Inflammation is one of the principal triggering mechanisms for left ventricular fibrosis and remodeling in heart failure, leading to adverse clinical outcomes. Soluble suppression of tumorigenicity 2 (sST2), a member of the interleukin-1 receptor family, is assumed to play a significant role in the fibrotic response to inflammation. Left ventricular mass index (LVMI) is a parameter of the prefibrotic inflammatory phase of heart failure preceding remodeling. The present study aimed to investigate the prognostic value of the sST2/LVMI ratio in heart failure with reduced ejection fraction.This was a prospective cohort study. A total of 45 consecutive patients with heart failure with reduced ejection fraction, treated between September 2015 and December 2016, were enrolled. The sST2/LVMI ratio was measured at baseline. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure. The prognostic impact of the sST2/LVMI ratio was evaluated using a multivariable Cox proportional hazards regression model.P = 0.022). The fully adjusted multivariable Cox regression analysis showed that the sST2/LVMI ratio was positively associated with the composite outcome in patients with heart failure with reduced ejection fraction after adjusting for confounders . By subgroup analysis, a stronger association was found with age between 40 and 55 years, systolic blood pressure < 115 or ≥ 129 mmHg, diastolic blood pressure < 74 mmHg, hematocrit < 44.5%, and interventricular septum thickness ≥ 8.5 mm.Forty-five patients were enrolled in this study. Their average age was 48 ± 14 years, and approximately 20% of them were men. Patients were followed for 9 months, during which the primary outcome occurred in 15 patients. Kaplan–Meier analysis showed that patients with a high sST2/LVMI ratio (≥ 0.39) had shorter event-free survival than those with intermediate (between 0.39 and 0.24) and low ratios (< 0.24) (log-rank, In patients with heart failure with reduced ejection fraction, the relationship between the sST2/LVMI ratio and the composite outcome was linear. A higher baseline ratio of sST2/LVMI was associated with an increased risk of cardiovascular mortality and heart failure rehospitalization in the short-term follow-up. As a fatal and malignant disease, heart failure (HF) is becoming an epidemic that poses significant clinical and economic challenges . CardiacSoluble suppression of tumorigenicity 2 (sST2), a powerful independent predictor of mortality in patients with HF , is repoWe hypothesized that the primary cause of increased sST2 levels in patients with HF is the anti-inflammatory response induced by biomechanical forces and that its pro-fibrotic effect is just a by-product of this response. This study was designed to test the hypothesis that the ratio of sST2/left ventricular mass index (LVMI), which is a novel parameter of the prefibrotic inflammatory phase of HF that adjusts for the cardiac-remodeling effect of circulating sST2 , 13, is 2. The study protocol conformed to the Declaration of Helsinki, and its subsequent amendments and was approved by the local ethics committee of Zhongshan Hospital, Fudan University. All participants provided written informed consent.We conducted a prospective cohort study at the Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai City, China, from September 1, 2015, to December 31, 2016. Patients with HFrEF were prospectively evaluated for inclusion in this study. HFrEF was diagnosed according to the current consensus statements of the American Heart Association . The incCovariates in the present study included general information, demographics, variables that could affect the ratio of sST2/LVMI or cardiac mortality, and HF hospitalization, based on our clinical experiences and previous reports.Demographic data and clinical variables, including age, sex, body mass index, diastolic blood pressure, systolic blood pressure, heart rate, NYHA functional class, medical history, and cardiovascular risk factors , were collected. Fasting venous blood was collected within 12 h after admission. After centrifugation at 3000 rpm for 15 min, the plasma was extracted and stored at 80 °C. Biochemical variables, including hematocrit, hemoglobin, white blood cells, NT-proBNP, sodium, creatinine, blood urea nitrogen, serum uric acid, albumin, total bilirubin, total cholesterol, high-density lipoprotein cholesterol, and hypersensitive C-reactive protein were measured. Serum biomarkers of myocardial fibrosis  were assayed simultaneously using the respective ELISA kits. The characteristics of the assays were as follows: sST2 ELISA : average intra-assay coefficient of variation (CV) of 5.1%, detection limit of 1.8 ng/mL; PIIINP ELISA : intra-and inter-assay CV of less than 10%, detection range 0.125–8 ng/mL; PICP ELISA : intra- and inter-assay CV less than 10%, detection range 0.78 to 50 ng/mL. Serum levels of PIIINP were measured using the Roche Elecsys autoanalyzer (Cobas e602), with intra-assay CV of 1.2%–4.1%, inter-assay CV of 3.75%, and a detection range of 5 to 1200 ng/mL.Echocardiography was performed according to the American Society of Echocardiography guidelines . All parAs described in our previous work , all subPatients were followed up by telephone calls and ambulatory visits at 9-month intervals. The primary outcome was a combined endpoint consisting of HF rehospitalization and cardiovascular death. The follow-up time was calculated from the time of discharge to the primary outcome, or 9 months after discharge. Endpoints were assessed by all coauthors.2 test , one-way ANOVA test , or Kruskal–Wallis H test (skewed distribution) was used to detect the differences among patients with different sST2/LVMI ratios (tertiles). We used univariate and multivariate Cox proportional hazards regression models to test the link between the sST2/LVMI ratio and the primary outcome with three distinct models. Model 1 was an unadjusted model. Model 2 was a minimally adjusted model only for sociodemographic variables. Model 3 was a fully adjusted model. Because Cox proportional hazards regression model-based methods are often considered inadequate to address nonlinear relationships, nonlinearity between the sST2/LVMI ratio and the primary outcome was addressed using a Cox proportional hazards regression model with cubic spline functions and smooth curve fitting . If nonlinearity was detected, we first calculated the inflection point using the recursive algorithm and then constructed a two-piecewise Cox proportional hazards regression model on both sides of the inflection point. Subgroup analyses were performed using a stratified Cox proportional hazards regression model. For each continuous variable, we first converted it to a categorical variable according to the clinical cut point or tertile and then performed an interaction test. Tests for effect modification of subgroup indicators were followed by the likelihood ratio test. Log-rank tests for Kaplan–Meier survival curves were performed to test the prognostic value of various sST2/LVMI ratios.Data were expressed as mean (standard deviation) for Gaussian distribution or median  for skewed distribution of continuous variables and as numbers and percentages for categorical variables. The χhttp://www.R-project.org, The R Foundation) and EmpowerStats . All statistical tests were two-sided, and a P-value < 0.05 was considered statistically significant.Data were analyzed using the statistical software packages R .After a baseline evaluation, 45 patients were enrolled. After 9 months of follow-up, 15 patients had reached the primary endpoint (33.3%), of whom two patients had died and 13 had been rehospitalized due to worsening HF. No patient was lost to follow-up. We show the baseline characteristics of the selected participants in Table P = 0.00258). In the minimally adjusted model (adjusted for sex and age), the results were similar , which means that for each additional 0.1-unit change in the sST2/LVMI ratio, the risk of readmission for HF increased by 25%.In this study, we constructed three models to analyze the independent effects of the sST2/LVMI ratio on the composite outcome using multivariate Cox regression analysis. The effect sizes (hazard ratios [HRs]) and 95% confidence intervals (CIs) are listed in Table P-value from the log likelihood ratio test . In the present study, stronger associations were observed in patients older than 60 years , female patients , and for systolic blood pressure ≥ 140 mmHg , serum uric acid < 416 μmol/L , and high-density lipoprotein cholesterol ≥ 0.9 mmol/L .As shown in Table P = 0.022). As shown in Fig. Kaplan–Meier curves estimated the composite outcome-free survival according to the sST2/LVMI ratio tertiles Fig. . Patient2.The present study demonstrated that the sST2/LVMI ratio, which adjusts for the cardiac-remodeling effect of circulating sST2, was positively associated with the composite endpoint of cardiovascular mortality and HF readmission in Chinese patients with HFrEF. The relationship between the sST2/LVMI ratio and the primary outcome was linear. Subgroup analysis showed stronger association for patients aged between 40 and 55 years, systolic blood pressure < 115 or ≥ 129 mmHg, diastolic blood pressure < 74 mmHg, hematocrit < 44.5%, interventricular septum ≥ 8.5 mm, and right ventricular end-diastolic volume index < 74.3 or ≥ 94.3 mL/mST2L and sST2 are the two primary functional forms of ST2 . After bCardiac fibrosis in HF patients is maladaptive and predisposes patients to cardiovascular morbidity and mortality . InflammSubgroup analysis can better depict the relationship between variables. As shown in Table We tried to address the inherent limitation of an observational study, i.e. the susceptibility to potential confounding factors, by using strict statistical adjustments, addressing nonlinearity, and performing modifying factor analysis for the different subgroups.However, some limitations remain: (1) Our study involved Chinese HFrEF patients. and our conclusions may not be universally applicable, (2) Single-center, medium-size sample data suffer from some bias. A multicenter, large-sample study is needed to verify our findings, (3) We only investigated the correlation between baseline (admission) sST2/LVMI and prognosis, and did not address the dynamic changes of the sST2/LVMI ratio.In summary, the relationship between the baseline sST2/LVMI ratio and the composite outcome was linear in patients with HFrEF. A higher baseline sST2/LVMI ratio was associated with a higher rate of cardiovascular mortality or HF readmission during the 9-month follow-up. The sST2/LVMI ratio has an independent prognostic value in patients with HFrEF.


