Objectives. The −420 C > G polymorphism located in the resistin gene (RETN) promoter has recently been suggested to play a potential role in proinflammatory conditions and cardiovascular disease. This study investigated the association of the RETN promoter polymorphism with Kawasaki disease (KD) and its clinical parameters in Chinese children. Methods. We compared patients with complete KD to incomplete KD children. Genotyping of the RETN promoter polymorphism was performed using MassARRAY system, and serum resistin levels were estimated using the sandwich enzyme immunoassay method. Results. There was no significant difference in RETN (−420 C > G) genotypes between KD and control groups. However, the frequency of the G allele was higher in iKD patients than in cKD children due to a significantly increased frequency of the GG genotypes. Serum levels of resistin were significantly higher in KD patients than in controls regardless of the presence of coronary artery lesions (CALs). Conclusion. The present findings suggest that while resistin may play a role in the pathogenesis of KD, there is no apparent association between CAL and the RETN (−420 C > G) gene polymorphism in KD children. However, the diagnosis of iKD is challenging but can be supported by the presence of the G allele and the GG genotypes. Kawasaki is an acute systemic vasculitis that predominantly affects infants and young children. The most serious complication of KD is the occurrence of coronary artery lesions (CAL), including myocardial infarction, coronary artery fistula formation , coronarAlthough more than 40 years have passed since the first description of KD  for KD bResistin, a novel adipocyte-derived peptide, belongs to a family of cysteine-rich secretory proteins . In humaG (rs1862513), was reported to be associated with the regulation of RETN gene expression and serum resistin level [G polymorphism with arteriosclerosis, coronary artery disease [G polymorphism with the risk of KD.RETN, the gene coding for human resistin, is located on chromosome 19p13.3 . To datein level . Several disease  and cere disease . To our G was associated with KD susceptibility and/or CAL formation. We investigated the association of RETN −420 C > G polymorphisms in the susceptibility of KD (cKD and iKD) patients and control subjects as well as KD patients with and without CAL formation.In this study, we hypothesized that the genetic polymorphisms of RETN −420 C > n = 57) or iKD (n = 34), cKD was defined as a fever and at least four of the five principal criteria [We enrolled patients with KD from the Children's Hospital of Chongqing Medicine University, Chongqing, China. The study group included 91 patients ; all of whom met the criteria proposed by the Japanese Kawasaki Disease Research Committee . AccordiEchocardiography was obtained within 2 weeks of the onset or before intravenous immunoglobulin administration. CALs were defined as coronary vessel internal diameter ≥2SDs above the mean for age adjusted for body surface area (BSA) . PatientLaboratory data were obtained for each child, including white blood cell (WBC) counts, red blood cell (RBC) counts, hemoglobin (HB), platelet count, alanine aminotransferase (ALT) level, aspartate aminotransferase (AST) level, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). All blood samples were drawn before IVIG therapy in the KD patient group.Venous blood samples were obtained from patients and healthy subjects. For biochemical analysis, blood samples were allowed to clot at room temperature, then immediately centrifuged to separate serum, and kept at −80°C. For molecular study, blood samples were collected in ethylenediaminetetraacetic acid (EDTA) tubes to prevent the coagulation of blood samples. Genomic DNA was extracted from whole blood using standard phenol-chloroform extraction technique.Resistin levels from the serum samples were determined using commercial immunoassay kit according to the manufacturer's instructions , as described previously . ResistiSNP genotyping was done using MassARRAY system (Sequenom) by means of matrix-assisted laser desorption ionisation-time of flight mass spectrometry method (MALDI-TOF) according to the manufacturer's instructions . Genotype calling was performed in real time with MassARRAY RT software version 3.0.0.4 and analyzed using the MassARRAY Typer software version 3.4 (Sequenom).t-test or the Mann-Whitney test. Analysis of variance (ANOVA) followed by Scheffe's test was used for analysis of the serum levels of each genotype. The probability values presented are based on two-sided tests. Statistical analysis was performed using the program SPSS for Windows program version 12.0 . A two-sided P value less than 0.05 was considered statistically significant.Clinical phenotypes, including WBC counts, platelet counts, RBC counts, HB levels, platelet count, ALT level, AST level, CRP, and ESR, were each analyzed as a quantitative trait. All values in this study are described as mean ± standard deviation (SD). Statistical significance of the differences between the continuous variables was evaluated by Student's P < 0.001), whereas hemoglobin and HB levels were significantly lower in KD patients compared to controls (P < 0.05).As shown in P < 0.05).The comparison of parameters between patients with CALs and patients without CALs was presented in P < 0.001) and higher HB levels and platelet count  were noted in patients with iKD. The characteristics of cKD patients and iKD groups are presented in Ninety-one children with KD and 115 healthy children were genotyped at the RETN (−420 C/G) polymorphism, and allele frequencies were examined. The genomic frequencies of the RETN (−420 C/G) polymorphism in children with KD were 17.6% (16/91) for CC, 