, which was negatively correlated with SCR and positively correlated with eGFR. This suggested that the change of Lachnospiraceae_NK4A136_group abundance might be related with the severity of kidney injury. Therefore, modulating gut microbiome disorder, especially Lachnospiraceae_NK4A136_group changing, might be a novel intervention to alleviate kidney damage.In the present study, we also investigated that the abundance of n et al.  analyzedn et al.  found thLactobacillus and Enterococcus was higher in AAV patients with kidney injury than healthy controls. More recently, accumulating data indicated that the alteration of gut microbiota also affected the efficacy of cancer immunotherapeutic drugs (Lactobacillus and Enterococcus could promote the anti-tumor immune response of cyclophosphamide. For AAV patients with kidney injury, cyclophosphamide also is a first-line therapy drug (In the present study, we further found that the proportion of ic drugs . Cyclophic drugs . A previic drugs  found Laapy drug . TherefoOf note, the study is the first to report the relationship between gut microbiota and AAV patients with kidney injury. However, this study has limitations due to its single-center setting and small sample size. What’s more, since only a few AAV patients did not receive any treatment at the time of fecal sample collection, it was impossible to perform subgroup analysis based on the treatment.In conclusion, we found reduced richness and diversity of gut microbiota in AAV patients with kidney injury compared with healthy controls. The alteration of gut microbiota might be associated with the severity of kidney injury of AAV patients. Targeted gut microbiota disorder may be the potential as a supplemental option for AAV patients with kidney injury.


Target-to-background ratio (TBR) was calculated by dividing the mean SUVmax from both superficial femoral arteries by the SUVmean in the superior vena cava (SVC) and calcium mass was measured on CT. The association between 18F-NaF TBR and cardiovascular risk factors was investigated using uni- and multivariate linear regression corrected for age and sex. In total, 68 patients  underwent 18F-NaF PET/CT. Higher CT calcium mass, total cholesterol, and HbA1c were associated with higher 18F-NaF TBR after adjusting.The study consisted of participants of a randomized controlled trial to investigate the effect of vitamin K2 (NCT02839044). In this prespecified analysis, subjects with type 2 diabetes and known arterial disease underwent full body 18F-NaF tracer uptake in patients with type 2 diabetes.This study shows that several modifiable cardiovascular risk factors  are associated with femoral The online version of this article (10.1007/s12350-020-02099-z) contains supplementary material, which is available to authorized users. The goal of this study is to investigate the potential determinants of 18F-NaF uptake as a marker of arterial calcification in patients with type 2 diabetes and a history of arterial disease.Arterial calcification on CT is used as a marker for the presence of intimal calcification (atherosclerosis) and medial arterial calcification. Microcalcifications < 50 µm) are observed in the early stages of the calcification process and are possibly associated with plaque rupture, whereas macrocalcifications contribute to stability of atherosclerotic plaques.0 µm are 18F-NaF PET/CT scans and patient data were used to determine the potential contributors of increased 18F-NaF uptake. Patient data were collected from questionnaires and available medical records. All participants completed a questionnaire on medical history, medication, smoking history, and a physical examination including height, weight and blood pressure. Non-fasting blood samples were collected to measure cholesterol levels, HbA1c levels and creatinine.The study population consisted of participants of a randomized controlled trial .18F-NaF PET/CT scan, performed on a Siemens Biograph 40 scanner . Imaging was performed 90 min after intravenous injection of 2.0 MBq/kg 18F-NaF, with a maximum dosage of 200 MBq. Circular regions of interest (ROI) were drawn bilaterally around the superficial femoral arteries , maximum values measured per ROI were summed and averaged. Target-to-background ratio (TBR) was calculated by dividing the mean SUVmax from both femoral arteries by the SUVmean from three sequential slices in the SVC . A p value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS software .Normality of the data was tested using Quantile–Quantile plots. Descriptive data were expressed as mean ± standard deviation (SD) for normally distributed continuous variables, and median (Q1-Q3) for