Some studies published previously have shown a strong correlation between hypertension and psychological nature including impulsion emotion or mindfulness and relaxation temperament, among which mindfulness and relaxation temperament might have a benign influence on blood pressure, ameliorating the hypertension. However, the conclusion was not confirmed.  The meta-analysis was performed to investigate the influence of mindfulness and relaxation on essential hypertension interventions and confirm the effects.  Systematic searches were conducted in common English and Chinese electronic databases  from 1980 to 2020. A meta-analysis including 5 studies was performed using Rev Man 5.4.1 software to estimate the influence of mindfulness and relaxation on blood pressure, ameliorating the hypertension. Publication bias and heterogeneity of samples were tested using a funnel plot. Studies were analyzed using either a random-effect model or a fixed-effect model. I2 = 0%, t2 = 0.000, P=0.41). The random pooled effect size (MD) was 0.30 . REM was used to calculate the pooled effect for mindfulness and relaxation on systolic blood pressure . The random pooled effect size (MD) was −1.05 . The results of this meta-analysis were influenced by publication bias to some degree.  All the 5 studies investigated the influence of mindfulness and relaxation on diastolic and systolic blood pressure, with total 205 participants in the control group and 204 in the intervention group. The random-effects model (REM) was used to calculate the pooled effect for mindfulness and relaxation on diastolic blood pressure ( All the results showed less influence of mindfulness and relaxation might act on diastolic or systolic blood pressure, when mindfulness and relaxation are used to intervene in treating CVD and hypertension. The primary aim of hypertension therapy is to condense the mortality and elude the diseases related to it, such as the strokes, cerebral hemorrhage, dementia, and metabolic syndrome, by practicing blood pressure management. The patients suffering from hypertension need to incorporate some lifestyle modifications where they follow certain diet and weight regulation programs before the initiation of the relative drug therapy , 2. AccoDespite multiple proven methods to treat hypertension, blood pressure is still counted as uncontrolled among the hypertensive patients. The elevated blood pressure is considered to be the “silent killer” because of no specific symptoms associated with it, and thus, people are not aware of it until regular monitoring of blood pressure is maintained. According to a consensus theoretical foundation in 2015, it was proposed that mindfulness can have a major impact on the cardiovascular disease in purpose to the blood pressure . Thus, aThe origin of mindfulness therapy has its roots from the Buddhist meditation traditional techniques fused with meditation. Mindfulness is the self-regulation of attentiveness to the conscious awareness of experiences in present moment with an attitude of acceptance, curiosity, and openness . MindfulIn the recent years, meditation techniques have proven to be considered under the clinical treatments of stress, where mindfulness-based stress reduction therapy (MBSR) is most popular. A clinically proven MBSR is an 8-week designed standard program founded by Brook et al. . The regA wider understanding towards the analysis of anxiety issues comprises of multiple elements like the biological, psychological, and social enticement, where different risk and protective factors are the mediators . There hBased on the guidelines  of the PThe data were recorded from each study on basis of hypertension baseline, systolic and diastolic blood pressure (control and intervention group), mean age, sample size, study duration, mean changes in blood pressure levels, standard deviation (SD), standard error (SE), estimated mean, and 95% CI. In total, 6 studies were considered for meta-analysis.Studies were excluded on the following basis: (1) dissertations were excluded from the study, (2) studies lacking intervention groups, (3) lack of protocols in the study, (4) lack of clinical context, (5) incomplete publishing of data, (6) data without statistical analysis, and (7) incompletely reported data.Studies were included on the following basis: (1) human participants in study, (2) type of intervention, (3) subjects in the study, (4) control groups inclusions, (5) baseline of systolic and diastolic values, (6) patients with prehypertension or hypertension, (7) mindfulness therapy and relaxation therapy as interventions, (8) studies published in English studies, and (9) statistics.Meta-analysis was performed using RevMan 5.4.1. The variables were analyzed as continuous via mean ± SD. The mean difference was evaluated with 95% CI .We carried out a random-effect meta-analysis. The sizes for meta-analysis was calculated with mean (MD). Mean values were calculated for sample sizes, blood pressures, and standard deviations (SD). Change in BP was detected in the studies with this analysis, and a comparison was drawn between intervention-control groups. The combination of sizes for both intervention and control groups was analyzed.The selection process of included studies is shown in The characteristics of 5 included studies are given in Quality evaluation of each included study with NOS scoring is given in I2 = 0%, t2 = 0.000, P=0.41). The random pooled effect size (MD) was 0.30 . All the results showed less heterogeneity between the studies in the analysis and no influence of mindfulness and relaxation on diastolic blood pressure  was used to calculate the pooled effect for mindfulness and relaxation on diastolic blood pressure . The random pooled effect size (MD) was −1.05 .All the 5 studies investigated the influence of mindfulness and relaxation on systolic blood pressure, with total 205 participants in the control group and 204 in the intervention group. REM was used to calculate the pooled effect for mindfulness and relaxation on systolic blood pressure  −0.12–0.27, SMD 0.07 for SBP and 95% CI −0.26–0.13 and SMD −0.07 for DBP. Hypertension is one of the highest risk factors of cardiovascular diseases; hence, it is also the primary cause of deaths worldwide. According to NICE guidelines, stress is a prime factor in development of this condition. The effective strategy for management of hypertension is relaxation and mindfulness therapy. In the studies discussed in this meta-analysis, the intervention groups were compared against control groups to get evident results. Forest plot and funnel plots were analyzed for effectiveness of the studies.The study uses meta-analytical techniques to pool data for effectiveness of mindfulness and relaxation programs. We have identified six studies for this topic.Various programs associated with mindfulness and relaxation were studied for their mean effect on systolic and diastolic blood pressures without any evidence of high heterogeneity values or publication bias. Results were insightful for both systolic and diastolic blood pressure which were considered as independent factors for cardiovascular outcomes.In the studies were incorporated 6 studies used for treating hypertension in early and later stages. Though the findings were not consistent as per CIs, the heterogeneity was not more than 90% and hence low. In order to determine the causes of heterogeneity, the analysis was conducted in research studies on basis of systolic and diastolic blood pressure by comparing the intervention group with the control group. The forest plot and funnel plot reflected that mindfulness and relaxation have a major effect in reducing the blood pressure; hence, they contribute in management and even treatment of hypertension –31.Mindfulness and relaxation-assisted feedback has shown reduction in the blood pressure. Though transcendental meditation has shown statistically significant results in improving clinical cases of hypertension, many other published studies have researched on transcendental meditation and relaxation programs which suggest their positive effects on CVD, reduction in clinical events, and other risk factors, thereby, reducing the mortality rates.


This study aimed to develop and validate an individualized nomogram to predict the risk of positive hidden blood loss (HBL) in patients with single-level thoracolumbar burst fracture (TBF) during the perioperative period.We conducted a retrospective investigation including 150 consecutive patients with TBL, and the corresponding patient data was extracted from March 2013 to March 2019. The independent risk factors for positive HBL were screened using univariate and multivariate logistic regression analyses. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model for positive HBL. The area under the receiver operating characteristic curves (AUC), C-index, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance of the prediction model. Bootstrapping validation was performed to evaluate the performance of the model.1%), preoperative total cholesterol, and preoperative fibrinogen were independent risk factors of positive HBL. The C-index was 0.831 (95% CI 0.740–0.889) and 0.845 in bootstrapping validation, respectively. The calibration curve showed that the predicted probability of the model was consistent with the actual probability. Decision curve analysis (DCA) showed that the nomogram had clinical utility.Among the 150 consecutive patients, 62 patients were positive for HBL (38.0%). The multivariate logistic regression analysis showed that the six risk factors of age, length of surgical incision, duration of operation, percentage of vertebral height restoration (POverall, we explored the relationship between the positive HBL requirement and predictors. The individualized prediction model for patients with single-level TBF can accurately assess the risk of positive HBL and facilitate clinical decision making. However, external validation will be needed in the future.The online version contains supplementary material available at 10.1186/s13018-021-02699-6. Thoracolumbar fractures are commonly encountered in clinical practice, and fractures of the burst type account for 25 to 58% –3 of allRemarkably, intraoperative blood loss is a prevalent issue that can be encountered in the surgical treatment of thoracolumbar burst fractures , 8. NeveThe HBL during the perioperative period is usually ignored, but it is important for the prognosis and outcome. Despite satisfactory management of blood loss during the perioperative period, it is puzzling that patient with thoracolumbar burst fractures often have lower postoperative HB levels than expected. We therefore deduced that it might be due to HBL. Unfortunately, however, few studies have been conducted to investigate the HBL in patients with thoracolumbar burst fractures during the perioperative period. In this study, we aimed to explore the risk factors related to HBL in patients with single-level TBF and develop an accurate individualized risk of HBL predictive tool based on routine parameters.The study protocol was approved by the Baoji City Hospital of Traditional Chinese Medicine  and the Research Ethics review board (NO. 2021GYKJD5N). Due to the retrospective nature of the study, a waiver of informed consent was obtained. From March 2013 to March 2019, patients with symptomatic single-level TBF were obtained and analyzed. The inclusion criteria for the study were as follows: (1) age of ≥18; (2) burst fracture (AO classification); (3) fracture level: T11-L2; (4) Thoracolumbar Injury Classification and Severity Score (TLICS) ≥ 5 , 15; andWe retrospectively collected the patients’ data, including age, sex, body mass index (BMI), underlying diseases ), history of smoking, history of alcohol, history of blood transfusion, and chronic steroid use. The preoperative visual analogue score (VAS), Japanese Orthopaedic Association (JOA) scores, and 36-Item Short Form Health Survey (SF-36) were recorded.1%) and vertebral height loss (P2%) by measuring preoperative and postoperative X-ray parameters [1% and P2% calculation are as follows:Surgery-related parameters including duration from admission to surgery, length of surgical incision, levels of fusion, and duration of operation were obtained from an electronic medical record system. The parameters relevant to the perioperative fluid management strategy, including intraoperative infusion of crystalloids, intraoperative infusion of colloids, autologous blood transfusion, and allogeneic blood transfusion, were recorded. Meanwhile, routine preoperative laboratory test data, including hematologic tests, blood chemistry, coagulation tests, and liver function tests, was obtained from the clinical laboratory database of the Baoji City Hospital of Traditional Chinese Medicine. In addition, to assess the influence of fractured vertebral height on hidden blood loss, we calculated percentages of vertebral height restoration , and e is the postoperative vertebral body height. This parameter measurement method is shown in Fig. Here, According to the formula by Nader et al. , patientHere, for male, k1 = 0.3669, k2 = 0.03219, and k3 = 0.6041; for female, k1 = 0.3561, k2 = 0.03308, and k3 = 0.1833.According to the gross formula, total blood loss (TBL) was calculated as follows:pre was defined as the Hct on preoperative day 1, Hctpost was defined as the Hct on postoperative day 3, and Hctave was defined was the average of Hctpre and Hctpost. Subsequently, intraoperative blood loss was determined as follows:where HctTherefore, HBL was defined as follows:when there was perioperative blood transfusion, HBL could be defined as follows:HBL = TBL – VBL + autologous blood transfusion + allogeneic blood transfusionχ2 test or Fisher’s exact test. Continuous variables were compared using Student’s t-test. Risk factor analysis was performed using univariate and multivariate logistic regression analyses. In order to facilitate the establishment of the prediction model, cut-off values for continuous variables were determined by the receiver operating characteristic (ROC) curve  with the “rms,” “SimDesign,” and “AICcmodavg” packages [Continuous data is presented as the means ± standard deviations. Categorical variables were grouped and compared using the  Figure S. Variablpackages –20.post, 28 patients were excluded. Finally, 150 cases were included, 99 (66.0%) males and 51 (34.0%) females, mean (38.1 ± 10.3) years old. The TBL was 1134.5±128.3 ml, the VBL was 269.1±82.5 ml, and the HBL was 491.3±104.5 ml (50.3 % of TBL). Among the 150 cases, 93 cases were negative HBL, i.e., HBL (−) group; 57 cases were positive HBL, i.e., HBL (+) group.In this study, a total of 178 consecutive cases were collected. According to the inclusion and exclusion criteria, 5 intraoperative dural ruptures, 10 postoperative tranexamic acid use, 2 intraoperative thrombin drug use, and 11 missing laboratory parameters about Hctp < 0.001), hypertension (p < 0.001), history of smoking (p < 0.001), diabetes (p = 0.017), duration from admission to surgery (p = 0.021), length of surgical incision (p < 0.001), duration of operation (p < 0.001), P1% (p < 0.001), P2% (p < 0.001), preoperative total cholesterol (p < 0.001), preoperative triglyceride (p < 0.001), preoperative Hb (p = 0.017), preoperative PT (p < 0.001), preoperative Fib (p = 0.038), and preoperative APTT (p < 0.001). There were no significant differences in remaining parameters between the HBL (−) and HBL (+) group. The detailed results of the parameters are shown in Table Among the HBL (−) and HBL (+) group, there were statistically significant differences in age p < 0.00, hyperte1%, intraoperative infusion of crystalloids, preoperative total cholesterol, preoperative triglyceride, preoperative ALB, preoperative PT, and preoperative fibrinogen (P < 0.05). Statistically significant variables selected from the univariate logistics analysis were imported into the non-conditional binary multivariate logistic regression. The six factors of age, duration from admission to surgery, duration of operation, P1%, preoperative total cholesterol, and preoperative fibrinogen were independent risk factors of positive HBL (Table P<0.05). Next, we developed a nomogram based on the result of logistic regression analysis sis Fig. .Table 2The area under the curve (AUC) of the receiver operating characteristic (ROC) curve Fig.  of the nTo evaluate the clinical usefulness of the predictive model, a decision analysis (DCA) was performed on the data. The DCA is a novel method that assesses the clinical net benefit of the nomogram. The DCA is demonstrated in Fig. 1%, preoperative total cholesterol, and preoperative fibrinogen.HBL refers to blood loss that cannot be measured directly in vivo after some of the larger trauma and surgery that is experienced, and this part excludes blood loss that can be quantified directly and postoperative drainage . At presBased on our research data and literature reports, we presume that the reasons may be as follows. Bone marrow hematopoiesis and the ability to store red blood cells in the body decline with increasing age and poor compensatory ability for blood loss anemia, resulting in a prolonged postoperative hematocrit in a low state, ultimately leading to high hidden blood loss calculated by gross formula , 25. In Surgical trauma may cause a stress response, which stimulates the synthesis of unsaturated fatty acids such as cholesterol and triacylglycerol in the blood. In our work, we observed that the concentrations of cholesterol and triacylglycerol were higher in the HBL (+) group compared with the HBL (−) group. Consequently, cholesterol was indicated as a risk factor for HBL (+) in multivariate logistics regression analysis. However, to the best of our knowledge, there is very little literature that explores this association. Based on previous literature, we suggest that non-esterified fatty acids may have played an important role in oxidative stress , 28. UnsAn important concern in the treatment of thoracolumbar burst fracture is timing –32. GeneMost previous studies believed that the early surgical time window was 24–72h after injury, but some scholars also believed that the early operation time should be within 12–24h after injury , 32. Bas1% was identified as a risk factor for HBL, which could presumably be ascribed to blood infiltration into the tissue compartments. Namely, the higher P1%, the more penetrable tissue compartments could be formed. It means that the more the vertebral height is restored, the bigger the “cavity” will be [Interestingly, our results demonstrated that P will be . Meanwhi will be , 34.Here, we developed a novel predictive nomogram for predicting the risk of positive HBL in single-level TBF patients during the perioperative period. Our nomogram can demonstrate the key parameters graphically and can individually evaluate the incidence of risk of positive HBL. We believe it can contribute to clinical decision-making and doctor-patient communication. More importantly, we can identify patients with a high risk of positive for HBL. Additionally, the nomogram may provide opportunities that might lead to improvements in perioperative management.There were a few limitations to our study that should not be ignored. First, due to the retrospective and observational nature of the study, the results are subject to limitations. Second, there was a lack of external validation for our proposed model, especially in other regions and countries. Third, specific data could not be obtained from the medical records or was missing. Finally, only patients with single-level TBF were enrolled. Patients with multi-level TBF need to be further studied in the future. Therefore, in future studies, our team should collaborate with the remaining medical centers and provide more data for more in-depth evaluation and validation of prediction models.In summary, by using a single center data in our hospital, we investigated the risk factors for HBL. Consequently, we established an individualized nomogram prediction model for positive HBL. Our nomogram is with satisfied performance in the evaluation of the risk of positive HBL, which may help clinical decision making. However, external validation will be needed in the future.Additional file 1: Figure S1. The receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off values for continuous variables.