46.2% (42/91) for CG, and 36.3% (33/91) for GG. In controls, these frequencies were 12.2% (14/115) for CC, 45.2% (52/115) for CG, and 42.6% (49/115) for GG. The genomic and allelic frequencies at this polymorphism did not significantly differ between children with KD and control subjects .The frequency of the combined CG + CC genotype was 67.9% (38/56) in KD patients without CALs and 74.3% (26/35) in KD patients with CALs. There was no significant difference in genotype between KD children with and without CALs . These r The genomic frequencies in children with cKD were 18.8% (11/57) for CC, 60.4% (34/57) for CG, and 20.8% (12/57) for GG. In children with iKD, these frequencies were 11.8% (4/34) for CC, 35.3% (12/34) for CG, and 52.9% (18/34) for GG. Statistical analysis revealed that significantly more iKD than cKD patients were homozygous for the G allele .Serum resistin levels were significantly higher in KD patients than control subjects  GG genotype or G allele.To our knowledge, this is the first study to examine the association between the RETN −420 C > G polymorphism is located in the promoter region of the RETN gene. To date, many studies have estimated the associations between the RETN −420 C > G polymorphism and coronary artery disease, although the results are inconsistent. Kunnari et al. investigated the associations between the RETN −420 C > G polymorphism and cerebrovascular disease in Finnish type 2 diabetes patients [G polymorphism in atherogenesis. In recent paper Tang and colleagues discuss an association of the G allele with cardiovascular disease in a Chinese population [G polymorphism and the risk of KD. Among our study population, we found no significant difference in RETN −420 C > G genotypes between KD and control subjects. In addition, there was no association between the RETN −420 C > G gene polymorphism and development of CALs in the enrolled KD patients. However, we found increased risk of iKD in subjects with RETN (−420 C > G) GG genotype compared with carriers of other genotypes (CC and CG). In recent years, patients who did not fulfill all the clinical criteria of KD have been described. Moreover, iKD group is associated with an increased risk of coronary aneurysm [In our control group, the −420 G allele frequency was observed at 65.2%, which was higher than that reported in the study by Xu et al.  . This inpatients . Their spulation . In contpulation . In the aneurysm , 24. GivIt has been reported that the RETN −420 C > G variant could gain the ability to bind the Sp1/3 transcription factor, which might markedly enhance RETN gene promoter activity and increase transcription of the RETN gene . Previouα levels were also significantly higher in KD patients with coronary aneurysm compared to those without coronary aneurysm [α in human and is associated with many inflammatory markers including C-reactive protein and intercellular cell-adhesion molecule (ICAM)-1 [Some studies have also shown correlations between KD with CALs and inflammatory parameters such as CRP , 29. Furaneurysm . In receaneurysm . In prevaneurysm . It is r(ICAM)-1 .Therefor(ICAM)-1 . In a re(ICAM)-1 . HoweverG polymorphism on the clinical parameters in KD patients. Our data showed that there were no significant differences between the genotypes with respect to WBC count, hemoglobin level, platelet count, CRP, ALT, and AST in KD patients. Several previous studies have focused on the associations between the RETN −420 C > G polymorphism and CRP levels, and no consistent results have been reported. Tang and associates have demonstrated that the RETN −420 C > G polymorphism leads to increased CRP concentrations in patients with stable CAD, suggesting a potential involvement of the protein in atherogenesis [G polymorphism and CRP. The inconsistency between these findings may be due to the difference in the region origin of the study populations.We also estimated the impact of the RETN −420 C > ogenesis . HoweverThe potential limitations of our study should be noted. First, hospital-based controls were used, possibly resulting in selection bias. However, the genotype distribution of controls in our study was compatible with the Hardy-Weinberg expectations. Second, our study was conducted in a Chinese population, and the data should be extrapolated to other ethnic groups with caution. Third, the sample size of the present study was relatively small, possibly resulting in wide confidence intervals that approach unity. Larger studies are required to confirm our observations. Lastly, we did not get the data of BMI (body mass index), and BMI is an important factor which may independently effect resistin levels . HoweverG polymorphism is associated with the presence of iKD. Although resistin appears to play a role in KD, the RETN (−420 C/G) gene polymorphism does not appear to be associated with the development of KD or CAL in Chinese children. However, further large-scale studies will be needed to firmly establish the relationships between RETN gene polymorphisms and CAL in KD. Collectively, this work will provide important new insights into the KD pathology and may provide new targets for the design of novel diagnosis measures for iKD.In conclusion, this study demonstrates for the first time that the RETN −420 C >


