Objective. The purpose of this prospective study was to investigate the predictive value of single prepartum findings combined with serum biomarkers sFlt-1 (soluble fms-like tyrosine kinase-1) and PlGF  indicating severity of preeclampsia (PE) for occurrence and extent of impaired postpartum kidney function. Study Design. In this prospective, single center study 44 PE patients were compared to 39 healthy controls  evaluated at time of delivery and at 6 months and 12 months postpartum. p values below 0.05 are considered statistically significant. Results. The majority of the PE patients had persistence of proteinuria (>120 mg/L after delivery) 6 months (p = 0.02) and 12 months postpartum (p < 0.0001) compared to controls. Also reduced GFR (glomerular filtration rate) persisted up to 6 months postpartum in PE patients compared to controls (p < 0.001). Prepartum sFlt-1 levels indeed correlated with impaired renal function parameters. Conclusion. A significant proportion of our PE patients had lower GFR levels and persistent proteinuria up to 12 months postpartum. Prepartum sFlt-1 is a trend-setting marker for impaired renal function postpartum, but it is not sufficient enough to predict renal impairment after PE. An evaluation of 24-month follow-up data is scheduled.  Preeclampsia (PE) is a clinically severe and potentially life threatening complication of pregnancy. It is characterized by the onset of hypertension (systolic blood pressure ≥ 140 mmHg or diastolic ≥ 90 mmHg) and proteinuria (≥300 mg/24-hour collection) later than 20 weeks of gestation in a previously normotensive woman and occurs in about 2–8% of all pregnancies. It is a progressive disease and delivery cures the mother from symptoms, normally blood pressure normalizes, and proteinuria vanishes within few weeks until 6 weeks [Its exact aetiology and pathophysiology still remain enigmatic . Pathoge % and a sensitivity of 82 % for their immunoassay.In this context, epidemiologic studies have demonstrated that preeclampsia predisposes the mother to cardio- and cerebrovascular complications such as hypertension, stroke, or ischemic heart disease –13. On tThe purpose of this prospective study was to investigate the predictive value of single prepartum findings indicating severity of preeclampsia for occurrence and extent of impaired postpartum kidney function. Furthermore we assessed the prognostic value of prepartum serum biomarkers sFlt-1 and PlGF for the development of persistent postpartum renal damage in PE patients.In this prospective, single center study 68 patients with singleton pregnancy between 2012 and 2014 presenting at our department later than 20 weeks of gestational age with elevated blood pressure (systolic blood pressure ≥ 140 mmHg or diastolic ≥ 90 mmHg) and confirmed proteinuria (>300 mg/24-hour collection) were screened.44 women (Caucasian patients) with preeclampsia meeting inclusion criteria  were included in this study and compared to 39 healthy Caucasian controls . Exclusion criteria were preexisting renal or rheumatologic diseases or diabetes stated in the case history. Also all individuals with a history of preeclampsia in a previous pregnancy were excluded. Also all patients with relevant proteinuria documented in the maternity card before 20 weeks of gestation were excluded. In order to characterize maternal pre- and postpartum kidney function we measured various maternal  and fetal (birth weight) parameters. Data was collected in both groups not later than 24 hours before delivery. Mothers were scheduled for follow-up examinations at 6 and 12 months including blood pressure measurements and blood and urine analyses (24-hour collection and proteinuria threshold before delivery <300 mg/24-hour collection and after delivery <120 mg/L).In PE patients maternal venous blood samples for sFlt-1 and PlGF measurements were collected immediately prior to delivery; serum was separated and stored at −70°C until analysis. sFlt-1 and PlGF analysis were performed as an enzyme linked immunosorbent assay (ELISA) as recommended by the manufacturer .This study was approved by the ethical board of Heinrich-Heine-University Duesseldorf and informed consent was obtained from all subjects prior to enrolment.p values below 0.05 are considered statistically significant. The comparison between the PE patients and the controls was entered by the two-sample t-test. The correlations are done by Pearson's correlation coefficient. The evaluation of the 95% confidence interval of the correlations was done by Fisher's transformation.Data analysis was carried out using R (version 3.1.3) . Boxplott-distribution (as shown in y = aexp((−x)/b)) was assumed after visual fitting of model functions from which also starting parameter estimates  were derived. A numerical simplified version of the parameter estimates is provided. Predictions using simplified parameters differ from predictions using exact parameter estimates less than 1% for GFR > 25 mL/min/1.73 m2. The validity of the NLS derived model can be verified using the confidence intervals from loess regression.Calculation of regression model for relationship between sFlt-1 and GFR  was done44 patients diagnosed with preeclampsia were compared with 39 gestational weeks and patient's age-matched controls. Compared to controls preeclampsia patients had a significantly increased proteinuria, higher serum creatinine, urea, uric acid, cystatin c, and elevated systolic and diastolic blood pressure. They also had significantly lower glomerular filtration rates (GFR-CDK-EPI), serum protein levels, and fetal birth weights  at delivp < 0.0001). Reduced GFR < 90 mL/min/1.73 m2 at delivery was found in 27/44 (61%) of PE patients and in 3/39 (7.7%) of controls (p < 0.0001). Serum creatinine was increased >79.2 μmol/L in 5/44 (11%) of patients and in 3/39 (7.7%) of controls (p = 0.72).As indicators for impaired kidney function we investigated proteinuria and serum creatinine levels and glomerular filtration rate (GFR-CDK-EPI) . By defip = 0.02) and 14/24 (58%) after 12 months (versus 2/30 (1%) of controls, p < 0.0001). The GFR reduction was found in 22/36 (61%) of PE patients after 6 (versus 5/39 (13%) of controls, p < 0.0001) and in 10/25 (40%) of PE patients after 12 months (versus 4/30 (13.3%) of controls, p = 0.21), respectively.A persisting proteinuria (>120 mg/L) was found in 29/36 (81%) of PE patients after 6 months (versus 1/39 (2%) of controls, r = 0.74; 95% CI +0.54 to +0.87) and 12 months postpartum .Next we identified predictors of persistently impaired kidney function after 6 and 12 months. Prepartum proteinuria was positively correlated with proteinuria at 6  and 12 months of  follow-up . Also, prepartum GFR was not correlated with postpartum proteinuria after 6  or 12 months , respectively.We found also a positive correlation between pre- and postpartum GFR in patients after 6 ) decreased from 109 mmHg (±9.6 SD) prepartum to 100 mmHg (±10.6 SD) at 6 months postpartum  and to 91 mmHg (±13.6 SD) at 12 months postpartum  in PE patients. In the controls MAP remained unchanged . y = aexp(−x/b)) we derived the modely = sFlt-1 (pg/mL) and x = GFR (mL/min/1.73 m2) using simplified numeric values. Predicted values for sFlt-1 from this model are shown in Then we investigated if sFlt-1 or PlGF alone or in combination with each other or other clinical parameters are good predictors of persistent postpartum renal impairment in PE patients. The comparison between GFR and sFlt-1 revealed a significant inverse relationship  and also the analysis between the ratio sFlt-1/PlGF and GFR .The biomarkers sFlt-1 and PlGF and proteinuria immediately prior to delivery were only weakly correlated . PlGF did not show any correlation with the investigated parameters.In our sample an inverse relationship between sFlt-1 and GFR is present; therefore we analysed all patients with reduced GFR, defined as a GFR below 90 mL/min/1.73 m Figures . FiguresImprovements in the management of PE patients have lowered fetal and maternal morbidity and mortality caused by PE. Second trimester sFlt-1/PlGF-ratio has the potential to predict PE in asymptomatic patients and therefore to allow early treatment. Early medical treatment and fetal monitoring help to prolong pregnancies in order to avoid increased fetal mortality and morbidity related to preterm delivery and therefore fetal immaturity. In some cases this takes into account that under prolongation of pregnancy PE progresses and therefore maternal morbidity increases. As PE is progressive and delivery cures symptoms for the mother it is crucial to investigate if severity of PE persistently affects mothers' health.Physiologically, during pregnancy the renal plasma flux and GFR increase until the end of first trimester by 50% and normalize 3 months following delivery . In our One consequence of endothelial dysfunction in PE is the progressive proteinuria, which itself is also an indicator for impaired kidney function beyond pregnancy. In a meta-analysis McDonald et al. combined data from seven cohorts and confirmed the association between PE and persisting albuminuria . At an aCritically high blood pressure in PE despite medical therapy can be a reason for preterm delivery. This might explain the correlation between increased prepartum blood pressure and lower birth weight and gestational age. High blood pressure during PE pregnancy can also persist .2) 6 and 12 months postpartum. Overall in our patients collective sFlt-1 is a trend-setting marker in PE, but it is not sufficient enough to predict persistent endothelial dysfunction and impairment of renal function.sFlt-1 levels are directly correlated with severity of PE and inversely correlated with time to onset of proteinuria and hypertension in preeclampsia patients . High sFNeither sFlt-1 and blood pressure nor prepartum proteinuria alone can predict the extent of renal impairment after delivery. sFlt-1 is indeed a trend-setting marker in PE. Particularly sFlt-1 values until 10000 pg/mL are sensitive to predicting a renal impairment after preeclampsia. Higher values are specific but without sufficient sensitivity. Further investigations are needed to evaluate the prediction of a persisting renal impairment after preeclampsia with angiogenic growth factor sFlt-1.Limitations of our study are the relatively low number of patients. In an analysis of 30 PE patients with low (<5 g/day) or high (>5 g/day) amounts of proteinuria, proteinuria itself was not correlated with kidney function parameters 5-6 years after pregnancy complicated by PE . We demo