Data regarding the influence of arterial stiffness on myocardial work (MW) has been scarce. This study was performed to investigate the association between brachial-ankle pulse wave velocity (baPWV) and MW by non-invasive left ventricular pressure–strain in a population of non-hypertensive and hypertensive individuals.Two hundred and eight participants  were prospectively enrolled into the study. All participants underwent conventional echocardiography, as well as 2D speckle-tracking echocardiography to assess MW by non-invasive left ventricular pressure–strain and global longitudinal strain (GLS). baPWV measurements were made at the same day as the echocardiography. Then, participants were categorized according to baPWV tertiles. Correlation between baPWV and MW were analyzed. Predicting ability of baPWV for abnormal WM was analyzed using receiver operating characteristic (ROC) curve.p < 0.05).The median baPWV from the low to high tertile groups were 1286.5 (1197.5–1343.5), 1490.0 (1444.5–1544.0), and 1803.8(1708.3–1972.0) cm/s, respectively. In simple linear regression analysis, baPWV had a significant positive association with global work index (GWI), global constructed work (GCW), and global wasted work (GWW), and a negative association with global work efficiency (GWE). The association remained significant after adjusting for major confounding factors in multiple linear regression analysis. The areas under the ROC curve of baPWV for predicting abnormal GWI, GCW, GWW, and GWE were 0.653, 0.666, 0.725, and 0.688, respectively (all BaPWV is significantly associated with all four components of MW using non-invasive left ventricular pressure-strain method in a mixed population of non-hypertensive and hypertensive individuals. An accurate and very early identification of the impairment in left ventricular contractility is pivotal in terms of prognosis in a majority of cardiac disease . Left ve2-metabolism. However, it is never implemented in clinical routine, because it is traditionally evaluated by an invasive pressure-volume loop  is a reliable index for assessment of myocardial function as it reflects the myocardial Oume loop . Recentlume loop . As it tume loop . Furtherume loop .Arterial stiffness is an important manifestation of sub-clinical organ damage and provides an established marker of cardiovascular disorders . It is nThe heart and the arterial system are anatomically and functionally linked. It has been reported that arterial stiffness impairs myocardial relaxation and augments LV stiffness and end-diastolic LV pressure . AdditioThis is a single-center, prospective study conducted in echocardiography room of the first affiliate hospital of Chongqing Medical University from September 1, 2020 and December 30, 2020. The study included consecutive hypertensive and non-hypertensive individuals aged between 18 and 65 years old, with LVEF equal to 50% or higher. Two hundred and thirty nine subjects were evaluated via echocardiography and baPWV. Of those, 208 participants underwent 2D speckle-tracking echocardiography for assessment of MW by non-invasive LV-PSL and LVGLS. Participants with documented diabetes mellitus, coronary artery disease or suggestive symptoms, valvular heart disease, atrial fibrillation, chronic kidney dysfunction, primary cardiomyopathies, secondary causes of hypertension, and ankle-brachial index (ABI < 1.0) were excluded from the study. Twenty one subjects did not undergo speckle-tracking analysis because of inability to fit with the study devices or suboptimal echocardiographic window .All participants underwent full clinical evaluation, including history of hypertension, the usage of antihypertensive drugs, status of smoking and alcohol use, height, weight, waist, blood pressure and electrocardiograph, etc. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg with use of any anti-hypertensive medication or not . CurrentBrachial blood pressure in the right arm was measured using an automated digital oscillometric sphygmomanometer  and immediately performed before the echo exam with the patient in supine position. Three sequential measurements with one minute interval were obtained, and the mean values were taken as the blood pressures for statistical analysis.This study was registered in clinicaltrials.gov . It was conducted in accordance with the “Declaration of Helsinki” and approved by the ethics committee of the first affiliated hospital of Chongqing medical university . Informed consents were obtained from all participants.Echocardiography was performed by 3 trained experienced sonographers using a GE E95 machine  equipped with a M5Sc transthoracic transducer. All recordings and measurements were performed in line with current American Society of Echocardiography recommendations . All parLeft atrial volume and LV volumes were calculated using the area-length methods and the Simpson biplane method. LV mass was calculated using the linear method and normalized by body surface area, and sex-dependent cut-off values were applied to indicate LV hypertrophy (LVH) .P < 0.001).Myocardial deformation of the LV was assessed using a semi-automated 2D speckle-tracking technique in the three apical views by one experienced sonographer blind to the other information of the participants. Images were analyzed using GE Echopac software  after manual tracing of the endocardial border at the end systole of the LV. Once the aortic values closure was set, the system automatically followed the myocardial wall motion at the cardiac cycle. GLS was calculated as the average values of all the 18 segments. To be consistent with clinical meaning, the higher values the better strain deformation, absolute GLS value was used for statistical analysis. Intra-operator variability exhibited excellent consistency . After at least 5 min of rest in the supine position, four blood pressure cuffs were wrapped around both bilateral upper arms and ankles and then connected to a plethymographic sensor and oscillometric pressure sensor. The equipment recorded the volume pulse form, phonogram, and arterial blood pressure at the bilateral brachia and ankles. The distance between the right brachium and ankle was estimated base on the subject's height. The baPWV was automatically calculated as the distance divided by the transmission time. In addition, ABI was calculated bilaterally as the ratio of ankle-SBP to brachium-SBP on the left and right sides. The mean baPWV and ABI for the left and right sides were used for analysis. baPWV measurements were made on the same day as the echocardiography.P-values (p < 0.05) in univariate analysis were included in the multivariate regression model. Potential multicollinearity was considered by computation of variance inflation factor. Collinearity was considered acceptable and the regression model was considered stable for a variance inflation factor of <3. Receiver operating characteristic (ROC) curve was used to detect the diagnostic value of baPWV for abnormal MV parameters. All analyses were performed with SPSS version 19.0 and GraphPad Prism version 7.0. P-values of two-tailed < 0.05 were considered statistically significant for all described analyses.The quantitative variables were expressed as mean ± standard deviation (SD) or median (interquartile range) based on the normality of their distribution evaluated by the Shapiro-Wilk test. The qualitative variables were expressed as frequencies and percentages. Analyses were carried out by categorizing the participants into tertiles according to the baPWV. Differences among the three groups were analyzed for statistical significance with variance (ANOVA) testing when comparing variables with normal distribution and Kruskal Wallis test for non-normally distributed variables. When comparing categorical data, Chi-square or the Fisher's exact test were used for comparison. Spearman correlation analysis was used for assessing the correlates of MW indexes. Univariate and multivariate linear regression analyses were performed using all potentially relevant variables to identify baseline independent predictors of 4 MW indexes including GWI, GWE, GCW, and GWW. The variables included in the regression model were: age, sex, body mass index (BMI), smoking and drinking status, hypertension, antihypertensive medication use, LVEF, cardiac index (CI), stroke volume (SV), Left atrial volume index (LAVI), E/e' Septum, Left ventricular mass index (LVMI), GLS, as well as baPWV. Only variables with statistically significant The final analysis included 208 participants with 104 of them diagnosed as hypertension. The study populations were categorized into tertiles according to the baPWV. Baseline clinical data and ehocardiographic data in non-hypertensive and hypertensive participants were shown in r = 0.338, p < 0.001), GCW , and GWW , as well as linear and negative association of the baPWV with GWE , as shown in We found linear and positive associations of the baPWV with GWI . As shown in The area under curve (AUC) of baPWV for predicting elevated GWI, GCW, and GWW and decreased GWE were 0.653, 0.666, 0.725, and 0.688, respectively . It was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University . Informed consent was obtained from all patients. The patients/participants provided their written informed consent to participate in this study.QDu, DZ, QDo, KL, YY, and LY performed the research and analyzed data. QDu and PG wrote the manuscript. QDu and SQ designed the study and critically reviewed the manuscript. All authors reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by Chongqing Science and Technology Commission, Key Project, (2019 ZLXM003); Chongqing Science and Technology Commission, Youth Project, (2018QNXM024).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.


No factor was found to be a predictor of lung function or asthma control. When choosing treatment for adult patients with SAA, our findings may help to select those who may benefit the most from omalizumab treatment.Several factors have been found to be predictors of a good response following omalizumab treatment in patients with severe allergic asthma (SAA). However, it remains unclear whether clinical characteristics can predict a minimal clinically important difference (MCID) following omalizumab treatment in this population. Therefore, the aim of this study was to investigate the features associated with an MCID following omalizumab treatment in adult patients with SAA. Of the 124 participants enrolled in this retrospective, cross-sectional study, 94, 103, 20 and 53 achieved the MCID following treatment with omalizumab and were considered to be responders of exacerbation reduction (no exacerbation during the 1-year follow-up period or ≧50% reduction in exacerbations from baseline), oral corticosteroid (OCS) sparing (no use of OCS to control asthma during the study period or a reduction of the monthly OCS maintenance dose to <50% of baseline), lung function (an increase of ≧230 ml in the forced expiratory volume in 1 s from baseline) and asthma control (an increase of ≧3 points in the asthma control test score from baseline), respectively. Normal weight [<25 vs. ≧30 kg/m Asthma is a heterogeneous respiratory disease that involves airflow limitation due to chronic airway inflammation. It has been reported to affect 1–18% of the general population and is categorized into five Global Initiative for Asthma (GINA) steps (Step 1–5) based on the strength of treatment needed to control symptoms and exacerbations. Severe asthma, defined as asthma which cannot be controlled despite the use of GINA Step 4 or 5 pharmacological therapies, good inhaler technique and adherence, and optimal management of contributory factors, is estimated to occur in 3.6% of asthmatic patients .Omalizumab is an anti-immunoglobulin E (IgE) monoclonal antibody that reduces circulatory free IgE, and it is approved for the treatment of moderate to severe IgE-mediated asthma. The GINA recommendations suggest the use of omalizumab as add-on therapy for severe asthma owing to its noticeable impact on medical resource utilization, quality of life and beneficial treatment outcomes, including improved exacerbation rate, reduced oral corticosteroid (OCS) maintenance dose, better asthma control and improvements in lung function in both adult and pediatric patients with severe allergic asthma (SAA) , 3–10.The statistical significance is the most widely used evidence to guide treatment decision making in both clinical trials and daily practice while this does not necessarily imply the clinical relevance. To overcome this gap, it is crucial to determine