The prognostic role of B-type natriuretic peptide (BNP) in septic patients is controversial. The study aimed to investigate the prognostic value of BNP in critically ill septic patients. Furthermore, because BNP is primarily released from ventricles in response to myocardial stretch, the second aim of the study was to test whether the change in BNP was correlated to the amount of fluid balance.This was a prospective observational study conducted in a tertiary 18-bed ICU. Patients fulfilled criteria of sepsis were enrolled. Exclusion criteria included renal dysfunction on ICU entry, age < 18 or >80 years old. BNP was measured on entry (BNP0) and day 3 (BNP1) and daily fluid balance over the three days were recorded. Diagnostic performances of BNP0 and ΔBNP (BNP1-BNP0) were analyzed. The correlation between fluid balance and ΔBNP were tested using Spearman’s correlation test.ICU) > 7 d and hospital  > 12 d were 0.71, 0.79, 0.66 and 0.71, respectively. The AUCs of ΔBNP in predicting duration of MV > 7 d, LOSICU > 7 d and LOShospital > 12 d were 0.80, 0.84 and 0.85, respectively. The amount of fluid balance was correlated to ΔBNP , and the correlation remained statistically significant in multivariate model.A total of 67 subjects were eligible for the study during study period. BNP0 was significantly higher in non-survivors than in survivors . The area under curves (AUCs) of BNP0 in predicting mortality, duration of mechanical ventilation (MV) > 7 d, length of stay in ICU (LOSICU and LOShospital. ΔBNP is able to predict the LOSICU and LOShospital with satisfactory sensitivity and specificity. ΔBNP is closely correlated to the amount of fluid balance during resuscitation period. However, this could only be considered as a hypothesis-generating pilot study due to its small sample size and the observational nature.BNP measured on ICU entry is associated with mortality, duration of MV, LOS Sepsis is a leading cause of mortality and morbidity in intensive care unit (ICU). It is estimated that 3 in 1000 people will be affected by sepsis, and 51% of them requires ICU admission,3. UnderB-type natriuretic peptide (BNP) is a 32 amino acid that is synthesized and secreted by myocytes and fibroblasts in the atria and ventricle in response to wall stress,9. It ha-1; hyperventilation evidenced by a respiratory rate of >20 min-1 or a PaCO2 of <32 mm Hg (4.3 kPa); and a white blood cell count of >12,000 cells μL-1 or <4,000 μL-1. Infection was considered by the presence of clinical signs and inflammatory markers, and the presence of polymorphonuclear cells in normally sterile tissue or fluid and/or culture or gram stain showing a pathogenic microorganism and/or radiological evidence of an infective focus[The study was conducted in a tertiary 18-bed ICU from September 2010 to March 2012. This was a mixed ICU enrolling both surgical and medical patients. During the study period, patients entered ICU were prospectively assessed for potential eligibility. Patients were eligible if they fulfilled the following criteria: 1) sepsis defined as systemic inflammatory response syndrome (SIRS) plus infection. SIRS was defined by the presence of more than one of the following criteria: body temperature, >38°C or <36°C; heart rate, >90 minve focus. 2) pative focus; 2) patiOn enrollment, baseline characteristics of patients were recorded, including age, sex, severity of illness as represented by Acute Physiology and Chronic Health Evaluation (APACHE II), admission diagnosis, sources of infection, hemodynamic variables (obtained by thermodilution technique). During follow up, the volumes of fluid balance in the first three days were recorded. The total net fluid balance referred to net fluid balance over the three days. Fluid balance was defined as total fluid intake including tube feeding, intravenous infusion and eating, minus total fluid output including urine output, drainage of fluid, fluid removal with renal replacement therapy and perspiration. B-type natriuretic peptide (BNP) was measured on admission (BNP0), and on the third day (BNP1). ΔBNP was calculated as BNP1 minus BNP0. BNP was measured using Triage BNP detector .ICU), LOS in hospital  and duration of mechanical ventilation (MV). For patients who had been transferred to general ward and then were re-admitted to ICU within three days, days spent in general ward were considered in ICU, and LOSICU included the first and second LOSICU. Mechanical ventilation included invasive mechanical ventilation and non-invasive mechanical ventilation with positive end expiratory pressure >5 cmH2O. In our institution, we considered tracheostomy for patients who could not wean from mechanical ventilation after day 7, thus, we used 7 days as a threshold to convert the continuous variable of duration of MV into a binary variable.The primary end point was in hospital mortality. Secondary end points included ICU length of stay  test was used. Multivariate analysis (backward stepwise logistic regression) was performed to screen independent variables associated with mortality. Variables entered into the model were defined a priori, including age, APACHE II score, BNP0, cardiac index, and extravascular lung water; also, variables with a p < 0.1 in univariate analysis were entered into the model. The goodness-of-fit was tested using Homser-Lemeshow method. Diagnostic performance of BNP0 and ΔBNP in predicting clinical outcomes  were evaluated using receiver operating characteristic (ROC) curves. Diagnostic statistics including sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were reported. The correlation between total fluid balance and ΔBNP was analyzed by using spearman’s rank correlation test. P < 0.05 with two tailed test was considered to be statistically significant. All statistical analyses were performed using the software Stata 11.0 .Data were tested for normality, and expressed as mean ± SD (standard deviation) or median and interquartile range as appropriate. If data were normally distributed, the comparisons were performed using student During the study period, a total of 544 patients were admitted to our ICU. 471 of them were excluded on entry due to various reasons . All authors read and approved the final manuscript.