non-normally distributed continuous variables. Categorical variables are displayed as count (percentage). Reliability for TBR measurements was assessed using intraclass correlation coefficient. Univariate linear regression (unstandardized betas) was used to identify associations between all variables and 18F-NaF was measured on average on 76 slices per patient (38 per side). Baseline characteristics of the patients are reported in Table The study population consisted of 68 participants  with a mean age 69 ± 8 years. Glucose lowering drugs were used by 60 (88%) patients, while insulin was used in 32 patients (47%). In total 25 patients used both insulin and glucose lowering drugs and only one patient was neither on insulin nor glucose lowering drugs. Fifty-two participants (77%) were treated with statins. As defined by the inclusion criteria all patients had a history of cardiovascular disease. Femoral arterial calcification on CT was present in 97% of the study population. Arterial 18F-NaF TBR . 18F-NaF PET TBR was lower in patients on statins with a trend towards significance (p = 0.058). No significant differences in TBR were observed for smokers, male sex or other medication , investigated vessels bedsPrevious research showed that multiple cardiovascular risk factors are associated with 18F-NaF uptake is significantly higher in microcalcifications compared to macrocalcifications.18F-NaF cannot penetrate into the deeper layers of macrocalcifications. Also, microcalcifications have a relatively big surface area compared to their volume. In a prior longitudinal study, we observed that areas without calcification on CT, but with increased 18F-NaF uptake, had more arterial calcification at follow-up.18F-NaF uptake, suggesting a significant effect of large calcium depositions on tracer uptake with clinical PET/CT systems.18F-NaF uptake for research.An important strength of the current study is that images were acquired 90 min after tracer injection. The 90 min time-point is considered to be advantageous, because of the balance between signal-to-background ratio and patient comfort. For comparability with other studies we used TBR as our measure of 18F-NaF uptake and calcification in the femoral arteries in patients with type 2 diabetes mellitus and a history of arterial disease. Our findings show that 18F-NaF uptake can be an imaging biomarker of arterial disease burden both related to dyslipidemia and diabetes control. Larger studies are needed to investigate whether these findings are generalizable to non-diabetic patients with cardiovascular diseases and if (further) modification of these risk factors is beneficial for 18F-NaF uptake and outcome.In conclusion, we showed that cardiovascular risk factors including total cholesterol, triglycerides and HbA1c are associated with 18F-NaF uptake may be an important arterial imaging biomarker related to dyslipidemia and diabetes control (HbA1c) even in extensively treated patients with type 2 diabetes.Supplementary material 1 (DOCX 12 kb)Supplementary material 2 (MP3 3557 kb)Supplementary material 3 (PPTX 7371 kb)Below is the link to the electronic supplementary material.


Arterial hypertension is a disease that has a high impact on cardiovascularmortality and morbidity; however, it is still insufficiently controlled.To assess hypertension control in patients seen at a specialized clinic andto identify associated variables.Cross-sectional study involving the analysis of medical records from 782patients treated in a highly complex outpatient clinic. Inclusion criteria:age ≥18 years, diagnosed with hypertension, in treatment ≥6 months. Patientswith secondary hypertension (104) and incomplete data (64) were excluded.The main outcome was blood pressure control (systolic <140 and diastolic<90 mmHg). The independent variables studied were: sociodemographic andclinical characteristics .Pearson's χ2 tests, Fisher's test, Student's t and Wilcoxon-Mann-Whitneytests were performed in the bivariate analysis and logistic regression inthe multiple analyses, adopting p≤0.05.The prevalence of hypertensive control was 51.1%. It was associated with alack of control: body mass index ,history of stroke , left ventricularhypertrophy , and number of medications.About half of the hypertensive patients had their blood pressure controlled;clinical variables and target organ damage were associated with thecontrol. A factalready expected, considering that this is where we concentrate care to hypertensivepatients. However, hypertensive patients with greater severity due to target organinjury, associated with comorbidity are seen in specialized services, and there is alack of data on the control of