the minimal clinically important difference (MCID), first described in 1989 by Jaeschke et al. and defined as the smallest improvement in a treatment outcome considered worthwhile by an individual patient, for healthcare providers. Several MCID cut-off values have been proposed and validated in the population of asthma, with most of the cut-offs are associated with patient-reported outcomes, lung function and exercise tolerance –14. NeveThe GINA guidelines state that a blood eosinophil count ≧260 cells/μL, a fractional exhaled nitric oxide (FeNO) level ≧20 parts per billion, the presence of allergen-driven symptoms, and childhood-onset asthma are statistically significant predictors for a good therapeutic response to omalizumab in reducing exacerbations for patients with SAA . HoweverWe hypothesized that the baseline clinical features could predict a worthwhile response to omalizumab as an add-on therapy for patients with SAA. Therefore, we investigated the pre-omalizumab treatment clinical characteristics associated with an MCID in reducing exacerbations, OCS sparing, and improvements in lung function and asthma control, the most representative and clinically vital treatment goals recommended by the GINA strategy , followiThis retrospective cross-sectional study was approved by the Institutional Review Board and Ethics Committee of Taichung Veterans General Hospital (TCVGH)  and implemented in accordance with the Declaration of Helsinki. The need for informed consent from participants was waived because of the retrospective nature of this study and data extraction based on an electronic medical chart review. The study was conducted at TCVGH, a tertiary referral center in central Taiwan, be-tween January 2010 and January 2019, and enrolled patients diagnosed of SAA who applied for reimbursements for omalizumab from the Taiwan National Health Insurance (NHI) according to the judgment of very experienced pulmonologists and immunologists in charge of asthma management. Patients whose applications were not ap-proved were excluded from this study .As detailed elsewhere , the invResponders with regards to a reduction in exacerbations were defined as those who had no exacerbations during the study period or who had a ≧50% reduction in the number of exacerbations in the 1-year follow-up period compared to the year prior to enrollment. An exacerbation was defined as a worsening of respiratory symptoms and lung function that required OCS treatment for ≧3 days at an outpatient service, emergency visit or hospitalization , 16. TheResponders with regards to OCS sparing were defined as those who did not use OCS to control asthma during the study period, or whose monthly OCS maintenance dose at the end of study was <50% compared to that at enrollment. Maintenance pharmacological therapy for SAA was defined as >7 days of OCS prescriptions in the outpatient department. The patients who did not meet these criteria were defined as non-responders.The patients with an MCID according to lung function and ACT following omalizumab treatment were defined as those with an increase of ≧230 ml and ≧3 points in the forced expiratory volume in 1 s (FEV1) and ACT score, respectively, between the end and start of the 1-year follow-up period , 14. Thet-test or Wilcoxon signed-rank-test according to the normality assumption between the study groups. Logistic regression models were used to analyze independent factors if they were significant in the univariate analysis for patients with binary results of treatment outcomes of interest. A significant difference was defined as a two-sided p-value <0.05. The data of all patients were de-identified before analysis.Categorical variables were presented as frequency and percentage and compared using the chi-squared test between the responders and non-responders. Continuous variables were presented using mean and standard deviation, and median and inter-quartile range, and were compared using a paired sample Nearly all of the patients met one or more of the responder criteria, while only 4.8% of the patients with complete data and 10.3% of the those with missing values met all four responder criteria, respectively .2 . Furthermore, of the 124 patients, 46 (37.1%) had blood eosinophilia of ≧300 cells/μL  compared to the non-responders . The logThe patients who exhibited an MCID in FEV1 improvement following omalizumab treatment were younger than those who did not , althougThe responders with an improvement in ACT following omalizumab treatment were associated with a higher initial dose of omalizumab and more use of either montelukast alone or methylxanthines alone to control asthma . None ofIn this study of 124 adult patients with SAA, 75.8, 83.1, 26.7, and 62.4% were considered to be responders following omalizumab treatment according to a reduction in exacerbations, OCS sparing, and improvements in lung function and asthma control, respectively. The responders with a reduction in exacerbations were characterized by normal weight and less smoking exposure; OCS sparing by a lower blood eosinophil level; lung function improvement by a younger age; and asthma control improvement by a higher initial dose of omalizumab and more use of either montelukast alone or methylxanthines alone to control asthma. In addition, normal weight was a significant predictor of an MCID in a reduction in exacerbations following omalizumab treatment; a circulatory eosinophil level of <300 cells/μL in OCS sparing; and none in improvements in lung function or asthma control.Our results showed that normal weight and less smoking exposure were associated with an MCID in a reduction in the annual number of exacerbations, and the former was an independent predictor. In contrast to our study, Casale et al. enrolled a relatively young population (a mean age of 47.3 years) with allergic asthma who were candidates for omalizumab treatment, and found that those with an increased number of exacerbations in the year prior to the study as well as female patients were more likely to be responders with a reduction in exacerbations defined using a similar criteria to our study , 17. TheWe also found that a peripheral blood eosinophil level of <300 cells/μL could predict responders with OCS sparing. Hanania et al. reported that a high level of FeNO could predict less albuterol use . In contFurther, our study showed that the responders with lung function improvement were younger compared to the non-responders, and that the patients with a higher initial omalizumab dose and more use of oral medications to control asthma were associated with an MCID in asthma control. In contrast, Casale et al. reported that patients with uncontrolled asthma and receiving asthma medications in addition to inhaled corticosteroids (ICS)/long-acting beta-agonists were more likely to be associated with an MCID in lung function, defined as a rise in FEV1 ≧120 ml from baseline, while those with higher baseline circulatory eosinophil levels were more likely to be responders with asthma control according to a definition similar to ours . Again, Obese patients with asthma have an increased risk of severe disease, which may arise from many factors, such as changes in airway anatomy, adipokines, glucose-insulin metabolism, oxidative stress, inflammation, and genetic and epigenetic variants . FurtherThe predictive value of total IgE and blood eosinophil levels with regards to the therapeutic benefit of omalizumab in patients with allergic asthma has yet to be shown in previous studies, although we found that a blood eosinophil level of <300 cells/μL was predictive of an MCID in OCS sparing in the SAA patients , 19, 22.Similar to the response rates of 75.8 and 62.4% for a reduction in exacerbations and improvement in asthma control, respectively, Casale et al. reported response rates of 77.8 and 64.7% , 23. As The main strength of the current study is that the diagnosis of SAA was made according to the GINA recommendations by clinicians who were actively involved in the management of asthma, while the initiation of omalizumab treatment in all patients was suggested by both the physician in charge and the Taiwan NHI committee for SAA , This enIt is extremely important to take clinical features into consideration when managing patients with asthma at different GINA steps, particularly at GINA step 5, because several inflammatory biomarkers used to predict a good therapeutic response to the biologic treatment, such as FeNO and periostin, are not always available in all hospitals or areas/countries. We identified several clinical characteristics associated with an MCID in terms of a reduction in exacerbations, OCS sparing, and improvements in lung function and asthma control in adult patients with SAA. This information could help when selecting patients who may benefit more from omalizumab treatment to manage asthma. Future well-designed studies including more subjects and more potential and easily-obtained inflammatory biomarkers are warranted to more accurately predict an MCID following omalizumab treatment.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Institutional Review Board and Ethics Committee of Taichung Veterans General Hospital . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.W-CH: conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft preparation, visualization, project administration, and agreement on the published version of the manuscript. P-KF, M-CC, C-SC, W-NH, K-LL, J-LW, W-TH, Y-DW, C-WH, and M-FW: methodology, formal analysis, investigation, data curation, writing—review and editing, visualization, and agreement on the published version of the manuscript. Y-HC and J-YH: conceptualization, methodology, validation, formal analysis, investigation, data curation, writing—review and editing, visualization, supervision, and agreement on the published version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Background and Objectives: Hypertension affects at least 80% of hemodialysis patients. Inappropriate control of blood pressure is mentioned as one of the essential cardiovascular risk factors associated with development of cardiovascular events in dialysis populations. The aim of the cross-sectional, retrospective study was the evaluation of the antihypertensive treatment schedule and control of blood pressure in relation to the guidelines in the group of hemodialysis patients. Additionally, we assessed the level of decrease in blood pressure by each group of hypotensive agents. Materials and Methods: 222 patients hemodialyzed in a single Dialysis Unit in three distinct periods of time—2006, 2011, and 2016—with a diagnosis of hypertension were enrolled in the study. The analysis of the antihypertensive treatment was based on the medical files and it consisted of a comparison of the mean blood pressure results reported during the six consecutive hemodialysis sessions. Results: The mean values of blood pressure before hemodialysis were as follows: 134/77, 130/74, and 140/76 mmHg, after hemodialysis 124/74, 126/73, and 139/77 mmHg in 2006, 2011, and 2016 respectively. The goal of predialysis blood pressure control (<140/90) was achieved by up to 64.3% of participants in 2006 as compared to 49.4% in 2016. Additionally, the postdialysis goal (<130/90) reached 57.1% of the study population in 2006 as compared to 27.1% of patients in 2016. The differences in percentage of patients using single, double, triple, and multidrug therapy during observation were not statistically significant. The most often used drugs were ß-blockers, diuretics, and calcium channel blockers in all points of the study. Blockades of the renin–angiotensin–aldosterone system in 2006 and calcium channel blockers in 2011 and 2016 were the drugs with highest impact on lowering blood pressure. Conclusions: The goal of predialysis or postdialysis blood pressure control was achieved in a lower percentage of patients during the period of the study. Blockade of renin–angiotensin–aldosterone system and calcium channel blockers decrease the blood pressure significantly. It is necessary to achieve better control of blood pressure in prevention of cardiovascular incidents. Hypertension (HT) is one of the major health problems of today’s world. Among the hemodialysis patients (HDp), HT is also one of the most common comorbidities. According to the literature, it affects at least 80% of the HDp population ,2,3. On The pharmacological treatment of HT is based on five main groups of medicines—β-blockers (BB), calcium channel blockers (CCB), RAAS blockers, such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARBs) called also sartans (AGTR1 blocker) and diuretics. All of them are used in the treatment of hypertensive HDp . MoreoveThe aim of the cross-sectional, retrospective study was to evaluate the antihypertensive treatment schedule and the control of BP in relation to the guidelines in the group of HDp in the years 2006, 2011, and 2016. Additionally, we assessed the blood pressure-lowering effect of each group of drugs. 