Background. Previous reports provided inconsistent data on the occurrence of postoperative delirium and emphasized its considerable impact on outcome. This study sought to evaluate the incidence and predictors of delirium, together with its relation to cerebral ischemia in a large cohort of cardiac surgery patients in a tertiary high-volume center. Methods and Results. Consecutive patients (n = 8792) were prospectively enrolled from 2003 to 2008. Exclusion criteria were history of psychiatric disorders, use of psychoactive drugs, alcohol abuse, and data incompleteness. Finally, 5781 patients were analyzed in terms of 100 perioperative patient-specific and treatment variables. The incidence of postoperative delirium (DSM IV criteria) was 4.1% and it coexisted with cerebral ischemia in 1.1% of patients. In bivariate analysis, 49 variables were significantly linked to postoperative delirium. Multivariate analysis confirmed that delirium was independently associated with postoperative stroke (logistic odds ratio (logOR) = 2.862, P = 0.004), any blood transfusions , age > 65 years , carotid artery stenosis , urgent/emergent surgery , fasting glucose level, intraoperative oxygen partial pressure fluctuations, and hematocrit. Area under ROC curve for the model was 0.8933. Conclusions. Early identification of nonpsychiatric perioperative determinants of delirium facilitates its diagnosis and might help develop preventive strategies to improve long-term outcome after cardiac surgery procedures. Despite the undeniable progress in surgical techniques and perioperative care of cardiac patients, composite rate of mortality and postoperative morbidity still remains considerable, which is vastly attributable to neuropsychiatric complications , 2. AccoSince the available management is purely symptomatic (neuroleptic and sedative agents)  and auxiThe study was performed in a tertiary high-volume cardiac surgery center. Consecutive patients were prospectively enrolled between January 2003 and December 2008. A flow chart of subjects is delineated in minus minimal value) of arterial blood gas parameters  during the surgery under general anesthesia (with 100% oxygen supply) we categorized these variables on the basis of their quartile distribution, taking <ΔQ1 as the cutoff for extremely low, ΔQ1–3 as a reference interval of no variation and >ΔQ3 as the cutoff for extremely high variations.Delirium was diagnosed postoperatively by the attending physician  according to the criteria of Diagnostic and Statistical Manual of Mental Disorders IV edition (DSM-IV) , which aμg/kg) and the use of non-depolarizing muscle relaxant (pancuronium 1.0-2.0 mg/kg or cisatracurium 0.15–0.2 mg/kg). The anesthesia was sustained with the technique of total intravenous anesthesia  or with combined intravenous and inhalational anesthesia . Muscle relaxation was sustained with the repeated doses of muscle relaxant. Intubation was achieved using 6.5–9 mm single- or double-lumen endotracheal tube (for one lung ventilation). We used pressure-control or volume-control mechanical ventilation with 100% oxygen, simultaneously monitoring respiratory rate and volume, airway pressure, end-tidal-CO2 and blood oxygen saturation. Patients were hemodynamically monitored in a continuous fashion . Body temperature was measured using thermistor-based esophageal temperature probe. Foley catheter was inserted and urine output was continuously assessed. Antibiotic prophylaxis of 1st generation cephalosporin was administered to every operated patient for at least 72 h after induction. Intravenous fluids were supplemented at the rate of 80–150 mL/h depending on hydration status .All patients were anesthetized in coherence with the unified protocol involving oral premedication with midazolam (7.5 mg–15 mg) and induction with intravenous etomidate (0.15 mg/kg) or propofol (1.0–2.5 mg/kg) and fentanil (7.0–10.0 2/min and pressure of 60–70 mmHg. The majority of surgeries were conducted in moderate hypothermia (32°C), except for the aortic dissection surgery requiring deep hypothermia. Rewarming rate was 0.5–1.0°C/5 min. On completion of all anastomoses, protamine was given to reverse the effect of heparin and return the ACT to preoperative levels.Surgical management varied depending on the type of procedure and surgeon's preference. Median sternotomy was the predominant approach with the exception of minimally invasive surgeries which involved lateral thoracotomy. On-pump cardiac surgery involved administration of full dose low molecular weight heparin (3 mg/kg) to achieve a target-activated clotting time (ACT) of ≥480 seconds before commencement of cardiopulmonary bypass (CPB), along with the insertion of cannula into the ascending aorta and right atrium. In the off-pump group, heparin (1 mg/kg) was administered before the start of the first anastomosis to achieve an ACT of 250 to 350 seconds. High-potassium (20–30 mmol/l) cardioplegic solution (4 : 1) was reversely injected into the coronary arteries . Standard circuit tubing set was used, which included a roller pump and a membrane oxygenator with the flow rate throughout bypass of 2.0–3.0 l/mt-test or analysis of variance, and Mann-Whitney U-test or Kruskal-Wallis test were used for those nonnormally distributed. As far as qualitative variables are concerned, Mantel-Haenszel chi-square or Fisher's exact test was applied. In bivariate analysis, delirium  was defined as a dependent variable, whereas independent variables were designated from amongst perioperative parameters. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Variables with a “P” value < 0.1 were consecutively subjected to a multivariate stepwise logistic regression model. Logistic ORs with 95% CIs were subsequently estimated. After the assessment of area under the receiver operator curve, the goodness of fit for logistic regression model was verified with Hosmer-Lemeshow test. A “P” value < 0.05 was considered significant.Statistical analysis was performed using SAS 9.2  software. Continuous variables are expressed as mean and standard deviation  or as median and interquartile range (IQR) . The type of distribution was verified using Shapiro-Wilk test. Qualitative variables are expressed as crude values and percent. Between-group differences for normally distributed quantitative variables were assessed using Student The characteristics of the study population are shown in P < 0.001). Compared to non-psychotic population, delirium significantly prolonged (P < 0.001) the time of ICU stay by 3.5 days  for subjects without and by 6.5 days  for those with cerebral ischemia. Total inhospital stay was also significantly longer (P < 0.001) by 5 days  for those without and by 9 days  for those with cerebral ischemia.Delirium developed postoperatively in 236 subjects  and cerebral ischemia alone was present in 148 patients . Coexistence of delirium and cerebral ischemia occurred in 65 patients . Median time of delirium was 3 days  for those without and 6 days  for the patients with cerebral ischemia (P < 0.1) association with postoperative delirium regardless of cerebral ischemia (Tables P < 0.0001), was the most powerful single determinant of delirium. Conversely, past medical history of cerebral ischemia failed to show any association with perioperative delirium. Among other determinants of neuropsychological complications, a noteworthy association was found for packed red blood cells transfusion , age older than 65 years , urgent mode of surgery , high perioperative risk calculated with EuroSCORE  and a history of chronic obstructive pulmonary disease . Although we reported only 16 cases of former CABG, the need for recurrent surgical revascularization strongly correlated with the risk of neuropsychiatric complications .In bivariate analysis it was found that 49 variables had a significant  [β-blockers, angiotensin-converting enzyme inhibitors), as well as decreased variations of blood pressure during the cardiopulmonary bypass [Although postoperative cerebral ischemia affected only 2.6% patients, our analysis indicated stroke as the most reliable predictor of delirium. In line with present study, Manji et al. documented that postoperative occurrence of seizures  corresponds with an increased rate of neuropsychological derangements, defined as delirium and/or stroke, as opposed to non-epileptic individuals  . The red< 0.001) , 20, 21.< 0.001)  and an a< 0.001) . The raty bypass .The study has several shortcomings, which may limit application of its results to all populations. First, it is based on the experience of a single medical center. On the one hand, it insures data and procedure consistency, but on the other hand, application of our results to other patient populations is limited. Second, although we enrolled consecutive patients, some of them were excluded due to data incompleteness. Consequently, only about 2/3 of patients were included, which may potentially be the source of selection bias. More to the point, this prospective observational study was conducted between 2003 and 2008 and may not address some advances of perioperative management in the last five years. Third, as the study population is relatively old, the impact of dementia is of great importance, and in some cases clinical differentiation between delirium and cognitive disorders was difficult or even impossible. Moreover, procedure-related depression and anxiety were not investigated. Fourth, it could result in underestimation of delirium prevalence that the diagnosis of delirium was not based upon uniform bed-site algorithms, such as Confusion Assessment Method (CAM), Delirium Observation Screening (DOS), or Delirium Rating Scale (DRS). However, the proximity of tertiary psychiatric center and a meticulous assessment during a routine checkup at least twice a day should have provided acceptable sensitivity of delirium screening. We realize that it requires additional psychological tests and a long-term observation so we decided to exclude patients with any psychiatric disorders in anamnesis and to assess nonpsychiatric variables only. Fifth, the occurrence of cerebral ischemia could be underestimated (silent ischemia with no deficits) because only those subjects with evident neurologic disorders underwent computed tomography examination. Although numerous medications may increase likelihood of delirium, the authors were unable to evaluate their impact on the results because of the heterogeneity of pharmacological treatment. For the same reason this study did not aim at evaluating the significance of perioperative pharmacological neuroprotection, which has been recently brought up by several investigators –32. FinaDelirium belongs to frequent psychiatric complications in cardiac surgery setting. Most of nonpsychiatric predictors of delirium are in direct relation with decreased cerebral perfusion and oxygen supply. Improper perioperative anesthetic management and the complications ensuing from the urgency of surgery are of great clinical significance. Early identification of the determinants of delirium may facilitate its diagnosis. It is advisable to utilize the abovementioned risk factors in the bed-site algorithms of perioperative risk assessment to improve the outcome of cardiac surgery patients with psychosis.