these patients. Therefore, the present study aimed toassess the prevalence of hypertension control to identify associated variables, in aspecialized hypertension care at a tertiary healthcare level.This is a cross-sectional study, carried out with data from the electronicmedical records of 782 hypertensive patients. This population was taken from theschedule of medical consultations held in the last nine months at theHypertension Clinic, in the department of Nephrology, of a Tertiary TeachingHospital in the city of São Paulo. The outpatient clinic serves approximately850 highly complex hypertensive patients, referred by primary care forspecialized follow-up. The inclusion criteria were age above 18 years old,hypertensive and undergoing treatment for at least six months in the clinic. Wehad 104 with a diagnosis of secondary hypertension, and 64 being taken out dueto insufficient data . Since t2for females and > 116 g/m2 for males). The laboratory examsanalyzed were fasting blood glucose, glycated hemoglobin, lipid profile , and glomerular filtrationrate using the MDRD equation, urea, creatinine and proteinuria. The drugtreatment was assessed using the drug records of the last medical prescription.The history of diseases was identified in the data recorded in the last threeconsultations. For the evaluation of anthropometric data, laboratory tests andblood pressure, we considered the values measured during the last consultation.Previously trained nurses and graduate students collected the data.The data was retrospectively collected from the patients' electronic medicalrecords. The dependent variable was blood pressure control, defined as systolicblood pressure lower than 140 mmHg and diastolic blood pressure lower than 90mmHg, in at least two of the last three medical appointments. The independentvariables analyzed were demographic characteristics including age (defined bydate of birth), sex , race  and marital status .The clinical characteristics evaluated were: weight and height, for calculatingthe Body Mass Index; history of stroke ; coronary insufficiency ; resistant hypertension ;chronic kidney disease ;diabetes ; dyslipidemia ; andleft ventricular hypertrophy  hadcontrolled blood pressure. The average follow-up time for patients at the clinic was5.73 ± 2.72 years.p≤0.05) from uncontrolled ones, because they are younger [61.2(16.0) vs. 66.4 (13.2) years] and have a higher percentage of black race .p≤0.05), because they had less history of diabetesmellitus (43.1% vs 56.9%), obesity (42.1% vs. 57.9% ), resistanthypertension (37.6% vs. 62.3%) and left ventricular hypertrophy(35.7% vs. 64.3%); as well as lower proteinuria (43.5% vs 56.5%),lower mean triglycerides [132.0 (61.1) vs 146.6 (81.2) mg / dL], fasting bloodglucose , glycated hemoglobin [5.9 (1.1) vs6.3 (1.4)%], creatinine [1.1  vs 1.2 (1.1) mg / dL], weight [73.2 (15.3) vs76.6 (16.1) Kg], body mass index [28.5  vs 30.1 (6.5) kg / m2] andhigher glomerular filtration rate [69.4 (24.1) vs 66.5 (25.1)]. As for bloodpressure values, the controlled hypertensive patients had a mean systolic anddiastolic blood pressure levels significantly lower than those of uncontrolledpatients  were not prescribed antihypertensivedrugs which was the most frequent medication class among the patients. Afterantihypertensive drugs, the most prescribed medication class was lipid-loweringagents, with just over half (58.1%), followed by anticoagulants/antiplatelet drugs(44.8%) and antacids (42.3%), and prescribed for slightly less of half the patients.About a third used hypoglycemic agents (32.7%), as well as non-opioidanalgesics/muscle relaxants (31.7%). To a lesser extent, they took vitamins anddigestive enzymes (24.8%), antidepressants (19.4%), medicines for thyroid treatment(16.1%), opioid analgesics (10.5%) and anti- inflammatory (8.7%).p≤0.05), due to the lower average of medications in general [8.0(4.2) vs. 9.9 (4.0)] and antihypertensive drugs [2.9 (1.3)vs. 3.7 (1.2) respectively], less use of four or moreantihypertensive drugs ; and lowernumber of different classes of antihypertensive agents, except foralpha-blockers.The data presented in p≤0.05): body mass index; history of strokeand left ventricular hypertrophy; and number of prescription drugs. Having a historyof stroke reduced the chance of uncontrolled hypertension by 55%, while the historyof left ventricular hypertrophy increased by 76%. With each increase in the bodymass index, the chance of non-control increased by 3.8%, and with each medicationadded to the prescription, the chance of non-control increased by 8.2%  showed that control rates were around 50%. The same was reported in aregional study, in which about 