Rationale. This paper describes the rationale and design of the SHEF-CSVD Study, which aims to determine the long-term clinical and radiological course of cerebral small vessel disease (CSVD) and to evaluate haemostatic and haemodynamic prognostic factors of the condition. Design. This single-centre, prospective, non-interventional cohort study will follow 150 consecutive patients with different clinical manifestations of CSVD  and 50 age- and sex-matched controls over a period of 24 months. The clinical and radiological course will be evaluated basing on a detailed neurological, neuropsychological and MRI examinations. Haemodynamic  and haemostatic factors  will be determined. Discussion. The scheduled study will specifically address the issue of haemodynamic and haemostatic prognostic factors and their course over time in various clinical manifestations of CSVD. The findings may aid the development of prophylactic strategies and individualised treatment plans, which are critical during the early stages of the disease. Effective therapeutic and preventive strategies in neurological diseases of the elderly are lacking. Cerebral small vessel disease (CSVD) is one of the most important and common vascular diseases of the brain. High morbidity rates are associated with CSVD; this disease leads to recurrent ischaemic and haemorrhagic strokes, gait disturbances, vascular dementia, and vascular parkinsonism , 2. The α, toll-like receptor 4, p-selectin, and C-reactive protein), nitric oxide release, and extracellular matrix   (n  (n 19] (orn = 50).  vascular dementia identified via the Modified Hachinski Ischemic Scale (score ≥ 7 points) and NINDS-AIREN  criteria , 21 (n =For CSVD patients:n = 50). age, sex, and vascular risk factors-matched control group without known neuropsychiatric disease , large (>1.5 cm) subcortical infarcts or any cortical infarcts, history of cardioembolic stroke risk factors  or carotid or intracranial artery stenosis ≥50% identified via ultrasound , 24,  lacunar stroke treated with thrombolysis or any other previous ischaemic or haemorrhagic stroke, severe neurological deficits , disturbed consciousness (NIHSS 1a ≥1), or severe dementia (MMSE < 12 points), requiring institutional care, psychiatric disorder interfering with cognitive testing or followup assessment , concomitant epilepsy, chronic heart failure (NYHA > II), malignant disease, and/or life expectancy of less than six months, significant visual and/or hearing impairment, MRI contraindications, such as claustrophobia, lack of reliable contact with study patients and their relatives during the study.Exclusion criteria for the study are This single-centre, prospective, noninterventional cohort study will follow 150 consecutive patients with different clinical manifestations of CSVD  and 50 age- and sex-matched controls over a period of 24 months. The study is designed to:(1) assess the long-term clinical and radiological course of CSVD, (2) evaluate haemostatic and haemodynamic prognostic factors that influence the clinical and radiological course of CSVD, primary goals:(3) compare the clinical and radiological course between groups with CSVD, as well as between the CSVD and control groups.secondary goal:All neurological, neuropsychological, and radiological assessments will be performed at baseline and at a 24-month followup examination. Baseline and followup assessments will be carried out by the same team of experienced investigators, who will be blinded to the clinical diagnosis of each subject.The primary outcome measures used in this study will be the observed changes in neurological status, cognitive function, gait/balance, and parkinsonian signs in addition to the progression of WMLs visualised via MRI. Secondary outcome measures that will be used are vascular-induced causes of death and the occurrence of dementia, depression and vascular events.It is planned to enroll eligible patients within 12 months of recruitment. The progression of CSVD will be assessed based on findings from the neurological, neuropsychological, and radiological examinations performed at the baseline and 24-month followup visits.2. The use of antiplatelet drugs, blood pressure-lowering medication, acetylcholinesterase inhibitors, and/or hypoglycaemic, hypolipaemic, and antiparkinsonian agents throughout the study will be recorded.All patients will undergo a clinical evaluation, which includes an interview of past medical history and physical examination. Vascular risk factor profiles, which include information related to hypertension, diabetes mellitus, coronary artery disease, hypercholesterolemia, peripheral vascular disease, smoking, and alcohol intake, will be recorded for all participants at baseline and followup. Hypertension is defined as the mean systolic blood pressure ≥140 mm Hg, mean diastolic blood pressure ≥90 mm Hg, or self-reported use of antihypertensive drugs . DiabeteHealth status as well as the presence and severity of disability will be assessed in all participants by the same two board-certified senior neurologists. The modified Rankin Scale (mRS) will be used to evaluate functional status, and the National Institutes of Health Stroke Scale (NIHSS) will be used to assess neurological impairment. To measure the ability to perform activities of daily living as well as disturbances in movement and gait, the Barthel Scale, the Unified Parkinson Disease Rating Scale (UPDRS), and the Berg Balance Scale will be used , 29. These neuropsychological tests were chosen to investigate executive function and other cognitive domains that are typically impaired in CSVD. Assessments of cognitive and executive abilities that have been standardised and psychometrically validated will be utilised. The entire battery of tests includes measures of global cognitive function  and various types of memory  –32. In aThe imaging protocol calls for multiple scan sequences, which include techniques performed at differing repetition and echo times . The protocol was designed to collect a series of T1-weighted images , T2-weighted images , fast fluid-attenuation inversion recovery (FLAIR) images , gradient-recalled echo (GRE) scans , and diffusion-weighted imaging (DWI) sequences . These sequences will be performed using a GE Healthcare 1.5 Tesla scanner, and the slice thickness for all images will be set to 5 mm with no intersectional gaps.The presence, number, and location  of various types of strokes will be recorded. Deep haemorrhagic strokes are defined as being in the late, subacute phase if hyperintense lesions on T1- and T2-weighted images are observed, or as being in the chronic phase if hypointensities are found on T1- and T2-weighted images. Lacunar infarcts are described as focal lesions between 3 and 15 mm in size, visualised as hyperintensities on T2 imaging, hypointense lesions on T1-weighted and hyperintense rim on FLAIR images. Scans from the imaging sequences will be assessed for subcortical and cortical infarcts (lesions ≥ 15 mm in size), microbleeds , and enlarged Virchow Robin spaces (dilated perivascular spaces that appear hypointense on T1 or punctate or linear hyperintensities on T2 images) , 42. DWIWhite-matter lesions, which are visualised on T2 and PD/FLAIR images as ill-defined hyperintensities ≥5 mm, will be evaluated. The ARWMC Scale and the Fazekas Scale are used to quantify the severity of these lesions because they take the location, pattern, and extension of WMLs into account  43–45].–45.43–45The complete set of baseline MRI variables of interest, which includes quantitative assessments of white-matter lesions, qualitative assessment of brain infarction, microbleeds, and cortical atrophy, will be compared with those obtained from followup MRI scans. Baseline and followup scans will be read independently and used to calculate change scores over time.BHT − MFVhyperventilation)/MFVrest]∗100, (2) breath holding index BHI = {[(MFVBHT − MFVrest)/MFVrest]/BHTT}∗100, and (3) vasomotor reactivity VMR = [(MFVACT − MFVrest)/MFVrest]∗100.Cerebral hemodynamic status is determined by assessing cerebral vasomotor reactivity (VMR) which provides information related to cerebral autoregulation and pulsatility indices (PIs); these indices reflect collateral circulation and increased vascular resistance that result from CSVD . An expeAssessments of carotid intima-media thickness and atheromatous stenosis of the extracranial arteries will be performed according to previously validated criteria by colour-flow B-mode Doppler ultrasonography  . Ischemia-induced brachial artery flow dilatation, which reflects endothelial function, will be assessed. The procedure for this technique includes ultrasound scanning of the brachial artery at rest (baseline), as well as during hyperaemia, which will be induced by 5 minutes of inflating and deflating a sphygmomanometer cuff placed around the forearm distal to the ultrasound site . Stress Twenty-four-hour ambulatory blood pressure (BP) monitoring (ABPM) will be performed using a portable noninvasive oscillometric and auscultatory device (Schiller MT-300). Measurements over a 24-hour period are recorded every 15 minutes during daytime hours (07.00 to 23.00) and every 30 minutes during nighttime hours (23.00 to 7.00). For recordings to be considered valid, a minimum of 15 daytime and 8 nighttime measurements is required. The mean 24-hour day and night systolic BP (SBP), diastolic BP (DBP), pulse pressure (PP), relative nocturnal dipping (SBP dipping), and mean heart rate will be calculated and recorded automatically. TCD and BP monitoring will be performed on the same day.For all participants, serum cholesterol, HDL, LDL, triglycerides, glucose, HbA1c, uric acid, and albumin levels will be assessed. Evaluation of the endothelial and thrombocyte functions include: hsCRP, ICAM 1, PAI-1, thrombomodulin, homocysteine, d-dimers, fibrinogen, IL-1, anticardiolipin antibody, vit.B12, MPV, PLT, and sP-selectin. These functions are measured with commercially available ELISA kits according to the manufacturer's instructions. μg/mL) . We will use the following aggregation agonists: arachidonic acid (AA), adenosine diphosphate (ADP), and thrombin receptor agonist peptide (TRAP), all of which are supplied by the manufacturer of the aggregometer. Blood for testing will be collected in the morning from fasting patients, and assays will be performed within 2 h of blood collection. Assessments of aggregation include evaluation of the area under the curve (AUC) of the aggregation plot, the degree of aggregation (AGR), and aggregation velocity (VAGR). Aggregation is determined twice in each sample, and the mean value is calculated if the two values differ by less than 10%. In the event that the values differ by 10% or more, the aggregation assays will be repeated.Platelet aggregation in whole blood will be evaluated with multiple electrode platelet aggregometry  . Blood iRetinal vessels can be visualised noninvasively and will be used to assess systemic vascular damage. The presence of retinal vessel abnormalities will be analysed using digitised fundus transparencies with a semiautomated system . After dTwo years after taking the baseline measurements, all participants will be contacted for prospective assessment of potential outcome events using the same instruments as at baseline visit including neurological , neuropsychological (full battery of previously described tests), and radiological (MRI) examinations. Recurrent strokes and/or death due to cardiovascular reasons will be noted. If these assessments cannot be administered in person, researchers will contact the patient or his/her caregiver via phone. The patient's functional state will be assessed according to the mRS in cases requiring a phone call. α value of 0.05 and a power of 0.8. Based on the hospital data set and estimated annual number of patients admitted due to CSVD we decided to establish unequal CSVD groups: with lacunar stroke (n = 50), vascular dementia (n = 50), deep hemorrhagic strokes (n = 25), and vascular parkinsonism (n = 25). Student's t-test and chi-squared tests will be used to make between-groups comparisons of continuous and categorical variables. Log-transformations will be used to correct for nonnormality of the data. Demographic data, vascular risk profiles, and hemodynamic data of the study groups will be compared by Student's t-test and ANOVA. The degree of neurological improvement or deterioration will be assessed via comparing the baseline and followup results. Pearson's correlation coefficients and ANOVA will be used to correlate haemodynamic data and neurological status at baseline and followup time points. The association between WML severity and haemodynamic and haemostatic data and cognitive, motor, and balance function will be assessed using linear regression models. Changes in MRI parameters neuropsychological and neurological data between the 2 time points will be assessed via paired t-tests for parametric data or the Wilcoxon signed-rank test for nonparametric data. Percent difference for each of the parameters will be calculated. Multivariate analysis that is adjusted for potentially confounding subject-relevant variables  will be performed to determine which haemostatic and haemodynamic factors are most useful measures of association to predict changes in neurological status, neuropsychological function, and severity of WMLs at baseline and followup.Recent studies demonstrated a high rate of WMLs progression (36%–75%/3 years) detected with repeated MRI even in otherwise healthy older populations . AdvanceDespite conceivable advances in our understanding of the natural history of WMLs over the past few years, several research questions need to be resolved. Numerous studies have shown that WMLs are related to vascular risk factors. The exact diagnosis of CSVD is, however, still not well known and requires systematic evaluation of potentially relevant clinical and other phenotypic features. It has been suggested that a prothrombotic state and endothelial activation are possible causal factors but recent neuropathology study did not confirm that relation –63. It i