Objectives. Bile duct invasion (BDI) is a rare event in hepatocellular carcinoma (HCC). The present study aimed at investigating clinical characteristics and surgical outcome of HCC patients with bile duct invasion. Methods. 413 patients with HCC undergoing curative surgery were divided into two groups with (B+) and without BDI (B−). BDI was further classified as central type (B1) and peripheral type (B2). Survival was compared, and risk factors affecting prognosis were identified. Results. 35 (8.5%) patients were diagnosed BDI. Total bilirubin was significantly higher in B+ group than in B− group (P < 0.001). Multiple lesions and large nodules (>5 cm) were predominantly identified in B+ group . Portal vein invasion was more frequently observed in B+ than in B− group (P = 0.003). Univariate and multivariate analyses identified central BDI as a significant factor affecting prognosis of HCC patients . The gross overall survival of patients in B+ was significantly worse than in B− (P = 0.001), which, however, was not different between B2 and B− (P > 0.05). Conclusions. Central but not peripheral BDI was associated with poorer prognosis of HCC patients. Curative surgical resection of tumors and invaded bile duct supplies the only hope for long-term survival of patients. Invasion of bile duct system by hepatocellular carcinoma (HCC) is rare, and its clinical characteristics and impact on prognosis of patient were not well defined. The first case of HCC patient presenting with “obstructive jaundice” was reported in 1947 as a consequence of tumor invasion and thrombosis in bile duct . And tilMost of these studies included only patients with obstructive jaundice due to biliary tumor thrombi. However, microscopic invasion of peripheral bile ducts in liver by HCC is being investigated as unique biological characteristic by surgeons and pathologists, which might have certain impacts on prognosis of patients after surgical treatment . UnfortuFrom January 2007 to January 2010, data of 413 cases of HCC undergoing curative liver resection  for HCC in our institute was retrospectively collected. The diagnosis of HCC was made by computed tomography (CT) scan, ultrasonography, magnetic resonance image (MRI), and/or angiography preoperatively and confirmed by histopathological examination of the resected specimen postoperatively.+ group, n = 35) and those without BDI . BDI by HCC was further classified as B1, central type ; B2, peripheral type .BDI was suspected when tumors located adjacently, or dilation of bile duct and the branches was detected. If necessary, certain invasive examination (percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiography (ERCP)) or magnetic resonance cholangiopancreatography (MRCP) was used to confirm invasion of main branches of bile ducts or the common hepatic duct, evaluate stricture extent of bile duct, and also used for bile drainage before surgery. Among them, 35 cases  were diagnosed as HCC with BDI macroscopically and microscopically including 14 patients with bile duct thrombi. Particularly, HCC of seven patients was found microscopic invasion of peripheral bile duct by pathological examination postoperatively but no invasion of first-order branch of bile duct or common hepatic duct. Two separate pathologists were in agreement with the pathological diagnosis of all cases. We compared the clinical characteristics of HCC with BDI  and nonanatomic resection. The invaded bile duct was resected with the entire tumors, and biliary-enteric anastomosis was performed if appropriate. All the cases were definitively diagnosed finally by paraffin pathological examination of the specimen.+ and B− groups who underwent curative surgery at the same time period. Tumor size, number, tumor cell differentiation, capsule formation, and surgical margin were determined finally with pathological examination. Operation time was defined as the time period from incision of skin to closure of wound. Intraoperative blood transfusion volume indicated the volume of transfused packed erythrocytes in the operation. Postoperative morbidity includes the complications related to the hepatic surgery, for example, ascites, pleural effusion, chest infection, intra-abdominal abscess, intra-abdominal or upper gastrointestinal bleeding, bile leakage and wound infection, and so forth.Laboratory test was documented at the admission before surgery. Clinical, pathological, and surgical variables were compared between BU test or t-tests were used to compare numerical variables, and the Chi-Square test or Fisher's exact test was carried out to compare nominal variables. The overall survivals were calculated by the Kaplan-Meier method, and the differences in survival between groups were compared using the log-rank test. Impact factors for prognosis of patients after hepatic resection were analyzed by univariate analysis firstly, and those with P value less than 0.05 were enrolled for multivariate analysis using Cox proportional hazards model. Statistical analysis was carried out using SPSS 17.0. P < 0.05 was considered statistically significant.Data were expressed as mean ± SD for numerical variables or percentages for nominal variables. Mann-Whitney + group was 51.3 years (range 41–77), comprised of 24 men and 11 women. 28 patients were classified as B1 including two patients with invasion of peripheral bile duct and first-order branches of bile duct, and 7 were classified as B2. Totally, 17 patients of B1 (60.7%) were presented with jaundice on admission. Abdominal pain was the most common symptom of the patients . 26 of B1 (93%) patients with HCC were diagnosed BDI by CT, MRCP, ERCP, or PTC preoperatively. The rest three of B1 and all of B2 were diagnosed intraoperatively by laparotomy and/or postoperative pathological examination. Partial hepatectomy was performed in 13 of B1 and all of B2. 