45% of patients were controlled,The results of the present study showed that, despite the complexity of the analyzedhypertensive patientsDespite the robust evidenceThe prevalence of control in the best possible scenarios is only reasonable. Recentdata showed poor results concerning control rates in twelve high-income countries:Finland, Ireland, Italy, Japan and Spain had the lowest rates (< 20% in some agegroups and sexes), while Canada and Germany had the highest ,,,,WeIt was also reported on which factors were associated with blood pressure control.With regard to biosocial data, the black race was more prevalent among the group ofuncontrolled hypertensive individuals, as well as older age; however, such variablesdid not remain in the final logistic regression model. It is widely described in theliteratureAs for the laboratory profile, significant changes were seen in uncontrolledhypertensive individuals, such as a greater presence of proteinuria and serumcreatinine levels, and a lower glomerular filtration rate. The higher level oftriglycerides, fasting glycemia and glycated hemoglobin also attracted attention.Although none of them remained in the final model, these characteristics showed therelationship between the lack of pressure control and the occurrence of severalother diseases. Such alterations suggest high cardiovascular risk and, even thoughmany are modifiable factors in the prevention of cardiovascular diseaseThus, when assessing the presence of other comorbidities, we found that uncontrolledhypertensive patients had higher percentages of diabetes, obesity, resistanthypertension and left ventricular hypertrophy. Diabetes, in cases of hypertension,elevates the patient to the group of highest risk for cardiovascular disordersIn a different way,the history of stroke reduced the chance of not being controlled and the model ofmultiple analysis remains. Possibly, these findings suggest that left ventricularhypertrophy, being asymptomatic and requiring diagnostic imaging, often does nothave an impact on the patient's behavior in the sense of increasing healthcare,unlike what happens with a patient affected by a stroke, often hospitalized, withthe risk of developing sequelae and imminent risk of death. In this perspective,stroke is the second leading cause of death in the world and the third most commoncause of disabilityLeft ventricular hypertrophy remained independently associated, representing aninstalled cardiovascular complication, directly associated with the lack oflong-term control. The relationship between pressure control and ventricularhypertrophy can be seen with some results from the SPRINT study, in which intensiveblood pressure control in patients without left ventricular hypertrophy at baselinewas associated with a 46% lower risk of developing hypertrophy at the end of thestudyRegarding antihypertensive drug therapy, most of the sample used combinations of twoto three drug classes or four or more classes, possibly related to the severityprofile of patients, often with the presence of associated diseases, such asdiabetes and chronic renal failure. A study with a similar methodology, carried outin primary care, found that 60.5% of uncontrolled hypertensive patients had theprescription of three or more antihypertensive drugsThe results of the present study showed that the increase in the number ofmedications increased the chance for poor control, a fact that is already wellportrayed in the literatureSome limitations of the study may be associated with the use of secondary data, asimportant aspects, such as compliance to treatment, could not be evaluated.Information such as a past of diseases and the presence of resistant hypertensionwere reported in medical records and could not be confirmed by more precisediagnostic criteria, but it should be noted that the percentages found were similarto laboratory rates and the prescription of corresponding drugs. Thus, we concludethat the studied hypertensive patients had a profile of greater cardiovascularseverity, in addition to reasonable blood pressure control.The data from the present study indicated that about half of the hypertensivepatients had their blood pressure under control. Evaluating the most complex profileof the studied population and similar estimates in developed countries, this datacan be considered encouraging. The profile of hypertensive patients outlined canprovide essential data to establish strategies aimed at meeting the real needs ofhypertensive patients, especially with regards to treatment compliance, which mayhave an impact on maximizing control and, consequently, modifying the morbidity andmortality profiles of this population.