In Africa and Asia hair dye is applied together with henna to decorate the hands and feet. Paraphenylene-diamine (PPD), a highly toxic constituent of hair dye can lead to acute kidney injury (AKI).A cohort study was conducted during the period from April 2012 to March 2013 in Khartoum Teaching Hospital, Sudan. It targeted adults presenting acutely with an evident history and clinical features of hair dye poisoning, together with AKI as per the RIFLE criteria. Analysis of data was done using SPSS.30 adults were included, their mean age was 25.6 ± 4.2 years, 93.3% were females. Exposure to PPD was suicidal in 86.7%. The mean duration to onset of renal symptoms was 34.8 ± 7.6 hours, maximum median serum creatinine was 8.6 ± 2.3 mg/dl, 86.7% had loss of kidney function as per the RIFLE classification and required dialysis. Initial renal recovery was seen after a mean duration of 9.8 ± 2.2 days. One patient died, 3.3%; all others, 96.7%, recovered normal kidney function. The amount of ingested PPD correlated significantly to the severity of symptoms, number of dialysis sessions required and time for renal recovery with P values < 0.05.Hair dye poisoning was associated with prolonged hospital stay, requirement of dialysis and increased morbidity. The severity of symptoms directly correlates to the dose of PPD ingested, with the kidney damage being reversible in almost all survivors. Lawsonia inermis). The combination, Black henna, is applied as a temporary tattoo to decorate the hands and feet in special social events such as wedding ceremonies [In Africa and Asia hair dye is applied by women as a cosmetic agent together with henna, leaves of a non-toxic herb . Descriptive analysis was done for all variables. Variables were expressed as percentages, means and / or medians with standard deviations. Comparison of data was done using the Student′s t test for continuous variables and Fisher′s exact XDuring the period from April 2012 to March 2013 a total of 30 adult Sudanese patients were admitted to Khartoum Teaching Hospital Emergency Department with hair dye poisoning and PPD induced AKI as per the inclusion / exclusion criteria set. All patients were using the same commercial brand of hair dye. The mean age of the study population was 25.6 ± 4.2 years, the majority were females, 93.3%, two-third of patients were having a secondary high school education level, 60% were unmarried, 43.3% unemployed and 26.7% were housewives. Exposure to PPD was via the oral route in all patients, 100%. Reasons for ingestion were a suicidal attempt in 86.7%, accidental in 10% and a suspected homicide in 3.3% .The mean duration from time of exposure to the appearance of renal symptoms was 34.8 ± 7.6 hours; these were mostly in the form of reduced urine output and the passage of dark chocolate brown urine seen in 90% and 76.7% of patients, respectively. Angioneurotic edema was seen in 53.3% of patients with emergency tracheostomy being done in all of them. All patients had normal echocardiographic studies despite that cardiac arrhythmias were documented in 40%.As per the AKI RIFLE classification most patients, 86.7%, had loss of kidney function and required dialysis therapy. In 73.3% of patients serum creatinine peaked to more than 10 mg/dl, with the maximum median serum creatinine for all patients being 8.6 ± 2.3 mg/dl. Dialysis replacement therapy was indicated in 86.7%, with only 13.3% of patients being treated conservatively. Indications for dialysis were mostly oliguria with rising blood urea of more than 200 mg/dl, uremic encephalopathy and pulmonary edema in 63.3%, 13.3% and 10% of patients, respectively. The average number of hemodialysis sessions required was 5 ± 1 sessions. Intradialytic complications in the form of hypotension and hypoglycemia were evident in 10%. Initial signs of renal recovery were seen after a mean duration of 9.8 ± 2.2 days. Overall, 96.7% of patients recovered normal kidney function, whereas 3.3% died. None of the study patients developed end-stage renal disease .Among the study group the dose of PPD ingested correlated significantly to the severity of symptoms in the form of occurrence of pulmonary edema, cardiac arrhythmias, high serum creatinine levels at presentation, requirement of dialysis therapy, number of dialysis sessions required and duration to onset of renal recovery; P values being less than 0.05 . FurtherHair dye poisoning had been repeatedly reported as an important cause of suicide and para-suicide, with various case series being described from East Africa, the Middle East and the Indian subcontinent , 15–19. Hair dyes contain PPD at various concentrations ranging from 0.2% to 3.75%. It is PPD, the toxic ingredient causing laryngeal edema, rhabdomyolysis, severe metabolic acidosis and AKI following hair dye poisoning . All patRenal involvement post hair dye poisoning can be transient and pass unnoticed; again it can be severe enough to necessitate dialysis , 21. In Hair dye poisoning had been widely reported in Sudan with the majority of patients being young females. Most of those who develop developed AKI require dialysis. The condition is associated with multisystem involvement, prolonged hospital stay, requirement of dialysis therapy, increased morbidity and a high risk of death due to angioneurotic edema and cardiac arrhythmias. The severity of symptoms was directly related to the dose of PPD ingested.


The aim of this study was to investigate the effect of intravitreal anti-vascular endothothelial growth factor (VEGF) injection on intraocular pressure (IOP) and mean ocular perfusion pressure (MOPP).MOPP results were obtained by measuring mean arterial pressure (MAP) and IOP just before the injection, immediately after the injection, at 30 min, 1 day, and 1 week after injection from 65 eyes of 42 patients.Pre-injection mean IOP was 16.66 ± 3.50 mmHg, and mean IOP was 43.81 ± 9.69 mmHg immediately after the injection, 17.57 ± 4.44 mmHg at 30 min, 15.00 ± 4.21 mmHg at 1 day, and 15.90 ± 3.63 mmHg at 1 week after the injection. Pre-injection mean MOPP was 46.39 ± 5.78 mmHg, and mean MOPP was 25.14 ± 8.79 mmHg immediately after the injection, 45.87 ± 6.31 mmHg at 30 min, 46.93 ± 6.25 mmHg at 1 day, and 46.50 ± 4.94 mmHg at 1 week after the injection.The instant increase in IOP by intravitreal anti-VEGF injection led to a transient decrease in MOPP. Based on this finding, the instant increase in IOP after intravitreal anti-VEGF injection does not significantly impair retinal blood flow. Intravitreal injection is an excellent method for delivering drugs for various vitreoretinal diseases, the incidences of which are increasing globally every year. Various vitreoretinal diseases such as choroidal neovascularization due to exudative age-related macular degeneration, diabetic macular edema, and macular edema due to retinal vein occlusion are treated with anti-vascular endothelial growth factors (VEGF) such as ranibizumab (Lucentis®) and bevacizumab (Avastin®). Thus, expansion of the use of intravitreal anti-VEGF is expected.The volume of the intravitreal injection can directly increase the intraocular pressure (IOP) and thereby negatively affect the retinal and optic nerve blood supply. Animal experiments show that an acute rise in IOP blocks axonal transport to the optic nerve head, and damage to the optic nerve is directly proportional to the rise in IOP . An acutThere are many reports about safe levels of an increase in IOP after intravitreal anti-VEGF injection –7. StudiAvastin®  is a drug used off-label for intravitreal treatment of various retinal diseases. A previous report on the levels of post-injection IOP demonstrated that intravitreal Avastin causes a volume-related increase in IOP that does not occlude the central retinal artery. The IOP fell below 30 mmHg in all selected eyes within 15 min [Although previous studies focused on the rise in post-injection IOP, substantially the entire blood supply of the retina and optic nerve head is affected by ocular perfusion pressure, which means that ocular perfusion pressure is more important than IOP. Mean ocular perfusion pressure (MOPP) is defined as the difference between the mean ophthalmic artery pressure and IOP . ClinicaA volume-related IOP increase due to intravitreal anti-VEGF injection will decrease the MOPP and negatively affect the retina and optic nerve head blood supply. The purpose of this study was to analyze the short-term change in IOP and MOPP after intravitreal anti-VEGF injection, and to evaluate the safety of the procedure.This study was a prospective case series of consecutive patients undergoing intravitreal injection of anti-VEGF at the Eulji Medical Center, Seoul, Korea from October 2011 to November 2011. Patients were asked to participate if they were over 20 years of age and were able to have a regular follow-up. To maximize generalizability, exclusion criteria were kept to a minimum. Patients who had intravitreal injections of triamcinolone acetonide any time up until 6 months prior to the study, patients with active uveitis or ocular ischemic syndrome, and diagnosed with any type of glaucoma were excluded from selection. According to these exclusion criteria, 103 eyes of 67 patients were excluded from a total 168 eyes of 109 patients. But the patients participating in this study would have undergone anti-VEGF intravitreal injection even if they had not been enrolled.The prospective clinical study was approved by the Institutional Review Board (IRB)/Ethics Committee at the Eulji Medical Center of Eulji University, Seoul, Korea. Informed consent was obtained from each patient prior to participation in the study. All procedures conformed to HIPAA regulations and the Declaration of Helsinki for research involving human subjects.Before intravitreal injection, patients signed a standard informed consent form describing the potential risks and benefits of the procedure and consecutive management, which included IOP and blood pressure measurements.The following basic tests were made on every subject before going to operation room for intravitreal injection: (1) best corrected visual acuity and IOP, (2) blood pressure, (3) slit-lamp examination. Patients who had one of the following conditions underwent the delayed procedure: (1) systolic blood pressure (SBP) over 140 mmHg, (2) diastolic blood pressure (DBP) over 90 mmHg, and (3) IOP over 30 mmHg.Intravitreal