10 patients of B1 underwent preoperative biliary decompression by PTC or ERCP. The entire tumors and invaded bile duct were removed, and choledochojejunostomy was also performed in ten of B1. The rest five patients of B1 underwent partial hepatectomy and thrombectomy and T tube drainage. Surgical complications occurred in 9 patients (25.7%), including bleeding (n = 1), bile leakage (n = 4), pleural effusion (n = 4), wound infection (n = 2), and hepatic decompensation (n = 1). Although liver transplant is available in our institution, no HCC patients with BDI underwent liver transplant.The average age of B+ and B− groups were compared and shown in P > 0.05, resp.). However, total bilirubin (TBIL) was significantly higher in B+ group than in B− group . Patients in the two groups had no difference in preoperative alpha-fetoprotein (AFP) level (P > 0.05).The clinical characteristics of B+ group . Portal vein invasion was more frequently observed in B+ group than in B− group (P = 0.003). Tumor capsule formation and tumor cell differentiation did not differ between the two groups. Although there was no difference of surgical mode between the two groups, HCC in B+ group had narrower surgical margin than those in B− group (P = 0.034). There was no difference in intraoperative blood transfusion quantity, operation time, postoperative morbidity, and hospital stay between the patients in B+ and B− groups.The pathological and surgical variables between the two groups were compared and shown in + and B− groups were plotted in + was significantly shorter than that of patients in B− group .To July 2012, the median followup of all patients was 24 months (3–65 ms). Kaplan-Meier curves for overall survival of B−, B1, and B2 were plotted and shown in −, or B2 , but not between B− and B2 (P = 0.431).Kaplan-Meier curves for overall survival of BP < 0.05, resp.). When we included these ten significant factors in univariate analysis into multivariate analysis using Cox proportional hazards model, tumor size larger than 5 cm , multiple lesions , capsule absence , BDI of B1 type , portal vein invasion , intraoperative blood transfusion larger than 600 mL , AST higher than 40 U/L , and AFP higher than 20 ng/mL  were identified as independent risk factors worsening the prognosis of HCC patients (Next, to investigate risk factors affecting prognosis of HCC patients after surgical treatment, we enrolled 20 potential variables including BDI and analyzed by univariate analysis . Univaripatients .HCC with BDI is a rare event, and little is known about this type of HCC. This type of HCC was firstly recognized as “icteric type” of HCC, since patients complained of “jaundice” because of obstruction of bile duct by tumor thrombi –5. SinceHowever, there is not yet a consensus regarding the impacts of bile duct thrombi or BDI on patient's survival after curative surgery, and whether BDI is an independent risk factor worsening prognosis of HCC patients after surgical treatment remains unknown. As summarized in Most previous studies focused on only HCC with bile duct thrombi –13, 18. Next, we also compared clinical, pathological, and surgical variables that might differentiate HCC with BDI from those without. Patients with BDI presented with higher preoperative bilirubin level, which might be a result of biliary tract invasion. Tumors with multiple and large lesions were predominantly observed in patients with BDI. And portal vein invasion was more frequently identified in patients with BDI. These differences suggested HCC with BDI had more aggressive biological behavior and was associated with late stage of cancer, which accounted for poorer prognosis of the patients even after surgical treatment. Since portal vein and bile duct are surrounded by the same Glissonian sheath, tumors can easily invade both of them . VasculaAlthough limited by a retrospective study, the results of the present study suggest that BDI was associated with more advanced tumor stage, and central BDI was an independent risk factor affecting the prognosis of patients with HCC. Curative surgery with complete removal of tumors and invaded bile duct supplies the only hope for long-term survival of patients.


Inhibition of the MEK1/2 and NFκB pathways abrogated the stimulatory effects of F. nucleatum on NAMPT. Furthermore, the expression and protein levels of NAMPT were significantly enhanced in gingival biopsies from patients with periodontitis, a chronic inflammatory infectious disease of the periodontium, as compared to gingiva from periodontally healthy individuals. In summary, the present study provides original evidence that gingival fibroblasts produce NAMPT and that this synthesis is increased under inflammatory and infectious conditions. Local synthesis of NAMPT in the inflamed gingiva may contribute to the enhanced gingival and serum levels of NAMPT, as observed in periodontitis patients. Moreover, local production of NAMPT by gingival fibroblasts may represent a possible mechanism whereby periodontitis may impact on systemic diseases.Adipokines, such as nicotinamide phosphoribosyltransferase (NAMPT), are molecules, which are produced in adipose tissue. Recent studies suggest that NAMPT might also be produced in the tooth-supporting tissues, that is, periodontium, which also includes the gingiva. The aim of this study was to examine if and under what conditions NAMPT is produced in gingival fibroblasts and biopsies from healthy and inflamed gingiva. Gingival fibroblasts produced constitutively NAMPT, and this synthesis was significantly increased by interleukin-1 Porphyromonas gingivalis and Fusobacterium nucleatum, in the subgingival dental plaque are essential for the initiation and progression of periodontitis [β, in the periodontal tissues. The inflammation, if exaggerated, can lead to matrix degradation and bone resorption and, thereby, formation of periodontal pockets. If periodontitis remains untreated, the disease can finally result in tooth loss [Periodontitis is a chronic inflammatory disease, which is characterized by the irreversible destruction of the tooth-supporting tissues, that is, periodontium. The periodontium consists of the gingiva, periodontal ligament (PDL), root cementum, and alveolar bone. Periodontopathogens, such as dontitis , 2. Howedontitis . The peroth loss , 4. Perioth loss , 6.Interestingly, several meta-analyses have revealed that periodontitis is associated with obesity, diabetes type II, and metabolic syndrome –10. EvenκB) as well as production of inflammatory