We quantified the two peaks associated with the concentration of plasma glycoproteins (GlycA and GlycB) and their height/width ratios (H/W GlycA and H/W GlycB), as higher and narrower signals have been related to inflammation. We also quantified GlycF, the signal of which is proportional to the concentration of the acetyl groups of free N-acetylglucosamine, N-acetylgalactosamine, and N-acetylneuraminic in the samples. The lipoprotein profile was also determined . Standard clinical and anthropometric measurements were taken. Multivariate classification models were developed to study the differences between the study groups. Reduced HDL-C levels, increased small dense LDL and HDL particles, and elevated TG levels were significantly associated with glycoprotein variables. Glycoprotein values in the diagnostic groups were significantly different from those in the CT groups. AD and DM conditions together contribute to a positive and significant synergetic effect on the GlycA area (<0.05) and the H/W ratios of GlycA (<0.01) and GlycB (<0.05). By adding the new glycoprotein variables to the traditionally used marker of inflammation C-reactive protein (CRP), the AUC increased sharply for classification models between the CT group and the rest (0.68 to 0.84), patients with and without dyslipidemia (0.54 to 0.86), and between patients with and without diabetes (0.55 to 0.75). 1H-NMR-derived glycoproteins can be used as possible markers of the degree of inflammation associated with T2DM and AD. Patients with type 2 diabetes mellitus (T2DM) and atherogenic dyslipidemia (AD) are at higher risk of developing cardiovascular diseases (CVDs), so an interest in discovering inflammation biomarkers as indicators of processes related to CVD progression is increasing. This study aims (a) to characterize the plasma glycoprotein profile of a cohort of 504 participants, including patients with and without T2DM and/or AD and controls, and (b) to study the associations between the glycoprotein profile and other lipid and clinical variables in these populations. We characterized the plasma glycoprotein profiles by using  Type 2 diabetes (T2DM) is one of the most common diseases and has been growing exponentially in recent years . Patient3 acetyl groups of N-acetylglucosamine and N-acetylgalactosamine (GlycA) and N-acetylneuraminic acid (GlycB) [C-reactive protein (CRP) can help to refine the global risk assessment for coronary heart disease (CHD), particularly among persons who are at intermediate risk on the basis of traditional risk factors alone. However, it has also been shown to be prone to fluctuations and is an inconsistent marker for predicting CVD in patients with chronic inflammatory diseases at an individual level . For som (GlycB) ,15. Unli (GlycB) ,16. This (GlycB) . AlthougParticularly, the scientific interest and number of studies demonstrating the strength of the NMR glycosylation profile as a biomarker for systemic inflammation has exponentially grown since the last decade . GlycosyIn this study, we characterized the plasma 1H-NMR glycoprotein profile of T2DM patients with and without AD; we explored its association with their advanced NMR lipoprotein profile; and, finally, we compared the ability of these new NMR based on inflammatory markers to discriminate specific patterns between study groups, other than those commonly used in clinical settings, including traditional risk factors and CRP.1H-NMR glycoprotein variables and continuous clinical variables, such as BMI, blood glucose, CRP, HbA1c, and Liposcale® . A similar pattern was observed in all five variables. We found no significant association between age and the concentration of glycated proteins in plasma. However, there was a positive and significant association between the concentration of glycated proteins and BMI, CRP, and blood glucose. For HbA1c, the trend was similar but only significant with the H/W GlycA (p < 0.05) and H/W GlycB (p < 0.01) ratios. Regarding the lipoprotein related parameters, we found that total abundance of GlycA, GlycB, and GlycF, and the shape of GlycA and GlycB were clearly associated with a proatherogenic pattern, which included a negative and significant association of the five glycoprotein parameters and HDL cholesterol (HDL-C) levels. The same applied to the medium HDL particle concentration and to the size of VLDL, HDL, and LDL particles.Some of the independent variables considered in the three linear models significantly affected each glycoprotein variable. In model A, all the glycoprotein variables were significantly associated with BMI. Moreover, both the area and H/W ratio of GlycB were associated with age. In model B, all the glycoprotein variables were equally significantly and positively associated with BMI and diabetes. In model C, after the adjustment by lipid variables, we observed that all the glycoprotein variables were significantly and negatively associated with HDL-C, and significantly and positively associated with TG. However, some differences were observed between the glycoproteins in this model: the area and H/W ratio of GlycB were also significantly associated with gender, BMI, and diabetes; the area and H/W ratio of GlycF were significantly associated with gender, diabetes, LDL-C, and TG; the area of GlycA was only significantly associated with the three lipid variables and diabetes; and the GlycA H/W ratio with gender and BMI. See .Significant differences were identified in the