injections were performed by one surgeon (Young Gyun Kim) using aseptic techniques in an operating room at an outpatient ophthalmology clinic. Patients were prepared and draped in a standard fashion and positioned supine for the procedure. After applying topical proparacaine for anesthesia, a lid speculum was used for lid control, and the eyeball was sterilized with a solution of 5 % povidone–iodine and irrigated with sterile BSS. Intravitreal injection of Avastin  or Lucentis  was injected with a 30-guage needle through the inferotemporal or inferonasal pars plana 3.5 mm posterior to the limbus. The needle was inserted approximately 1.0 cm into the globe, and the injection was performed. After injection, a sterile cotton swab was placed on the injection site to prevent reflux of the medicine or vitreous.MBP and IOP values were obtained at baseline, immediately after the injection, and at 30 min, 1 day, and 1 week after injection. The MBP of the brachial artery was measured with an automatic sphygmomanometer with the patient in the sitting position, and the IOP was measured in the same position with an Icare® PRO rebound tonometer model  by the same examiner. MOPP was measured using the following formula . MOPP = t-test. Variable factors that can affect IOP and MOPP after intravitreal injection—the difference in dosage  and the presence of post-injection vitreous regurgitation—were set and each group was analyzed using the Student’s t-test.Statistical tests were performed using SPSS software version 14.0  The baseline values and individual values of IOP and MOPP at each time-point were analyzed using a paired The data for 65 eyes of 42 patients were included in this analysis. Table Figure p < 0.001). Only the MOPP immediately after the injection was significantly different from the pre-injection MOPP value .Only the IOP immediately after injection was significantly different from the pre-injection IOP .In addition, the patients were divided into two groups according to the injection type (0.05 mL Avastin or 0.07 mL Lucentis) and their IOP and MOPP values immediately after injection were analyzed. We also evaluated the presence of post-injection vitreous regurgitation. The mean IOP of the Avastin group was 41.72 ± 9.74 mmHg and that of the Lucentis group was 45.15 ± 9.65 mmHg. The mean MOPP of the Avastin group was 26.81 ± 8.68 mmHg and that of the Lucentis group was 24.27 ± 8.51 mmHg. IOP and MOPP values were not significantly different between the Avastin group and Lucentis group (Table p > 0.05).Mean IOP was 39.92 ± 9.12 mmHg in the group with post-injection vitreous regurgitation and 44.68 ± 9.27 mmHg in the group without post-injection vitreous regurgitation. Mean MOPP was 28.83 ± 9.56 mmHg in the group with post-injection vitreous regurgitation and 24.48 ± 8.27 mmHg in the group without post-injection vitreous regurgitation. Post-injection vitreous regurgitation did not significantly change mean MOPP and IOP  and by the presence of post-injection vitreous regurgitation. These variables, however, had minimal effects on the difference in post-injection IOP and MOPP Tables , 5. ThisIn designing this study, it was predicted that the stressful situation of intravitreal injection would increase the MBP, resulting in an attenuation of the decrease in MOPP. Evaluation of serial changes in MBP revealed that pre-injection mean BP was 95.39 ± 9.16 mmHg and mean MBP immediately after the injection, and at 30 min, 1 day, and 1 week after the injection was 104.28 ± 8.92 mmHg, 95.93 ± 9.39 mmHg, 93.57 ± 8.54 mmHg, 94.27 ± 7.48 mmHg, respectively. Compared to the pre-injection MBP, MBP immediately after the injection increased by 9 mmHg, equivalent to the 6 mmHg increase in MOPP. Consequently, the rise in MBP right after the intravitreal Avastin or Lucentis injection can be considered to have a protective effect against the decrease in post-injection MOPP.p > 0.05).A previous report by Rasier et al. revealed an increase in blood pressure, which was checked 1 week, 3 weeks, and 6 weeks after intravitreal Avastin injection . Rasier In conclusion, Most eyes in our study achieved normalization of IOP and MOPP within 30 min without need for any immediate intervention, such as paracentesis. Additionally, the decrease in MOPP caused by the increase in IOP did not induce an extremely low pressure level (< 10 mmHg). Based on these findings, the instant increase in IOP after intravitreal anti-VEGF injection does not cause a significant decrease in the blood flow of the retina and optic nerve head. Therefore, except for patients with glaucoma, uveitis, which can cause impaired ability of IOP regulation, repeated or prolonged IOP monitoring for normalization of IOP after intravitreal anti-VEGF injections is not necessary.VEGF, vascular endothothelial growth factor; IOP, intraocular pressure; MOPP, mean ocular perfusion pressure; MAP, mean arterial pressure; MBP, mean blood pressure; DME, Diabetic macular edema; PDR, proliferative diabetic retinopathy; AMD, age-related macular degeneration; RVO, retinal vein occlusion; CSC, central serous chorioretinopathy; CNV, choroidal neovascularization.


In 2013 the World Health Organization deemed hypertension as a global crisis as it is the leading risk factor attributed to global mortality. Therefore, there is a great need for effective alternative treatment strategies to combat a condition that affects 40% of adults worldwide. Recently, the FlaxPAD Trial observed a significant reduction in systolic and diastolic blood pressure in hypertensive patients with peripheral arterial disease that consumed 30 g of milled flaxseed per day for one year. However, these patients were already on anti-hypertensive medication. Therefore, there is a need to assess if dietary flaxseed can effectively reduce blood pressure in the absence of peripheral arterial disease and anti-hypertensive medication in newly diagnosed hypertensive patients.The HYPERFlax Trial is a parallel, superiority, phase II/III, randomized, double-blinded, controlled clinical trial. St. Boniface Hospital and the Health Sciences Centre of Winnipeg, Canada, will recruit 100 participants newly diagnosed with stage 1 hypertension who have yet to be administered anti-hypertensive medication. Participants will be randomly allocated with a 1:1 ratio into a flaxseed or control group and provided food products to consume daily for six months. At baseline, two, four, and six months, participant assessments will include the primary outcome measure, averaged automated blood pressure, and secondary measures: 24-hour food recall, international physical activity questionnaire, anthropometrics, and blood and urine sampling for biochemical analysis. Plasma will be assessed for lipids, metabolomics profiling, and molecules that regulate vascular tone. Urine will be collected for metabolomics profiling. With an estimated dropout rate of 20%, the trial will have a power of 0.80 to detect differences between groups and across time, out of an effect size of 0.7 (SD) at an α level of 0.05.This trial will determine if dietary flaxseed is efficacious over six months as an anti-hypertensive therapy in subjects newly diagnosed with hypertension. If flaxseed can effectively reduce blood pressure as a monotherapy, then flaxseed will provide individuals on a global basis with a cost-effective food-based strategy to control hypertension.NCT01952340, Registered 24 September 2013. In 2013 the World Health Organization highlighted that high blood pressure is a global crisis [Dietary interventions have been suggested as a preferential complimentary strategy to current pharmacological strategies to control blood pressure . FlaxseeIn humans, patients with peripheral arterial disease (75% hypertensive) were administered 30 g of milled flaxseed per day for six months . FlaxseeDespite the significant anti-hypertensive effects demonstrated in the FlaxPAD trial, the results contained some important limitations. Firstly, participants of the FlaxPAD trial were already on anti-hypertensive medication yet still exhibited poorly controlled blood pressure . TherefoThe hypothesis to be tested in the present study is: dietary flaxseed will reduce blood pressure in patients with newly diagnosed hypertension and will reduce the need for anti-hypertensive medication. In order to test these hypotheses, a phase II, randomized, double-blinded, controlled clinical trial called HYPERFlax has been designed. The acronym for the HYPERFlax trial stands for the anti-HYPERtensive effects of dietary Flaxseed. Parameters such as blood pressure, plasma and urine metabolomics, plasma lipid profiling, and plasma vascular tone regulators will be analyzed to assess the efficacy and mechanisms of action of dietary flaxseed in hypertension management.The aims of the HYPERFlax trial are to:1. determine if consuming 30 g of milled flaxseed daily can effectively reduce blood pressure over six months in newly diagnosed stage 1 primary hypertensive participants;2. determine if dietary flaxseed is efficacious as a monotherapy;3. determine if flaxseed can reduce the need for anti-hypertensive medication; and4. identify the mechanisms of action responsible for the potential anti-hypertensive effects of flaxseed.The HyperFlax trial is a parallel, phase II, randomized, superiority, double-blinded, controlled study with an allocation ratio of 1:1. The participants, study coordinator , nurse, overseeing medical doctor (Dr Brian Penner), principal investigator (Grant Pierce), and researchers will be blinded to the group designation. One individual that dispenses the food products will be aware of the group designation. The trial sponsor is St Boniface Hospital. The trial has received approvals from the Health Canada Natural Health Products Directorate (#192282), the University of Manitoba Research Ethics Board (B2013:079), the St Boniface Hospital Research Review Committee (RRC/2013/1324), and the Health Sciences Department of Research (R12014:048). The trial is registered at clinicaltrials.gov (NCT01952340).The trial will take place at the Health Sciences Centre Hospital and St Boniface Hospital in Winnipeg . The aim is to enroll 100 participants. Based on the previous FlaxPAD trial  the expeInclusion criteria includes:1. stage 1 essential hypertension (average automated systolic blood pressure of 135 to 160 mmHg or diastolic blood pressure of 85 to 100 mmHg) ;2. Newly diagnosed; defined as being clinically diagnosed within the last six months. This includes being diagnosed at the screening examination;3. Male or female;4. Untreated by medications for hypertension;5. 