222 patients were enrolled to the study group of HDp in a single Dialysis Unit placed in the Pomeranian District of Poland. The retrospective analysis of the antihypertensive treatment was based on the medical files and it comprises the comparison of the mean results of BP reported in six consecutive hemodialysis. BP was measured before needles placing in fistula or connecting lines to the catheter after a minimum 5 min of rest before the session. Postdialysis BP was measured after removing of needles or disconnecting lines from the catheter. No drugs were taken by the patients during the dialysis. Moreover, sex, age, diabetic, and cardiovascular status, and current treatment were included to analysis.HT was diagnosed when systolic blood pressure (SBP) was ≥ 140 mmHg or diastolic blood pressure (DBP) was ≥ 90 mmHg, or antihypertensive drugs were prescribed. Patients without HT and patients hemodialyzed as a result of acute kidney injury were excluded from the study.p < 0.05 was considered statistically significant. The influence of drugs on blood pressure was evaluated by linear regression.Data were evaluated using a GraphPad Prism (version 7) software package. In order to measure the differences, we used the U Mann Whitney test and Kruskal–Wallis with Dunn post-hoc test. In order to measure differences in BP before and after hemodialysis we used the Wilcoxon test. A The years 2006, 2011, and 2016 included 56, 81, and 85 HDp in the analysis, respectively. The general characteristics of the studied groups are presented in It is worth underlining that the period of time of hemodialysis was significantly longer in HDp assessed in 2016 and (45 months) as compared to 2006 (23.4 months) and 2011 (33.7 months). Furthermore, the dialysis adequacy ratio (Kt/V) improved significantly during this period of time. Also, there was no significant difference between vascular access and giving of erythropoietin . In our BP ≤ 140/90 mmHg as the goal of predialysis BP was reached more often in 2006 (64.3%), but the difference was not statistically significant as compared to 2011 and 2016 . Moreover, BP ≤ 130/80 mmHg as the goal for postdialysis BP, was reached statistically significant more often in 2006 .The average number of antihypertensive agents taken by patients increased from 2.25 to 2.53 in evaluated periods of time 2006 to 2016, respectively .Monotherapy was used less often in 2016 (14.1%) as a compare to 2006 (23.2%), usage of 2 and 3 hypertensive drugs were the most common in 2011 (34.6%) and in 2016 (30.6%) respectively, but there were not significant differences between the groups .BB were the most commonly used drugs in all periods of time . In the On the other hand, there was a significant decrease in the administration of ACEI from 39.3% in 2006 to 20% in 2016. However, the ARBs were administered in 2011 and 2016, therefore the overall usage of RAAS blockade was stable. RAAS blockade was applied in one third of the study population.The linear regression analysis showed the most significant lowering BP by RAAS blockers in 2006 and CCB in 2011 and 2016 . In the In our study, the goal of BP control according to recommendations was achieved only in half of the patients, especially in 2016, despite the fact that usage of antihypertensive drugs increased. RAAS blockers and calcium-channel blockers decreased the blood pressure significantly as compared to others hypertensive agents.According to the review performed by Agarwal et al. in 2003 among 2535 clinically stable adult HDp with routine BP measurements prevalence of HT was 86% and only 30% of hypertensive patients have well controlled BP . In the In the last decades, the recommendation on the treatment of HT were still based on physicians/hemodialysis unit, individual efficacy, tolerability and medical comorbidity due to the lack of randomized controlled trials. Clinicians who are taking care of HDp face the fact that, despite additional risk factors, this group of patients do not have special guidelines based on randomized studies. As a result, most doctors rely on guidelines that are prepared for the general population and extrapolated the goal of BP to HDp. A report from 2009 suggests that there is a ‘U-shaped’ association between prehemodialysis BP and mortality . HoweverAdditionally, other important consequences of inappropriate BP control are higher CV morbidity and mortality . TherefoIn our study, the majority of HDp  were treated by BB followed by CCB. According to meta-analyses, BBs are an effective therapeutic strategy compared with placebo because they reduce the risk of major CV events . They arIn our study, the average number of drugs increased from 2.25 in 2006 to 2.53 in 2016. Among patients with CKD in large clinical studies average 3.5 drugs were necessary to optimize value of BP . HoweverIn our study in 2006, the predialysis BP was < 140/90 mmHg in 64.3% of HDp, but in 2016 this level was only achieved in 49.4% of HDp which may be related to older age and longer duration of dialysis treatment. The postdialysis goal that was < 130/80 mmHg was reached in 57.1% of HDp in 2006 and only in 27.1% in 2016. On the first look achieved values are not optimistic. However, they are very similar to results achieved by patients from the same unit with CKD in stage 1–4  and bettThere are some limitations of the study. First, the use of office BP readings to monitor the quality of BP control may be subject to significant error due to the white-coat syndrome and stress during hemodialysis. In reality, treatment results may be even better. On the other hand, the assessment of antihypertensive treatment effectiveness was based on a retrospective analysis of causal BP measurements, frequently following the morning dose of medications, which can significantly reduce the mean value of BP. Second, the surveys, in fact, were not performed on the same patients, and therefore, there is the possibility that differences in demographic and clinical characteristics between patients enrolled in particular surveys influenced the results. Also, we did not measure RRF and do not check side effects of diuretics. The exact doses of drugs and period of usage also were not measured. In summary, the results showed that during a ten-year period, the control of BP was worse. The main hypertensive treatment regimen is based on BB and CCB agents. Surprisingly, the usage of RAAS blockade and CCB decrease BP significantly. Additional studies concerning the control of BP and the role of RAAS blockade in HDp are necessary.


Aims: Deprescribing of antihypertensive drugs is recommended for some older patients with polypharmacy, but there is little evidence to inform which drug (or dose) should be withdrawn. This study used data from the OPTiMISE trial to examine whether short-term outcomes of deprescribing vary by drug class and dose of medication withdrawn.Methods: The OPTiMISE trial included patients aged ≥80 years with controlled systolic blood pressure , receiving ≥2 antihypertensive medications. This study compared SBP control, mean change in SBP and frequency of adverse events after 12 weeks in participants stopping one medication vs. usual care, by drug class and equivalent dose of medication withdrawn. Equivalent dose was determined according to the defined daily dose (DDD) of each medication type. Drugs prescribed below the DDD were classed as low dose and those prescribed at ≥DDD were described as higher dose. Outcomes were examined by generalized linear mixed effects models.Results: A total of 569 participants were randomized, aged 85 ± 3 years with controlled blood pressure (mean 130/69 mmHg). Within patients prescribed calcium channel blockers, higher dose medications were more commonly selected for withdrawal (90 vs. 10%). In those prescribed beta-blockers, low dose medications were more commonly chosen (87 vs. 13%). Withdrawal of calcium channel blockers was associated with an increase in SBP  and reduced SBP control  compared to usual care. In contrast, withdrawal of beta-blockers was associated with no change in SBP  and no difference in SBP control . Similarly, withdrawal of higher dose medications was associated with an increase in SBP but no change in BP control. Withdrawal of lower dose medications was not associated with a difference in SBP or SBP control. There was no association between withdrawal of specific drug classes and adverse events.Conclusion: These exploratory data suggest withdrawal of higher dose calcium channel blockers should be avoided if the goal is to maintain BP control. However, low dose beta-blockers may be removed with little impact on blood pressure over 12-weeks of follow-up. Larger studies are needed to confirm these associations. Antihypertensive treatment is effective at preventing stroke and cardiovascular disease in older high-risk patients with hypertension  and manyGuidelines therefore recommend using clinical judgment when prescribing in frail older patients , emphasiThere is little evidence to guide antihypertensive deprescribing , and theThis was a post-hoc exploratory analysis of data from the OPTiMISE trial of antihypertensive medication reduction . All parIndividuals were eligible if they were aged ≥80 years, with systolic blood pressure at baseline <150 mm Hg  and prescribed two or more antihypertensive treatments for at least 12 months. Recruiting primary care physicians were asked to only enroll patients whom in their opinion might potentially benefit from medication reduction due to existing polypharmacy, co-morbidity, non-adherence or dislike of medicines, and/or frailty. This clinical judgment was considered important given the current lack of evidence as to who should be targeted for such an intervention. Patients with a history of heart failure due to left ventricular dysfunction or myocardial infarction/stroke in the preceding 12 months, secondary hypertension or lacking in capacity to consent were excluded.Potentially eligible patients were identified from searches of electronic health records in participating sites and sent letters of invitation. Those expressing an interest attended a screening appointment.Participants were allocated  to one of the two study groups using a non-deterministic minimization algorithm, with minimization designed to balance site and baseline systolic blood pressure, via a fully validated, web-based, password protected system. Investigators and participants were unaware of the treatment allocation prior to consent and baseline assessments. The trial used an unblinded design with patients and investigators not masked to randomization group.Participating primary care physicians reviewed each participant’s medication regimen before randomization and decided which antihypertensive would be removed if they were allocated to medication reduction, using a pre-specified algorithm . This alOutcomes examined in this analysis were not pre-specified before the end of the trial and should be treated as exploratory. Outcomes included between group differences in systolic blood pressure control, adverse events and change in systolic and diastolic blood pressure at follow-up by drug class and dose of medication chosen for withdrawal. Adverse events were defined as any clinical event occurring during follow-up, regardless of whether it was deemed to be possibly, probably or definitely related to the intervention by the treating physician. Systolic and diastolic blood pressure were defined as the mean of the second and third consecutive readings taken at 1 min intervals. Measurements were taken in the seated position, using the clinically validated BpTRU blood pressure monitor  after a For each analysis by drug class, groups were determined according to drug classifications in the British National Formulary (BNF) . EquivalData relating to participant demographics, body mass index, blood pressure, cognition  , functioDescriptive statistics were used to describe the study population, the proportion of participants maintaining medication reduction and the proportion experiencing no increase in systolic blood pressure in the intervention group at follow-up. These were estimated by drug class and dose of medication chosen for withdrawal. Since the choice of drug to withdraw was not