glycoprotein variables and CRP between the study groups see . The firAll the glycoprotein parameters distinguished between having AD or not in a population with DM, and were also capable of detecting significant differences between the group that only had one of the conditions: DM or AD. These data indicated that the dominant condition was AD, and that the glycoprotein variables were much more affected when both conditions coexisted.p < 0.05), H/W GlycA (p < 0.01), and H/W GlycB (p < 0.05), which showed a synergistic effect between the two conditions.To examine the influence of AD and DM on each glycoprotein variable and CRP, we analyzed the main effect of each independent condition and its interaction. To refine the separation between the groups, three different PLSDA models were built see  with theFor each of these models, we represented firstly the PLS-DA scores biplot in the space spanned by the two latent variables (LV1 vs. LV2), which reflected the classification of the samples. The LV1 explained more than 70% of the variance in the 3 models, while the LV2 explained between 9 and 13 of variance depending on the model. The biplot for model 1 , panel ASecondly, we also presented the ROC curve plot (sensitivity versus 1-specificity) for each model, illustrating the diagnostic ability of the inflammatory variables between the two groups beyond the traditional risk factors. Six ROC curves were evaluated: one for CRP alone and the other five curves for CRP plus one or more glycoprotein. 1H-NMR glycoprotein variables greatly improved the separation between the groups. The AUC of the CRP ROC curve in the three models was much smaller than the AUC, when the glycoprotein variables were added .In all cases, the 1H-NMR plasma glycoproteins of T2DM patients with and without AD, we have explored their relation with lipoproteins and clinical variables, and we have evaluated them as new emerging inflammatory markers of disease in comparison to CRP.The enhanced synthesis of proinflammatory cytokines and acute-phase proteins characterizes the early stages of T2DM and increases as the disease progresses . Many st1H-NMR. More studies are needed to establish the bases of the inflammatory pathways of these blood proteins.Our study showed that the glycoprotein profile was positively associated with being female, BMI, blood glucose, CRP, and a proatherogenic lipoprotein pattern with increased levels of LDL-C and TG. These results are in line with those of some studies in which GlycA has been associated with CRP  and a hiThe significant negative associations found between the five glycoprotein variables and HDL-C and the size of VLDL, HDL, and LDL particles, and the high positive correlation with TG are in line with the literature ,32, wher1H-NMR glycoprotein variables, which confirms the higher intra-variability mentioned in the literature [The significant differences in the glycoprotein values of each of the diagnostic groups versus the CT group were expected. However, the CRP showed greater dispersion among individuals from each group than the terature ,25. It aPLSDA models suggest that using the new glycoprotein variables in conjunction with common inflammation markers, such as CRP, maximizes the sensitivity and specificity of classifying DM and AD. This set of new inflammatory markers can be used to develop effective and novel strategies for disease intervention.1H-NMR, is known to be a marker glycemia because prolonged inflammation decreases glucose tolerance [These results are in line with those of several studies in the literature, which report an increased concentration of GlycA in patients with T2DM ,36. The olerance ,38. The olerance .1H-NMR, we can obtain both the glycoprotein variables and the advanced lipid profile, which leads to lower costs and less experimental variability. Nevertheless, our study is not free from certain limitations. The sample size and the distribution of the main anthropometrical cofounding factors, including age, gender, and BMI were not homogeneous between the groups. The univariant analysis was intrinsically affected by this asymmetry among groups, which directly represents what is generally found in clinical assessments for these specific patients, such as age, gender, and BMI, the main drivers for this metabolic syndrome related conditions. However, the regression models were properly adjusted in an attempt to minimize this variability. In addition, we have not been able to provide data on other clinical complications of diabetes because this was beyond the scope of this article. The concordance between alternative technologies to simultaneously measure glycosylated proteins, independently of the protein and sugar structure, is also limited because of the unique nature of the NMR. Among the strengths of this study, are the quality and novelty of the analytical procedures used and, from a single experiment with The present study compares protein glycosylation markers in relation to CRP, for assessing inflammation in specific metabolic conditions, opening the door to a future clinical application, although alternative inflammatory markers could potentially be implemented earlier in clinical settings. Therefore, these novel NMR glycoprotein parameters should be further compared in terms of improving inflammatory evaluation.1H-NMR glycoproteins can be used as markers of the degree of inflammation associated with diabetes and dyslipidemia. Furthermore, we have shown that these