18 to 85-years-old and able to provide informed consent;6. Females who are not pregnant and not planning on becoming pregnant during the course of the trial. A pregnancy test will not be administered for the trial;7. Subjects who are receiving anti-platelet therapy must be on a stable dose for three months prior to the study;8. Subjects who are receiving lipid-lowering drugs must be on a stable dose for three months prior to the study;9. Subjects must have access to freezer space in their residence to hold up to one month of the frozen food products associated with this study.Exclusion criteria includes:1. Patients with ischemic pain at rest in limbs, ulceration, or gangrene.2. Patient has undergone percutaneous coronary angioplasty, or has had coronary bypass within the last six months.3. Known secondary hypertension of any etiology.4. Patients with confirmed and clinically significant renal or hepatic abnormalities  two to three times the rate, ALT  > more than two to three times the normal consentration) and/or electrolyte imbalance serum K (potassium) + <3.5 or >5.5 mM;5. History of major bleeding;6. Patients with diabetes mellitus, bowel disease , or other diseases such as active systemic lupus erythematosus, cancer, or end-stage respiratory disease;7. Patients with macrovascular target organ damage, including cerebrovascular disease, stroke, dementia, hypertensive retinopathy, left ventricular dysfunction, myocardial infarction, renal disease, and peripheral artery disease;8. Patients with clinical evidence of heart failure or an estimated life expectancy of less than two years or with a high baseline cardiac risk ;9. Subjects that are on supplements other that those prescribed by their clinician for the entire duration of the study. Please see point 10 below;10. Subjects ingesting more than two servings of fish per week, taking omega-3 fatty acid supplements, and/or consuming milled flaxseed or flax oil on a regular basis . If the participant is willing, a four-week washout period eliminating these supplements may be allowed before entry into the trial;11. Patients who have participated in an investigational drug program in the proceeding 30 days or who are unable or unwilling to comply with the protocol;12. Subjects with allergies to any ingredient in the study product or placebo (including gluten);13. Patients who will undergo surgery or intend to move outside Winnipeg during the trial period.Interested individuals will contact the study coordinator by telephone, upon which a pre-screening will be conducted to exclude participants based on the criteria above that can be determined over the phone. If the first criteria are met, a meeting will be scheduled to go through the consent and a secondary screening process will take place. Each participant will provide informed consent before the secondary screening process takes place. The study coordinator will again go through the exclusion and inclusion criteria to see if the participants are eligible for the study. Next, all study details will be outlined and the participants will be given a chance to ask any questions. If they consent to the study, the participant’s blood pressure will be measured six times within 10 to 15 minutes using a BPTru automated blood pressure machine BPTru, Coquitlam, BC, Canada to test if the participant has elevated blood pressure and meets the study criteria. The healthcare professional will also perform a brachial blood pressure measurement with a sphygmomanometer BPTru, Coquitlam, BC, Canada as is standard procedure at the doctors’ office. At this time, they will also see the lead medical doctor, Dr Brian Penner, at the hypertension clinic at the Health Sciences Centre for an examination to exclude any macrovascular target organ damage. If the participants meet the inclusion and exclusion criteria they will be notified by telephone of their acceptance into the trial if they still choose to participate. Figure Upon acceptance into the trial all participants will be provided information on lifestyle management of hypertension. These strategies include the dietary approaches to stop hypertension, limiting alcohol and salt intake, limiting or stopping cigarette smoking, increasing physical activity, and losing weight if the individual is overweight or obese. However, it is not mandatory to adopt these lifestyle changes to be eligible for the trial.Immediately after the baseline assessments, subjects will be randomized to one of two possible groups by a non-restricted computer-generated randomization schedule. The allocation ratio will be 1:1. The study coordinator will enroll the participants and the individual in charge of food delivery will be in charge of participant allocation. The allocation order will be in sequential, opaque, sealed envelopes. At this point all those involved in the study will be blinded to the group allocation excluding the individual responsible for food delivery.The participants will be provided either the control or flaxseed-containing food products such as muffins, bagels, snack bars, and milled seeds to consume once a day for six months. A variety of flavors will be provided to assure the participants do not tire of the foods. In addition, participants will be encouraged to remain in the study and be adherent by describing to them the importance of their contribution to identifying new treatment strategies for hypertension. The control food products will contain a combination of wheat, pecans, and/or mixed dietary oils to replace the flaxseed. This combination of ingredients for the control food product will and has allowed for the best concealment and ability for a blinded trial. The formulation and flavor profiling of the flaxseed food products has been previously published ,11.The primary outcome measure is blood pressure. Blood pressure will be measured at a total of five visits: screening, baseline, two, four, and six months. A BPTru machine will be utilized to measure blood pressure six times within 10 to 15 minutes. The first reading will be discarded and the remaining five will be averaged. This measurement will take place in a quiet room while the participant is in a seated position and arm rested on an arm rest at heart level. A blood pressure reading with a sphygmomanometer and stethoscope will also be performed to ensure the congruency between this measurement and the automated measurement.One of the secondary outcome measures is the need for anti-hypertensive medication. In the first two months of the trial the participants will not be prescribed anti-hypertensive medication as this is the lifestyle intervention period. A meta-analysis published in 2008 concluded the administration of a placebo to patients with hypertension for four to eight weeks provided no objective reason against safety . At two,The secondary outcome measures also include anthropometrics, food intake, and physical activity. At baseline, the participants will be asked to fast (9 to 12 hour overnight fast) for blood and urine collection. The blood and urine will be analyzed utilizing techniques including metabolomics and lipid profiling. Biological specimens will be coded with an anonymous patient code and locked in a -80°C freezer. Height, weight, and waist circumference will be measured and body mass index (BMI) will be calculated to assess if the intervention may cause any changes in weight or waist circumference. They will also be asked to fill out a 24-hour food recall form with the study coordinator using the multiple-pass method as established by the United States Department of Agriculture  and the The secondary analysis will include the biochemical analysis of plasma or blood. Biochemical analysis also will be performed to determine potential anti-hypertensive mechanisms of action and adherence to intervention. Plasma samples from baseline, two, four, and six months will be analyzed for lipid profiles, metabolomics profile, and for any circulating plasma component that may influence blood pressure regulation. Plasma analysis of alpha-linolenic acid and enterolignans will act as adherence markers. Urine samples from baseline, two, four, and six months will also be analyzed for metabolomics profiling.post-hoc comparison of the least squared means with a Tukey’s adjustment will be utilized to determine where the specific differences lie. Absolute change will also be calculated only for participants who provide clinical information and samples at all time points. Absolute change can be analyzed with one way analysis of variance (ANOVA) and the Kruskal-Wallis test, or multiple t-tests and the Mann Whitney U test with a false discovery rate correction. Multiple regression may be used to determine the influence of flaxseed on blood pressure while including factors such as age, BMI, gender, diet, or physical activity. Correlations will be utilized to determine relationships between biochemical markers and blood pressure. Subgroup analyses may also be performed, for example, the dichotomization of change in biochemical markers and observing subsequent change in blood pressure. All statistical tests will be set at a significance level of 0.05. Data will be published in peer-reviewed journals and discussed in public forums such as radio and television broadcasts.All data will be stored without identifiable participant information in a password protected electronic document or locked cabinet. The final trial data set will be accessible only to researchers involved in the trial and any medical review board that requires access for safety purposes. In the likelihood of an unbalanced data set, absolute values will be analyzed with a mixed two-way repeated measures model with group and time as the between and within factor, respectively. A No adverse effects are expected based upon published literature and our past experience with dietary flaxseed supplementation for one year . FlaxseeDue to the ability of flaxseed to increase stool bulk and frequency of defecation, patients with a history of bowel obstruction, irritable bowel syndrome, or diverticular disease will be excluded. When large amounts of dietary fibre are consumed, gastrointestinal discomfort may occur. Results from our lab have indicated that the gastrointestinal discomfort and flatulence disappear within a few weeks once the participants have become accustomed to the fibre load. In addition, the gradual addition of flaxseed or wheat and wheat bran (control) throughout the first month allow the participants to become easily accustomed to the increase in fibre intake.However, adverse events, as identified by the World Health Organization scale, will be followed up on if medically indicated, with relevant laboratory investigations under the direction of the study medical monitor. At this point, the medical board independent from the sponsor will be unblinded to the participant group allocation. Research staff will record the final outcome and the resolution date of the event wherever possible. If deemed necessary, the medical board will have the final say if the trial should be ended.All serious adverse events  will be reviewed by the medical monitor within 24 hours of becoming aware of the events. The monitor will notify the Ethics Review Board within 7 to 14 days of the event. The University of Manitoba and St Boniface Hospital have research ethics boards that review all clinical trials for safety and ethical considerations. Health Canada, the University of Manitoba, or St Boniface Hospital may conduct audits at random to ensure adherence of guidelines. If any changes are required to be made to the protocol the above parties will be notified.The HyperFlax trial will be the first study to investigate flaxseed as a therapeutic strategy for the reduction and management of blood pressure in patients newly diagnosed with hypertension who are yet to receive anti-hypertensive medication. Dietary flaxseed can reduce blood pressure in peripheral arterial disease patients already taking anti-hypertensive medication . TherefoThe trial has received approval from the Health Canada Natural Health Product Directorate, the University of Manitoba Research Ethics Board, the St Boniface Hospital Research Review Committee, and the Health Sciences Department of Research. Participant recruitment will start as early as April 2014.ALA: Alpha-linolenic acid; BMI: Body Mass Index; FlaxPAD: Flaxseed for peripheral arterial disease; HYPERFlax: Anti-HYPERtensive effects of dietary Flaxseed; ANOVA: Analysis of Variance.The authors declare they have no competing interests.SPBC, BP, and GNP designed the trial and are responsible for conducting the trial. SPBC and GNP wrote the manuscript. GNP has final responsibility for all content and all authors have approved the final manuscript.