fixed, but rather at the discretion for the treating physician, multivariable logistic regression was used to examine predictors of physician drug choice. Statistically significant predictors were included as factors for adjustment in the main analysis.Data from participants examining outcomes of medication reduction by drug class and medication dose were analyzed according to the groups to which they were allocated (i.e. by intention to treat). The relative risk (RR) for blood pressure control and adverse events between groups were examined by drug class and medication dose chosen for withdrawal using a robust Poisson regression model. Each model was adjusted for baseline systolic blood pressure, covariates predictive of drug choice for medication withdrawal and those predictive of missing blood pressure data at follow-up . Since the treating physician’s choice of medication to withdraw was made prior to consent and randomization, data were available for all randomized participants, even though only half went on to have the medication withdrawn. Therefore, models compared patients withdrawing specific drugs (the intervention group) to patients where the same drug was selected for withdrawal, but treatment was actually continued . Separate models were fitted according to the drug class and medication dose chosen for withdrawal. Adjusted mean difference in change in blood pressure was analyzed by means of generalized linear mixed model with binomial error and log link, with factors predictive of physician choice of drug to withdraw and baseline systolic blood pressure, gender, cognitive function (MoCA Score), EQ-5D-5L Index and Searle Frailty Index as fixed effects and primary care site as a random effect.All data were analyzed using Stata statistical software . Data are presented as means, medians and proportions with 95% confidence intervals (CI) unless otherwise stated.A total 569 patients were recruited to the trial from 69 general practices in Central, Eastern and Southern England. The characteristics of participants in the trial were broadly comparable to those of a similar age group in the general population . Two hunThe most commonly prescribed medications at baseline were calcium channel blockers , ACE inhibitors  and beta-blockers . Calcium channel blockers were typically prescribed in combination with ACE inhibitors , angiotensin II receptor blockers  or beta-blockers  . ThiazidAfter adjusting for factors predictive of drug choice for medication reduction , particiWithdrawal of higher dose medications was associated with an increase in systolic and diastolic blood pressure  but no difference in blood pressure control (adjusted RR 0.98 95% CI 0.92–1.46) . WithdraAll 282 patients randomized to the intervention arm of the trial attempted to withdraw the medication chosen by their primary care physician. Overall, 91 (32.4%) had their medication reintroduced and 101 (35.9%) experienced no increase in systolic blood pressure at 12 weeks follow-up . The higThe OPTiMISE trial  found thThis is the first analysis of medication reduction by antihypertensive drug class and medication dose using data from a randomized controlled trial . The triAlthough follow-up was achieved in 93.8% of participants, the period of follow-up was short, and so it was not possible to examine clinical endpoints such as hospitalization, cardiovascular disease or death at this stage, though the cohort will be followed up. In addition, although routine prescription of beta-blockers is often accompanied by monitoring of heart rate, we did not collect this or related outcomes  during follow-up, precluding any analyses of these outcomes.Previous trials of antihypertensive medication reduction have only attempted medication reduction in up to two thirds of participants , had smaPhysicians participating in the OPTiMISE trial  were givCalcium channel blockers were less likely to be chosen for medication reduction in patients with higher baseline systolic blood pressure and despite this, withdrawal of these medications was associated with a higher likelihood of uncontrolled blood pressure at follow-up. One explanation for this might be that these medications were predominantly prescribed at higher doses, where the blood pressure lowering effect might be expected to be greater. There is also evidence to suggest that calcium channel blockers are more effective in older individuals, leading to recommendations in clinical guidelines that these should be used as a first line therapy . These fThe proportion of patients prescribed beta-blockers at baseline was relatively high, particularly since patients with a history of heart failure due to left ventricular dysfunction were excluded . Given tThese data show that a high proportion of patients withdrawing beta-blockers maintained medication reduction at follow-up and that withdrawal of such medications may be associated with no change or even a reduction in systolic blood pressure. Beta-blockers were more likely to be prescribed at lower doses for patients enrolled into the trial, and selected for medication reduction if participants were prescribed a higher number of antihypertensive medications at baseline. Since polypharmacy is associated with reduced adherence to medications , it is pWhile withdrawing low-dose beta-blockers with no resulting increase in blood pressure maybe an appealing strategy for physicians, it is important to note that beta-blockers have other cardio-protective properties and may be indicated for other reasons beyond hypertension, such as ischemic heart disease, tachycardia and heart failure with reduced ejection fraction. There was also some evidence to suggest that withdrawal of low dose medications resulted in an increase in adverse events, although these varied widely in terms of severity . Only 23 participants  experienced a serious adverse event resulting in hospitalization during the trial . Until sThis exploratory analysis found some evidence to suggest that withdrawal of higher dose calcium channel blockers should be avoided if the goal is to maintain blood pressure control. However, low dose beta-blockers may be removed with little impact on blood pressure at follow-up. More appropriately powered studies are needed to determine whether withdrawal of certain drug classes and/or doses are preferable over others in older patients with multi-morbidity and polypharmacy.Julie Allen, Sue Jowett, Jill Mollison, Eleanor Temple, Carl Heneghan, Ly-Mee Yu, Marney Williams, James P. Sheppard, Mark Lown, Jenni Burt, Gary A. Ford, F. D. Richard Hobbs, Paul Little, Jonathan Mant, Rupert A. Payne, Richard J. McManus.


Chronic Kidney Disease (CKD) is a disease in which the kidney’s functionality declines gradually. The aim of this study was to identify significant laboratory prognostic factors on death due to CKD in a clinical complex.  A retrospective study including 109 patients with the end-stage renal disease treated at Iran Helal pharmaceutical and the clinical complex was conducted between 2014-2018. The survival time was set as the time interval between starting dialysis until death due to CKD. Also, the transplantation was considered as competing risk, which was occurred for a few patients. A three-parameter Gompertz model was used that considers both the event of interest and the competing event simultaneously.  Death due to CKD occurred in 29 (26.6%) of the patients and 19(17.4%) with transplantation. Serum uric acid was a significant prognostic factor that decreased the hazard of mortality by 21%. Serum phosphorus and age by increasing the risk of death, were poor prognoses for the event of interest. Serum uric acid and phosphorus 6.9-9.9 (mg/dl) were associated with 72% and 4.05- fold increased hazard of transplant, respectively. The 4-year cumulative incidence of death and transplant was 48.4% and 29.2%, respectively.  We have deduced that high serum phosphorus levels and increased levels of age were associated with worse outcomes. High serum uric acid level was related to better survival, which could be explained by having a better protein-rich diet alongside the high albumin level. Chronic kidney disease (CKD) is a matter of healthcare associated with the slow loss of kidney function over time . General In this retrospective cohort study, a total of 109 hemodialysis patients were enrolled and registered in the Iran Helal pharmaceutical and clinical complex during 2014-2018. The inclusion criteria were age higher than 18 years old, and routine dialysis started at least three months before the study. The exclusion criteria were evidence of acute kidney injury and acute illness. Demographics and laboratory results were collected from hospital medical records and included all CKD patients given hemodialysis three times a week. The survival time was calculated as the time interval between starting dialysis and time of death due to CKD. The transplantation was considered as a competing risk. The study was confirmed by the ethical committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran . At the beginning, information on demographics was collected. A blood sample was drawn after 12–14 hours on an empty stomach and was centrifuged within 30–45 min of collection. The analyses of the blood tests were completed at the reference laboratory on the day of sampling. Total cholesterol was measured using the enzymatic colorimetric method with cholesterol esterase-cholesterol oxidase. Serum creatinine levels were evaluated by kinetic colorimetric Jaffe. Serum uric acid, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), bilirubin, hemoglobin, potassium, Alkaline phosphatase (ALP), hemoglobin A1c (HbA1C), ferritin, calcium, serum phosphorus, parathyroid hormone (PTH) and albumin were also measured. All biochemical tests were carried out using commercial kits  by a Selectra 2 auto-analyzer .Descriptive statistics (mean standard deviation (SD) for continuous variables and frequency for categorical factors) were used to summarize demographic and prognostic variables in the study of the population. The quantitative variables were classified based on the criteria in the handbook of dialysis . The cat The analysis was performed on 109 hemodialysis patients  with mean age of 57.99 17.10. Overall, 29 (26.6%) of the patients experienced death due to CKD and others were censored . The oneet al. illustrated that despite the higher prevalence of CKD in females, hemodialysis patients’ mortality rate was higher for males [Designating the right statistical approach for determining the effect of prognostic factors is very significant . In thisor males . The hazor males . Other sor males -25. Theset al. illustrated that low renal function was linked to higher serum uric acid levels, which leads to a lower survival rate [et al. and Rincon et al., serum uric acid was strongly associated with increased risk of progression to end-stage renal disease in which the survival rate was lower than early stages [et al, and Hruska et al., hyperphosphatemia had led to CKD, which was associated with excess mortality [Studies showed that the prevalence of CKD in all stages was higher in elderly patients . Howeverval rate . In othey stages ,34. In oortality ,36. Our  There were some limitations in our study, such as the small sample size, which could have reduced the power of the test. The other issue was multicollinearity that made it impossible to use all significant variables in the multivariate model. We have found that patients with relatively high phosphate levels were associated with a worse outcome than those with serum phosphate in lower ranges. Our study pointed out that higher serum uric acid level was connected with a lower risk of mortality. Moreover, we have demonstrated that the 3-parameter Gompertz model was more flexible for the evaluation of the significant laboratory prognostic factors compared to cause-specific and subdistribution models since it considers the event of interest and the competing event simultaneously. However, further investigations are required with larger sample sizes for reaching accurate conclusions. This study is related to project No. 1398.10495 from the Student Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran. We also appreciate the Student Research Committee and Research & Technology Chancellor at Shahid Beheshti University of Medical Sciences for their financial support of this study. The information needed for this research was provided with the help of the Iran Helal pharmaceutical and clinical complex. The authors declare that there is no conflict of interest regarding the publication of this article.