new markers have a lower inter-individual variability; therefore, they can improve the predictive outcomes of CRP in patients with and without diabetes and in patients with and without dyslipidemia. Future studies will be necessary to understand the mechanisms underlying inflammation in AD and diabetes.In conclusion, the present study suggests that Design and study subject: For this cross-sectional study, we recruited 504 individuals attending the vascular medicine and metabolism unit of the University Hospital Sant Joan de Reus, for disorders associated with the lipid metabolism. Type 2 diabetes was diagnosed using standard clinical criteria. Atherogenic dyslipidemia was defined as TG > 150 mg/dL and HDL-c < 40 or 50 mg/dL for males and females, respectively. Subjects with chronic lung, renal or liver disease, cancer, or any other serious disease were excluded. Patients on lipid-lowering drugs underwent a 6 week wash-out period (8 weeks if they were on fibrates). Anamnesis, anthropometric, and physical examination data were recorded.The entire population was classified into 4 groups, depending on whether they had T2DM (DM) and/or AD; DM and AD (DM (+) AD (+), n = 129); AD (DM (−) AD (+), n = 38); or DM (DM (+) AD (−), n = 222). A total of 115 patients had neither T2DM nor AD, and they were referred to as the control population . The study was approved by the randomized controlled trial and Clinical Investigation Committee of the Pere Virgili Institute for Health Research (IISPV), and all the participants signed the written consent form. Clinical and standard biochemical variables: Participants had their clinical history and their anthropometric data recorded and were subject to a physical examination. A blood sample was obtained in a fasting state and deeply frozen plasma and serum aliquots were stored in our research institute’s biobank until use. Standard biochemical determinations were performed using standard biochemical methods. If the patients were on lipid lowering therapy, the blood sample was obtained after a six week washout period.1H-NMR:Glycoprotein and lipoprotein profiling by  For glycoprotein profiling, plasma samples were analyzed by 1H-NMR. Serum samples (200 μL) were previously diluted with 50 µL deuterated water and 300 µL of 50 mM phosphate buffer solution (PBS), at pH 7.4 consisting of 30.70 Na2HPO4 mM and 19.30 NaH2PO4 mM, before NMR analysis. The 1H-NMR spectra were recorded at 310 K on a Bruker Avance III 600 spectrometer operating at a proton frequency of 600.20 MHz (14.1 T). One-dimensional 1H NMR pulse experiments were carried out, including nuclear Overhauser effect spectroscopy (NOESY) and longitudinal eddy-current delay (LED) pulses. To measure the glycoprotein variables, we analyzed the glycoprotein region of the 1H-NMR spectra, which is between 2.19 and 1.90 ppm, and represented the resonance of the N-acetyl methyl groups of the N-acetylglucosamine, N-acetylgalactosamine, and N-acetylneuraminic acid moieties on the carbohydrate portions of circulating glycoproteins, such as α1-acid glycoprotein, haptoglobin, α1-antitrypsin, α1-antichymotrypsin, and transferrin [0.20 MHz .1 T. Onensferrin ,40. We mnsferrin  glycopro® (CE), as previously reported [https://drive.google.com/drive/folders/1wfsryp6KbgWDnd-WM-6udjbHQzFMlLXj?usp=sharing, accessed on 15 December 2021).We also obtained the lipoprotein profile using the NMR test Liposcalereported . This prStatistical methods: Firstly, we used the one-factor Anova with Bonferroni post-hoc correction or the χ2 test, depending on whether the variable was continuous or categorical, in order to study the distribution of the clinical variables. Spearman correlation coefficients were used to evaluate relationships involving the glycoprotein variables, the clinical variables, and the lipoprotein-related variables. A logarithmic transformation and an outlier test were performed for all those dependent variables that, according to the Lilliefors test, did not follow a normal distribution.Secondly, a Wilcoxon–Mann–Whitney test was used to capture the differences in the glycoprotein profile and CRP values of each of the four groups. A Two-way Anova was performed, to examine the influence of the AD and DM conditions of each glycoprotein variable. Multivariate data analysis: In the first place, we used three linear regression models adjusted for the anthropometric and traditional risk factors of age, gender, BMI, DM, and traditional lipids to study the contribution of the clinical variables to each glycoprotein parameter. The independent variables considered were age, gender, and BMI for model A (i); model A + diabetes for model B (ii); and model A + LDL-C, HDL-C, and total triglycerides (TG) for model C (iii). The dependent variable (X) was each of the 5 1H-NMR glycoprotein variables for each of the three models. The beta coefficients  and the Y matrix (classes of samples), to find the maximum discrimination between classes (groups of study) and the maximum covariance between the X and Y matrices, simultaneously. [Partial least squares discriminant analysis (PLSDA) models were used as a supervised classification method between the study groups. PLS-DA relates the neously.  The area®  statistics ver. 22  was used to study the clinical statistical distribution between the groups and the adjustment of the linear regression models. Multivariate data analyses were computed in MATLAB , ver. 7.10.0, using PLS-Toolbox, ver. 5.2.2 .IBM SPSS