Renal disease is a known contributor to mortality in adults with sickle cell disease (SCD) and renal abnormalities are evident in childhood. Hyperfiltration  occurs in children with SCD early in disease. However, the incidence of low GFR (<90 ml/min/1.73 m2) suggestive of chronic kidney disease (CKD), is not well established. The prevalence of hypertension is also not well known. The goal of this study was to determine the prevalence of hypertension and CKD in a cohort of children with SCD.We performed a retrospective chart review of patients followed at the Rainbow Babies and Children’s Sickle Cell Disease Clinic who were seen during routine follow up visits. Inclusion criteria were all patients ages 3–18. Exclusion criteria included recent (within 2 weeks) hospitalization and/or episode of acute chest, pain crises, febrile illness or red blood cell transfusion. Data collected included serum creatinine, blood pressure and history of sickle cell complications . Estimated GFR (eGFR) was calculated using the updated Schwartz creatinine-based estimating formula. Analysis examined the associations among eGFR, blood pressure and sickle cell complications. The Institutional Review Board at University Hospitals Case Medical Center approved this study.2 +/- 34.9 (range 71.9-404.2 mL/min/1.73 m2). Four patients (8.3%) had eGFRs < 90 mL/min/1.73 m2, 35 patients (72.9%) had eGFRs > 120 mL/min/1.73 m2 and 9 patients (18.8%) had eGFRs in the normal range. Eight patients (16.7%) had evidence of elevated blood pressures (pre-hypertension or hypertension). There was no correlation between eGFR and age, and no association of eGFR with acute chest or stroke risk.A total of 48 children had complete data available. Mean eGFR was 140 mL/min/1.73 mIn this SCD cohort, we identified abnormally low eGFR (suggestive of early CKD) in 8.3% of patients and elevated blood pressure in 16.7%. These findings are in contrast to other published studies that show primarily normal or elevated GFR and the absence of or minimal hypertension. These findings indicate that elevated blood pressure and decreased eGFR are not uncommon in children with SCD, and should be more rigorously studied. Chronic kidney disease (CKD) in patients with sickle cell disease (SCD) is a risk factor for early death. This mortality association is stronger than that of an episode of the acute chest syndrome, febrile episode with positive blood culture, acute stroke, right upper quadrant syndrome, or severe acute anemia . RetrospRenal consequences of SCD are evident in early life, and can involve multiple segments of the nephron. Impaired urine concentrating ability is almost universally present early in childhood. Hematuria and overt papillary necrosis can develop as a result of medullary ischemia -10. GlomBecause the survival rate of SCD patients is increasing, CKD will likely play a greater role in morbidity and mortality in the future. Characterizing the early kidney disease phenotype will be important in designing clinical trials. The goal of this study is to describe the prevalence of hypertension and abnormal renal function in a well-characterized group of children with SCD.This study was approved by the Institutional Review Board at University Hospitals Case Medical Center.We retrospectively reviewed records of children ages 3–18 years actively receiving care at the University Hospitals- Rainbow Babies and Children’s Pediatric Sickle Cell Clinic between March 2010- January 2011. Data obtained from the most recent well outpatient visit included age, gender, height, blood pressure, and serum creatinine concentration. Blood pressure measurements reflect a single seated oscillometric measurement obtained during clinic vital sign assessments using a Dynamap® device. The serum creatinine was the most recent one obtained during a routine outpatient visit. Because serum creatinine can be affected by hydration status and/or medication use  in the context of an acute illness, the value utilized was one that was obtained at least 2 weeks after an acute illness.Sickle cell genotype was identified from the patient record, determined by hemoglobin electrophoresis or high-performance liquid chromatography (HPLC). We also collected historical information regarding the occurrence of two severe sickle cell complications: (1) acute chest syndrome (ACS); and (2) stroke or high risk for stroke as identified by trans-cranial Doppler screening . PatientRenal function was assessed by determination of eGFRs calculated using the updated “bedside” Schwartz equation:This formula, which utilizes standardized serum Isotope Dilution Mass Spectrophotometry (IDMS) traceable creatinine measurements has been validated in pediatric patients with and without CKD using measured glomerular filtration methodologies (iohexol clearance) -18. All Pearson correlation coefficients were used to determine the correlation between eGFR and age and systolic and diastolic blood pressure percentiles. The association between eGFR and the presence of clinical events including ACS, high stroke risk based on trans-cranial Doppler velocity screening, and genotype was determined using distributionally appropriate two-sample tests .Data from 48 patients were included in this analysis. Demographics, clinical characteristics, and measurements are shown in Table 2 +/- 34.9 (range 71.9- 404.2). Four patients (8.3%) had eGFR below the normal range (<90 mL/min/1.73 m2), suggestive of CKD. Conversely, 35 patients (72.9%) had eGFR above the normal range (>120 mL/min/1.73 m2). A total of 8 patients had elevated blood pressures. Pre-hypertension was present in 4/48 (8.3%) and overt hypertension was present in 4/48 (8.3%) of patients. The characteristics of the patients in the low eGFR, normal or elevated eGFR, elevated BP, and non-elevated BP are summarized in Table Mean eGFR was 140 mL/min/1.73 mThere was no significant correlation between eGFR and age or blood pressure. eGFR was not associated with gender, genotype, or the presence or absence of acute chest history or stroke risk.2) were noted in 8.3% of our population, a cohort with a mean age of 12.5 years. This finding is contrary to some published reports which have suggested CKD is a later finding [The results of this study demonstrate the presence of abnormal kidney function (eGFR > 120 or <90 ml/min/1.73 m2) in a significant proportion of the study population. The majority of these 35/48) had elevated eGFR consistent with hyperfiltration. This finding is consistent with previous published reports in SCD. In contrast, low eGFR values  provide accurate results comparing favorably with inulin clearance and does not require timed urine collections [Taken together, our data and that of others suggest that abnormally low GFR is not an uncommon problem for children with SCD, and renal function should be assessed routinely in these patients. However, determining the optimal method for assessing renal function in the clinical setting as well as frequency of monitoring can be problematic. Quantification of inulin clearance in a timed urine collection is considered the “gold standard” measurement of GFR. However, this method is technically demanding, requiring bladder catheterization and 24 hour urine collection ,24. Nucllections -28. HowePediatric patients with SCD have typically been thought to have low normal blood pressures. In a study of 85 children, Aygun et al.  identifiAlthough rates of hypertension are high in patients with CKD, we were unable to demonstrate a correlation between eGFR and systolic or diastolic hypertension in our population. This lack of correlation may have been due to the relatively small number of patients with CKD. However, it does suggest that hypertension is present in this population in the absence of clear evidence of renal dysfunction.Our study had several important limitations. These included a relatively small sample size, and the retrospective design. Utilization of data obtained during routine clinical practice and abstracted from retrospective chart review imposed significant constraints. Blood pressure measurements recorded at each visit were collected according to the standard clinical practice, and not in accordance with approved methodology . BecauseOne important additional limitation is the absence of data on albumin excretion. Albuminuria has been shown to be an early marker for pathology in various kidney diseases. Other investigators have demonstrated that albuminuria may be an important early marker of kidney disease in children with SCD, with Yee, et al. demonstrating prevalence rates of 20.7% . Among 9In addition to albuminuria, multiple investigators are pursuing novel candidate biomarkers that are not currently used in common clinical practice. Urinary levels of renal kallikrein, ,37 transIn conclusion, the results of this retrospective study identified abnormally low eGFR (suggestive of early CKD) in 8% of patients and elevated blood pressure in 16.6%. These findings highlight the importance of performing standardized blood pressure measurements and monitoring serum creatinine and urine albumin excretion on a regular basis in this population. The subset of children with SCD who have low eGFR, hypertension and/or albuminuria may be at particular risk for development of overt sickle cell nephropathy and/or advanced CKD and merit close attention. Our findings highlight the need for a larger prospective longitudinal study aimed at identifying and following children at risk for CKD to determine which factors are predictive of progression. In addition, newer markers of early sickle cell nephropathy   should bSCD: Sickle cell disease; GFR: Glomerular filtration rate1; CKD: Chronic kidney disease; eGFR: Estimated glomerular filtration rate; HPLC: High performance liquid chromatography; ACS: Acute chest syndrome; MRI: Magnetic resonance imaging; ABPM: Ambulatory blood pressure monitoring; ESRD: End stage renal disease.The authors have no competing interests to disclose.PB conceived of the study, participated in its design, performed the background review and performed the cross sectional analysis, and drafted the manuscript. AH participated in manuscript review and design. MAO performed the statistical analysis. JRS helped draft the manuscript. KD conceived of the study, participated in its design, and helped to draft the manuscript. All authors read the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2369/14/237/prepub


Glaucoma is the second leading cause of blindness worldwide. Although the mechanism of the development of primary open-angle glaucoma (POAG) is not fully understood, elevated intraocular pressure (IOP) is considered the most important risk factor. Several vascular factors have also been identified as risk factors and can lead to hypoperfusion of the optic nerve head and thus may play an important role in the pathogenesis and progression of POAG. The results of the present study suggest that both high and low blood pressure (BP) are associated with an increased risk of POAG based on a comprehensive literature review. Elevated BP is associated with elevated IOP, leading to increased risk of glaucoma, but excessive BP lowering in glaucoma patients may cause a drop in ocular perfusion pressure (OPP) and subsequent ischemic injury. The relationship between IOP, OPP, and BP suggests that the relationship between BP and glaucoma progression is U-shaped. Glaucoma is commonly defined as optic neuropathy characterized by progressive loss of retinal ganglion cells (RGCs) which is associated with characteristic structural damage to the optic nerve and visual field loss. Risk factors related to glaucoma include intraocular pressure (IOP), age, family history, clinical appearance of the optic nerve, race, and potential vascular disease –4.Although the mechanism of RGC death is not fully understood, elevated IOP is considered the most important risk factor , 6. SeveAmong vascular factors, systemic hypertension may contribute to increases in IOP via overproduction or impaired outflow of aqueous humor . HoweverSome but not all population studies found statistically significant positive associations between systolic blood pressure (SBP) and diastolic blood pressure (DBP) with IOP , 20–28.In the present study, we reviewed the relationship between POAG and BP, focusing on two aspects: hypertension and hypotension.The Medline database was used for the literature search in this review. Although every effort was made to use the most recent references possible, articles were used irrespective of the year of publication if deemed appropriate. The key words searched included the following: intraocular pressure, ocular perfusion pressure, glaucoma, blood pressure, circadian fluctuation, and risk factors. After retrieving relevant articles using these key words, a search was conducted through the studies cited in these articles, and additional papers were identified. Abstracts of papers in languages other than English were also surveyed. Medical Subject Headings (MeSH) searches were also performed. Case reports and abstracts from meeting presentations were excluded.The ophthalmic artery, which is the first branch of the internal carotid artery, gives off 2–4 posterior ciliary arteries. Posterior ciliary arteries later divide into 10–20 short posterior ciliary arteries that pierce the sclera and enter the globe around the optic nerve. It was reported that the superficial layers of the ONH are supplied by the central retinal artery while the deeper prelaminar regions are supplied by the posterior ciliary arteries, which branch off the circle of Zinn-Haller .ONH circulation is thought to be anatomically and physiologically similar to the circulation in the retina, which is characterized by tight junctions, abundant pericytes, and nonfenestrated endothelium . The capBlood flow in the anterior optic nerve depends on many factors, which include the ocular perfusion pressure (OPP) and the resistance to flow as determined by the vascular caliber in the arterioles and capillaries . The abiSubstances produced by the vascular endothelium play a major role in the control of ocular blood flow, and these include the vasodilators nitric oxide and prostacyclin and vasoconstrictors such as angiotensin and the endothelins .Regulation of blood flow through the choroid is under the control of the autonomic nervous system. Data regarding choroidal autoregulation are contradictory. The autonomic tonus may protect the eye from transient elevations in systemic BP under normal circumstances; however, the autonomic nervous regulation may break down in the presence of systemic hypertension.BP is one of numerous metabolic systems in humans that exhibit a circadian rhythm –39 Figu. Millar-Circadian variations in IOP also exist, and many studies were conducted to characterize these rhythmic patterns. The traditional view is that IOP is generally higher in the morning, but recent research in both healthy and glaucomatous eyes questioned this pattern , 40, 41 Lui et al. performed IOP measurements every 2 hours over 24 hours in young healthy volunteers . The aveI2, 42.5%) and 0.17 mm Hg  associated with a 10 mmHg and 5 mmHg increase in DBP, respectively, with similar results seen in cross-sectional and longitudinal studies [The majority of population-based studies reported a positive association or correlation between SBP, DBP, and IOP , 43–45.  