Moreover, a positive correlation was observed between the percentage change in hs‐CRP and percentage changes in SBP , DBP , and MAP . Garlic supplementation can be a safe and potentially adjunct treatment to reduce blood pressure and the risk of cardiovascular disorders in patients with NAFLD.Based on the anti‐inflammatory and antihypertensive properties of garlic, the current study was designed to evaluate the garlic powder effects on blood pressure and high‐sensitivity C‐reactive protein (hs‐CRP) among Nonalcoholic Fatty Liver Disease patients (NAFLD). This randomized, double‐blind, placebo‐controlled trial study was conducted on 110 patients with NAFLD. The patients were randomly divided into 2 groups, receiving two tablets of either 400 mg garlic or placebo daily for 15 weeks. At baseline and the end of the study, blood pressure and hs‐CRP were determined. Of 110 patients enrolled in the trial, 98 subjects were included in the final analysis. After the intervention, systolic blood pressures (SBP) , diastolic blood pressure (DBP) , and Mean Arterial Pressure (MAP) (mean: −6:95%CI: −8.4 to −3.6 mm Hg) decreased significantly in the garlic group as compared to the placebo group. Also, the percentage of reduced hs‐CRP was significantly higher in the intervention group compared with the control group , diastolic blood pressure (DBP), and Mean Arterial Pressure (MAP) decreased significantly in the garlic group as compared to the placebo group. Also, the percentage of reduced hs‐CRP was significantly higher in the intervention group compared with the control group. Moreover, a posetive correlation was observed between percentage change in hs‐CRP and percentage changes in SBP, DBP, and MAP. NAFLD is characterized by excessive lipid accumulation within hepatocytes in the absence of excessive alcohol intake or other known causes of steatosis such as hepatic viral infections and drugs  such as allicin and s‐allylcysteine are thought to be the main bioactive compounds responsible for the management of blood pressure, inflammation, and hepatic steatosis  in the Mean Arterial Pressure (MAP) response to garlic intake with an anticipated dropout rate of 20% and power 80% at a significance level of 5% (two‐tailed)  and serum glutamic‐pyruvic transaminase (SGPT) levels equal or over 40 IU/L, and stable blood pressure control by diet regimen or/and a stable dose of antihypertensive medication in the last 3 months. The exclusion criteria also were as follows: smoker patients, prior history of adverse reaction to garlic, pregnancy or lactation, other known causes of hepatic steatosis including alcohol intake, viral infections, and hepatotoxic drugs, medical history of endocrine diseases, renal disease, stroke, heart failure, hemochromatosis, Wilson's disease, and cirrhosis, or regular consumption of garlic. Patients were withdrawn from study participation when they become pregnant or need to any change their drugs.The trial was conducted following the principles of the Helsinki Declaration. Each individual was informed of the overall objectives and procedures of this trial before obtaining the written informed consent. The study protocol was approved by a research ethics committee at Isfahan University Medical Sciences and then was registered at the Iranian Registry of Clinical Trials with the identifier number IRCT2014110819853N1.2.2Eligible participants were stratified according to sex and degree of fatty liver diagnosed by ultrasonography and then randomly allocated (in a 1:1 ratio) to receive 400 mg garlic tablet  or placebo  two times a day for 15 weeks. Each garlic tablet contained dried garlic powder, aerosil, magnesium stearate, and croscarmellose sodium. Placebo tablets were quite similar to garlic tablets by the means of shape, size, color, taste, and smell. This dosage was chosen based on the previous studies conducted on the blood pressure and hs‐CRP  and diastolic blood pressure (DBP) to the nearest 2 mm Hg using a calibrated mercury sphygmomanometer at the beginning and the end of the intervention. In each visit, measurements were implemented three times, at the two‐minute interval, on the left arm, with the patient in a sitting comfortable position, after 10 min rest, in the morning time (8–9 a.m.). The mean of three measurements was reported as the blood pressure values. The Mean Arterial Pressure (MAP) was calculated using the following equation: MAP = (SBP + 2DBP)/3.2.4g for 10 min to separate serum and stored at −80°C until bioanalysis. Serum hs‐CRP was measured by the relevant ELISA kit.After 10–12 hr fasting condition, a venous blood sample was taken at baseline and after 15 weeks. Blood samples were immediately centrifuged at 3000 2.4.1Weight was measured using a digital Seca scale (Saca 831), with light clothing, to the nearest 100 grams. Height was measured using a portable stadiometer (Seca) in the standing position to the nearest 0.5 centimeters. Then, Body Mass Index (BMI) was calculated by dividing weight in kilograms by height in meters squared. Waist circumference was measured without clothing at a level midway between the lower rib margin and the iliac crest at the end of exhalation and standing position using a tape, to the nearest 0.5 centimeters.The change in dietary intakes was measured using a three‐day food record at the beginning and the end of the intervention. A trained nutritionist instructed patients on how to complete their food records. The amounts of each food item were converted to gram/day using Iranian Household Measures and then converted to the value of nutrients and calorie using Nutritionist IV software .Physical activity was measured using the international physical activity questionnaire (IPAQ) at the beginning and the end of the intervention. IPAQ is an instrument designed for population surveillance of physical activity among adults [15]. The Farsi‐translated version of IPAQ was validated among the Iranian population. The physical activity of the participants was calculated as metabolic equivalents (MET)‐minutes/week. According to the guidelines for data processing and analysis of the IPAQ, participants were stratified into three categories .2.5ttest and Wilcoxon test. Independent Student's t test, Mann–Whitney U test, and chi‐square test were also used to ascertain differences in characteristics between two groups. We adjusted results by using the Analysis of Covariance (ANCOVA) test with baseline value, age, the grade of fatty liver, and change in energy intake, BMI, WC, and physical activity as covariates. Pearson correlation coefficients were analyzed to determine the inter‐variable relationships.Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 16 (SPSS Inc). The Kolmogorov–Smirnov test was used to examine the normal distribution of variables. A within‐group comparison was done with the use of the Paired Sample 3p = .22).A total of 205 patients were enrolled and underwent screening to participate in the trial; of whom 110 eligible patients were selected and allocated to receive either garlic tablet or a placebo tablet. Twelve patients were excluded from data analyses as follows: in the garlic group, 3 patients were lost to follow‐up, and 5 patients were withdrawn from the study; in the placebo group, 1 patient was lost to follow‐up, and 3 patients were withdrawn from the study  age was 45.2 ± 11.6 years , weight was 80.8 ± 14.6 kg , and BMI was 29.5 ± 6.1 kg/m2 . The majority of patients were female (59.2%); 72.5% had previous cardiovascular diseases, 52% had metabolic syndrome, and only 43.9% of patients used antihypertensive medication in which diuretics (65.1%) were more frequent drug use. Thirty‐seven patients (37.8%) had mild fatty liver; 54 patients (55.1%) had moderate fatty liver, and 7 patients (7.1%) had severed fatty on ultrasound imaging. Table (Table ). However, the mean change of body weight was statistically significant in the garlic group compared to the placebo group .The participant's mean ( ± Multivariable‐adjusted mean change in blood pressure variables from baseline to 15 weeks intervention is shown in Table SD) hs‐CRP concentration was 1.67 ± 0.52 mg/L in the garlic group and 1.62 ± 0.72 mg/L in the placebo group at the beginning of the trial. The two groups did not differ significantly in the serum concentration of hs‐CRP (p = .76). The mean ( ± SE) of percentage change in hs‐CRP concentration from baseline to 15 weeks of the intervention was −14.35 ± 0.58 and 1.75 ± 5.69 in the garlic and placebo groups, respectively. After adjusting the potential confounding factors including sex, age, BMI, physical activity, energy intake, weight change, and fatty liver grade, the percentage of reduced hs‐CRP was significantly higher in the garlic group compared with the placebo group . We also observed a significant positive relationship between percentage changes in hs‐CRP and percentage changes in SBP , DBP , and MAP   to patients with NAFLD can reduce the blood pressure and the risk of CVDs independent of potential risk factors. We also found a positive relationship between change in hs‐CRP and blood pressure. To the best of our knowledge, no attempts were made to determine the effect of garlic on blood pressure and hs‐CRP in patients with NAFLD.Our results showed that garlic intake can reduce SBP, DBP, and MAP in patients with NAFLD independent of potential risk factors. These findings are consistent with recent meta‐analysis reports. Xiong et al. reported that the administration of garlic powder can reduce SBP by 6.7 mm Hg and DBP by 4.8 mm Hg in hypertensive patients ; Writing‐original draft (lead). Seyedeh Parisa Moosavian: Writing‐original draft . HamidZolfaghari: Formal analysis (lead). zamzam paknahad: Conceptualization .This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the research ethics committee at Isfahan University Medical Sciences and then was registered at the Iranian Registry of Clinical Trials with the identifier number IRCT2014110819853N1. Written informed consent was obtained from all study participants.