studies . These t studies .Several studies investigated the vascular risk factors in the pathogenesis of glaucoma, with BP and OPP being the most studied. The vascular hypothesis is based on the assumption that abnormal perfusion and the subsequent ischemia of the ONH play a major role in the loss of RGCs.OPP can be defined as the systolic, diastolic, or mean OPP. The mean OPP (MOPP) can be calculated as 2/3 of the mean arterial BP-IOP, where mean arterial pressure = DBP + 1/3(SBP − DBP). The factor of 2/3 accounts for the drop in BP between the brachial and ophthalmic artery when the subject is seated . SystoliWhen calculated by this equation, a certain change in IOP or BP results in the same value of MOPP. However, an experimental study showed that IOP is more important than BP in determining retinal function and that, for a given OPP, a higher IOP elevation induces greater retinal dysfunction . This isAs previously mentioned, data on the association between hypertension and IOP is consistent across studies. However, the relationship between POAG and BP is complex and poorly understood. Several large-scale epidemiologic studies investigated this relationship, with most studies describing conflicting reports. Several studies reported a low risk of glaucoma in individuals with elevated BP –53, wherAlthough the influence of systemic hypertension on glaucoma is complex, several mechanisms are suggested. The Baltimore Eye Survey showed an age-related association between BP and glaucoma . In younAnother important consideration is the relationship between BP, IOP, and POAG. Elevated IOP is considered the most important risk factor for the development and progression of POAG. Therefore, the relationship between BP and IOP should be considered when evaluating the association between POAG and hypertension. Moreover, OPP is regarded as another important risk factor for disease development and progression. As previously mentioned, as OPP includes IOP, it is possible that some of the findings attributed to OPP are in fact exclusively secondary to IOP. Therefore, it is always important to verify whether previous studies adjusted for IOP. Several large epidemiology studies that adjusted for IOP are shown in Pache and Flammer reported hypotension, and in particular a nocturnal drop in BP, as an important risk factor for OAG . RandomiIn terms of the association between BP and glaucoma, nocturnal hypotension may exacerbate the progression of visual field loss in patients with glaucoma , 61. WheSeveral studies demonstrated that both high and low BP are associated with increased risk of POAG. An increase in BP is associated with an elevated IOP, leading to increased risk of glaucoma. In addition, the microangiopathy of hypertension can result in end organ damage including the retina and optic nerve. Hypertension must be treated because it is one of the most important risk factors for cardiovascular morbidity and mortality. But excessive BP lowering in glaucoma patients may cause a drop in OPP and subsequent ischemic injury. In particular, DOPP is useful for displaying the lowest OPP values and is regarded as an independent risk factor for OAG. Although low OPP is an established risk factor in POAG, as OPP includes IOP, it is possible that some of the findings attributed to OPP are in fact exclusively secondary to IOP. Current treatment of POAG aims to reduce IOP; however, there is no evidence to support the value of increasing BP as therapy for POAG. Such recommendations are not currently warranted, since we lack crucial information about the microvascular beds in which perfusion is important in glaucoma, and the appropriate methods to evaluate their blood flow . More reThe relationship between IOP, OPP, and BP may be related to a U-shaped relationship between BP and the progression of glaucoma. Therefore, both high and low BP should be monitored with caution especially in patients with progressive glaucoma despite controlled IOP.


Brain-derived neurotrophic factor (BDNF) has neuroprotective, proangiogenic and myogenic effects and, therefore, possibly acts as a psychosomatic mediator. Here, we measured serum BDNF (seBDNF) level in hypertensive patients (HT) and healthy controls (CONT) and its relation to affective temperaments, depression and anxiety scales, and arterial stiffness parameters.In this cross-sectional study, affective temperaments, anxiety, and depression were studied with questionnaires . SeBDNF level and routine laboratory parameters were measured as well. Arterial stiffness was evaluated with a tonometric method.p < 0.05). In the final model of regression analysis, hyperthymic temperament score  and the presence of hypertension  were independent determinants of seBDNF. In interaction analysis, it was found that in HT, a unit increase in hyperthymic score was associated with a 533.3 (95 %CI 241.3–825.3) pg/mL higher seBDNF. This interaction was missing in CONT.Allover, 151 HT, and 32 CONT subjects were involved in the study. SeBDNF level was significantly higher in HT compared to CONT (24880 ± 8279 vs 21202.6 ± 6045.5 pg/mL, Our results suggest a complex psychosomatic involvement of BDNF in the pathophysiology of hypertension, where hyperthymic affective temperament may have a protective role. BDNF is not likely to have an effect on large arteries. Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophic factor family, playing a central role in the regulation of neuronal growth, maintenance, and survival . Its invAffective temperament types  are subclinical, trait-related manifestations and commonly the antecedents of minor and major mood disorders . PreviouArterial stiffening is increasingly recognized as an independent risk factor for cardiovascular diseases. Carotid–femoral pulse wave velocity (PWV) is the most accepted non-invasive arterial stiffness parameter for cardiovascular risk assessment among hypertensive patients . In diffWe hypothesized that as hypertension is a risk factor for cardiovascular diseases and BDNF is protective in cardiovascular pathology, seBDNF can be altered in hypertension. We also presumed that seBDNF is associated with different affective temperaments, depression, anxiety, and arterial stiffness parameters providing a new bridge of psychosomatic processes.In this cross-sectional study, chronic (>12 months medication) well-controlled or grade 1 consecutive hypertensive Caucasian patients (HT) and age-matched healthy controls (CONT) of three primary care practices were involved. All of the chronic hypertensive patients of our previous, pilot study  were invdepressive temperament: questions 1 to 21 (21 points);cyclothymic temperament: questions 22 to 42 (21 points);hyperthymic temperament: questions 23 to 63 (21 points);irritable temperament: questions 64 to 84 (21 points in women and 20 points in men version);anxious temperament: questions 85 to 110 (26 points).The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) was used to assess affective temperaments on depressive, cyclothymic, hyperthymic, irritable, and anxious subscales, requiring ‘yes’ (score 1) or ‘no’ (score 0) answers . It contThe Beck depression inventory (BDI) is a 21-question multiple-choice self-report questionnaire, one of the widely used instruments for measuring the severity of depression. Participants are asked to make ratings on a four-point scale, where a higher score correlates with more severe depression .Hamilton anxiety scale (HAM-A) was evaluated by the examiner to study the severity of anxiety. The scale consists of 14 items, and each item is scored on a scale of 0 (not present) to 4 (severe anxiety) .Arterial stiffness parameters were evaluated with the validated tonometric PulsePen device . Measurements were performed in a temperature-controlled room in supine position, on the day of blood sampling, prior to it, between 7:00 and 8:00 a.m. Patients were asked to refrain from eating, smoking, and caffeine-containing drinks in the morning of the procedure, but to take the regular blood pressure medication. Upon arrival after 5 min rest, two brachial blood pressure measurements were taken on each arm in the sitting position with a validated oscillometric blood pressure device (Omron M3). The mean value of the higher side was further taken into calculation as brachial systolic  and diastolic  blood pressures and heart rate. Next, subjects were equipped with arterial stiffness measurement devices and then rested in the supine position for approximately 15 min before being measured. The mean of two successful measurements was used in the statistical calculations. In the PWV calculations, 80 % of the carotid–femoral distance was used following the recent guideline . AugmentPeripheral blood samples of patients were collected in anticoagulant-free tubes, right after the measurement of arterial stiffness. After centrifugation (3600 rpm for 6 min), the serum was stored at −20 °C. SeBDNF was measured using commercially available sandwich enzyme-linked immunosorbent assay  according to the manufacturer’s protocol, and serum BDNF level was determined in pg/mL.t tests or Mann–Whitney rank sum test for data failing tests of normality. The equality of variances was studied with Levene’s test. Pearson correlation coefficients were calculated to study the relationship between seBDNF and all other factors measured. Hierarchic linear regression analysis was used to study the determinants of seBDNF in the whole population with a stepwise entry of variables with either previously described association with seBDNF or with a significant univariate correlation with seBDNF in the present data set. As a bidirectional association can be hypothesized between affective temperaments and hypertension [Normality of the parameters was tested with the Kolmogorov–Smirnov test. Descriptive characteristics, laboratory, arterial stiffness parameters and TEMPS-A, BDI, HAM-A scores were compared between CONT and HT groups using unpaired Student’s rtension , predetep < 0.05 was considered to be significant. SPSS 13.0 for Windows was used in calculations.Data were expressed as mean ± standard deviation or mean with interquartile ranges. r = 0.174, p = 0.018), serum cholesterol , LDL  and HDL level , platelet count , pulse pressure amplification , and hyperthymic temperament score . Tendencies of inverse correlations were found with the presence of diabetes or the use of alprazolam, but these were not significant .Altogether, 151 HT and 32 CONT subjects were involved. Eleven of the invited HT and four CONT did not give their informed consent and were excluded. Baseline demographic and laboratory parameters, current medication, TEMPS-A, BDI, and HAM-A scores, central blood pressure, and arterial stiffness parameters as well as seBDNF levels are shown in Table p = 0.002) between hypertension and hyperthymic temperament score on seBDNF in the whole study population: there was no significant association between hyperthymic score and seBDNF in CONT (p = 0.545) and a unit increase in hyperthymic score was associated with a 533.3 (95 %CI 241.3–825.3) pg/mL higher seBDNF level in HT (p < 0.001). The different impact of hyperthymic score in seBDNF in HT and CONT is shown in Fig. Table 95 %CI 24.3–825.3 Here, we demonstrated for the first time in the literature that in chronic hypertensive patients, seBDNF is elevated, and hyperthymic affective temperament score and the presence of hypertension are independent determinants of seBDNF level. In hypertensive patients, the elevation of hyperthymic temperament score is associated with the elevation of seBDNF; however, this association is not present in healthy subjects.We suppose that the observed BDNF elevation in HT can be part of a protective compensatory mechanism targeting peripheral neurons and vascular cells. BDNF has beneficial effects on the regulation of blood pressure, as it is involved not only in the development, but also in the survival of arterial baroreceptor system . VasculaSome of the findings of our study were already described in the literature, such as the seBDNF correlation with cholesterol and LDL , as wellAnother main finding of our study is that hyperthymic affective temperament is an independent determinant of seBDNF. This temperament is characterized by exuberant, upbeat, overenergetic, and overconfident lifelong traits . We suppInterestingly, in our study, no association of seBDNF with anxiety or depression was found. We suppose that this phenomenon can be explained by the mild anxiety and depression severity of HT patients.In contrast to the literature, the presence of diabetes or the use of the benzodiazepine alprazolam was not significantly correlated with seBDNF; however, the direction of correlations was as expected. We think that in both cases, the lack of significance was caused by the low proportion of diabetic or alprazolam user patients in our cohort.The associations between seBDNF level and arterial stiffness parameters have never been evaluated in any patient population yet. Since BDNF has a relaxant effect on pulmonary arterial and aortic rings in different animal models , 18, we The main limitation of our study comes from its cross-sectional design which precludes causal inference. In addition, the number of the subjects involved into the study limited the number of potential confounding variables that were involved in the final regression model. Consequently, the presence of sleeping disorder, the amount of alcohol intake or the habit of regular exercise, variables with documented influence on BDNF level, were not involved into the final analysis . Moreover, other potential confounders, like childhood trauma, stress or sunlight exposition were not evaluated. In addition to these limitations, although we used standardized questionnaires and excluded patients with dementia, a complete exclusion of misinterpretations or mistakes by the patients is impossible.In conclusions, our results suggest a complex psychosomatic involvement of BDNF in the pathophysiology of hypertension, where hyperthymic affective temperament may have a protective role. The impact of this phenomenon for cardiovascular outcome has to be clarified in prospective studies, but its mechanism is probably not mediated by large arteries.


Orthostatic intolerance is common in chronic fatigue syndrome (CFS), and several studies have documented an abnormal sympathetic predominance in the autonomic cardiovascular response to gravitational stimuli. The aim of this study was to explore whether the expectancies towards standing are contributors to autonomic responses in addition to the gravitational stimulus itself.A total of 30 CFS patients (12–18 years of age) and 39 healthy controls underwent 20° head-up tilt test and a motor imagery protocol of standing upright. Beat-to-beat cardiovascular variables were recorded.At supine rest, CFS patients had significantly higher heart rate, diastolic blood pressure, and mean arterial blood pressure, and lower stroke index and heart rate variability (HRV) indices. The response to 20° head-up tilt was identical in the two groups. The response to imaginary upright position was characterized by a stronger increase of HRV indices of sympathetic predominance (power in the low-frequency range as well as the ratio low-frequency: high-frequency power) among CFS patients.per se.These results suggest that in CFS patients expectancies towards orthostatic challenge might be additional determinants of autonomic cardiovascular modulation along with the gravitational stimulus  Chronic fatigue syndrome (CFS) is characterized by unexplained, long-lasting, disabling fatigue accompanied by several other symptoms ,2. CFS iOrthostatic intolerance is a main complaint among CFS patients ,2,7. Accexpectancies modulate autonomic nervous activity. Thus, the response towards an orthostatic challenge is not only a consequence of the gravitational stimulus per se, but also a consequence of the expectancies towards the stimulus as well as the compensatory abilities.We have suggested that the autonomic alterations, as well as other features of CFS, might be attributed to a persistent stress response or “sustained arousal” , paralleThe aim of the present study was to explore the differences between autonomic responses due to gravitational stimuli and autonomic responses due to expectancies in adolescent CFS. We hypothesized that expectancies might be an important determinant of the autonomic responses in CFS.CFS patients were recruited from all hospital pediatric departments in Norway n = 20), as well as primary care pediatricians and general practitioners. A diagnosis of CFS was based upon a standardized set of investigations  carried out by the referring unit, as well as independent clinical assessment by two of the authors (EF and DS). In agreement with recent clinical guidelines 0, as wel and prevHealthy controls were recruited from local schools. They were required not to have any chronic disease and not to use pharmaceuticals regularly (including hormone contraception).All participants underwent an investigational program at our research unit consisting of a one-day in-hospital assessment. Autonomic assessments that included a head-up tilt-test and a motor imagery protocol were performed around noon in a quiet room in a fixed sequence and by three researchers only  Figure . All parThis study is part of the NorCAPITAL-project  , which encompasses a cross-sectional design, a double-blind, randomized, placebo-controlled design and a qualitative design. Details of NorCAPITAL are described elsewhere . Data weThis study is based upon a subset of CFS patients generated from a computer-based randomization procedure, where one fourth of the patients were randomized to be included in the present study; 18 months disease duration served as stratification criterion (cf. below).Participants lay in a horizontal position and were connected to the Task Force Monitor , a combined hardware and software device for noninvasive recording of cardiovascular variables. They were allowed five minutes to accommodate to the situation, after which a 300 sec baseline registration was obtained. Thereafter, a head-up tilt-test (HUT) was performed in which participants were tilted to 20 degrees for 15 minutes using an electronically operated tilt table with a footboard support . Details of the HUT protocol have been described elsewhere . The feaIn a separate experiment, participants were subjected to a motor imagery protocol . First, Instantaneous RR intervals and heart rate (HR) were obtained from the electrocardiogram (ECG). Continuous arterial blood pressure was obtained noninvasively using photoplethysmography on the right middle finger, a method that correlates satisfactorily with invasive pressure measurements and that is validated for adolescents and children. Mean arterial blood pressure (MBP) was calculated by numerical integration of the recorded instantaneous BP. The recorded value was calibrated against conventional oscillometric measurements of arterial BP on the left arm. Impedance cardiography was used to obtain a continuous recording of the temporal derivative of the transthoracic impedance (dZ/dt). Beat-to-beat stroke volume was calculated from the impedance signal . Power sData from the baseline registration, the HUT procedure and the motor imagery procedure were exported to Microsoft Excel for further calculations. Beat-to-beat stroke index (SI) was calculated by dividing stroke volume by body surface area estimated from height and weight, and beat-to-beat total peripheral resistance index (TPRI) was calculated as MBP divided by the product of SI and HR. Thereafter, the median value of all cardiovascular variables was computed in the following epochs: Baseline: 270 to 30 seconds before HUT. Early Tilt: 30 to 270 seconds after HUT. Supine Imagination: 10 to 25 seconds after the instruction was given. Upright Imagination: 10 to 25 seconds after the instruction was given. As the imagery procedure was performed three times in each individual, the mean value across three identical epochs was calculated. Finally, Delta Tilt (Early Tilt – Baseline) and Delta Imagination (Upright Imagination – Supine Imagination) were computed.The Autonomic Symptom Profile (ASP) , which iThe sample size was based on a previous study in which the mean difference between CFS patients and healthy controls was in the range 0.8 – 0.9 SD for variables reflecting autonomic cardiovascular control during orthostatic challenge (such as changes in HR and diastolic blood pressure during tilt) . In the A total of 30 CFS patients and 39 healthy controls were included in this study. The two groups were comparable regarding sex, ethnicity, age, body mass index, and usage of alcohol/tobacco/narcotics Table . CFS patSymptoms of orthostatic intolerance were significantly more common in CFS patients, as reflected in the composite sum score as well as the answers to single items Table .abs, HFabs, Total power)  among CFS patients.At supine rest, CFS patients had a higher heart rate (HR), diastolic blood pressure (DBP), and mean arterial blood pressure (MBP) and lower stroke index (SI) and heart rate variability (HRV) indices measured in absolute units (LFr) Table . The resper se.This study shows that CFS adolescents are burdened by symptoms of orthostatic intolerance. Their baseline cardiovascular variables as well as response to imagery of upright position is significantly different from healthy controls; however, their response to head-up tilt is not. We speculate that their expectancies towards orthostatic challenge might be important determinants of autonomic cardiovascular control in addition to the gravitational stimulus The group differences at baseline confirm findings from several previous reports ,10,24,25Motor imagery activates the autonomic nervous system due to central processes; the magnitude of activation is proportional to the simulated effort ,29. To tDuring head-up tilt, blood tends to pool in the legs due to gravity; the associated unloading of the cardiopulmonary receptors activates compensatory reflexes characterized by increased HR and total peripheral resistance index (TPRI) . In thisOther limitations of this study include a relatively small number of participants. The wide diagnostic criteria of CFS patients might have obscured results relevant to subgroups: however, similar criteria have been successfully applied in previous studies of autonomic responses in CFS patients ,24. Furtper se. The impact of expectancies on other CFS phenomena might be an important area for further research.CFS adolescents have symptoms of orthostatic intolerance and a different autonomic cardiovascular control at baseline as well as during imagery upright position as compared to healthy controls; however, their response to HUT is almost identical. Thus, the CFS patients’ expectancies towards orthostatic challenge might be an important and previously under-emphasized determinant of autonomic cardiovascular modulation along with the obvious determinant of the gravitational stimulus ASP: Autonomic symptom profile; CFS: Chronic fatigue syndrome; CDC: Centers for disease control and prevention; DBP: Diastolic blood pressure; HF: High-frequency; HR: Heart rate; HUT: Head-up tilt test; LF: Low-frequency; MBP: Mean arterial blood pressure; RRI: RR-interval; SBP: Systolic blood pressure; SI: Stroke index; TPRI: Total peripheral resistance index.The authors declare that they have no competing interests.EF, DS and AW collected clinical data, contributed to study design and participated in data analyses. JPS contributed to study design. ES supervised data analyses. VBW conceived of the study, contributed to study design and participated in data analyses. All authors contributed to data interpretation and drafting of the manuscript. All authors read and approved the final manuscript.