molecules [NAMPT is mainly synthesized by macrophages and adipocytes in the adipose tissue and stimulates activation of nuclear factor-kappaB  at 37°C in a humidified atmosphere of 5% CO2. Cells from passages 3 to 5 were seeded  on cell culture plates and grown to 80% confluence. One day prior to the experiment, the FBS concentration was reduced to 1%. In order to simulate inflammatory conditions in vitro, HGF were exposed to IL-1β , as done in our previous studies [Porphyromonas gingivalis ATCC 33277 and Fusobacterium nucleatum ATCC 25586 . Bacteria were suspended in PBS  and exposed two times to ultrasonication (160 W for 15 min) resulting in a complete killing, as previously reported [κB  and MEK1/2  signaling pathways 1 h prior to experiments.HGF were obtained from healthy gingiva of 8 individuals , who had to undergo wisdom teeth extraction in the Department of Oral Surgery of the University of Bonn. Written informed consent and approval of the Ethics Committee of the University of Bonn were obtained (#043/11). HGF were grown in Dulbecco's minimal essential medium  supplemented with 10% fetal bovine serum , 100 units penicillin, and 100  studies –27. In oreported , 23. In Human gingiva was obtained from 10 periodontally healthy donors , 10 gingivitis subjects , and 10 periodontitis patients . Exclusion criteria were presence of systemic diseases or medications as well as smoking. Sites were categorized into three groups according to the gingival index (GI), probing pocket depth (PD), clinical attachment level (CAL), and radiographic bone loss. Periodontally healthy sites were characterized by GI = 0 , PD ≤ 3 mm, no CAL, and no radiographic bone loss. Sites with gingivitis had a GI > 1 , but also no periodontal pockets, attachment loss, and radiographic bone loss. Sites of periodontitis had also a GI > 1 and, additionally, PD ≥ 5 mm, CAL ≥ 3 mm, and radiographic bone loss. Gingiva was harvested during wisdom teeth removals or teeth extractions for orthodontic or periodontal reasons in the Department of Oral Surgery of the University of Bonn. Written informed consent and approval of the Ethics Committee of the University of Bonn were obtained (#043/11).μg of RNA was reverse transcribed using iScriptTM Select cDNA Synthesis Kit  at 42°C for 90 min followed by 85°C for 5 min. The expression of NAMPT, adiponectin (Adipo) and its receptors (AdipoR1 and AdipoR2), leptin and its functional receptor (LeptinR), resistin, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was detected by real-time PCR using the iCycler iQ detection system (Bio-Rad Laboratories), SYBR Green (Bio-Rad Laboratories), and specific primers . One μL of cDNA was amplified as a template in a 25 μL reaction mixture containing 12.5 μL 2x QuantiFast SYBR Green PCR Master Mix (Qiagen), 2.5 μL of primers, and deionized water. The mixture was heated initially at 95°C for 5 min and then followed by 40 cycles with denaturation at 95°C for 10 s and combined annealing/extension at 60°C for 30 s. GAPDH was used as an endogenous control. The data were analyzed by the comparative threshold cycle method.RNA was extracted with an RNA extraction kit . A total of 1 The levels of NAMPT in the supernatants of HGF were determined by a commercially available ELISA kit  according to the manufacturer's instructions. The absorbance was measured with a microplate reader  at 450 nm. The data were normalized by the cell number measured with an automatic cell counter .β, P. gingivalis, or F. nucleatum on glass coverslips  in 24-well plates for 48 h. Afterwards, cells were fixed in 4% paraformaldehyde  at pH 7.4 and room temperature (RT) for 10 min and then permeabilized in 0.1% Triton X-100 (Sigma-Aldrich) for 5 min. Nonspecific antigens were blocked by incubation with serum block  for 20 min. Cells were then incubated with rabbit polyclonal antibody to NAMPT  at 4°C overnight. Subsequently, cells were labeled with goat anti-rabbit IgG-HRP secondary antibody (Dako) for 30 min. For staining, cells were exposed to DAB chromogen  for 10 min at RT in the dark. After each incubation step, cells were washed twice with PBS (Invitrogen). Counterstaining was performed with Mayer's Hematoxylin  for 1 min. Coverslips were mounted in Aquatex mounting agent (Merck Eurolab). Standardized photomicrographs were taken using an Axioskop 2 microscope . The images were captured with an AxioCam MRc camera (Carl Zeiss) and the AxioVision 4.7 software (Carl Zeiss).HGF were grown in the presence and absence of IL-1μm thickness were obtained, mounted on glass slides (Carl Roth), and dried at 37°C overnight. Sections from healthy and inflamed gingival tissues were stained with hematoxylin and eosin . Selected tissue sections were then deparaffinized, rehydrated, and rinsed in PBS (Invitrogen) for 2 min. Endogenous peroxidase was blocked in 0.3% methanol (AppliChem)/H2O2 (Merck Eurolab) solution for 5 min in the dark. After rinsing, sections were pretreated with serum block (Dako) for 20 min. Then, sections were incubated with rabbit polyclonal antibody to NAMPT  in a humid chamber at 4°C overnight. For detection of the antibody binding, sections were washed and then incubated with goat anti-rabbit IgG-HRP secondary antibody (Dako) at RT for 30 min. After rinsing, peroxidase activity was visualized with DAB chromogen (Thermo Fisher Scientific). Subsequently, all slides were rinsed and then counterstained with Mayer's hematoxylin (Merck Eurolab) for 1 min, dehydrated, and coverslipped for light microscopical analysis. Standardized photomicrographs were taken using an Axioskop 2 microscope (Carl Zeiss). The images were captured with an AxioCam MRc camera and the AxioVision 4.7 software (Carl Zeiss).Gingival biopsies were fixed in 4% paraformaldehyde (Sigma-Aldrich) for 2 days. Subsequently, the tissues were hydrated, then dehydrated in an ascending ethanol series , and finally embedded in paraffin . Tissue sections of 2.5 U) tests were applied. Differences between groups were considered significant at P < 0.05.For statistical analysis, the IBM SPSS Statistics 20 software was used. Mean values and standard errors of the mean (SEM) were calculated. All experiments were performed in triplicate and repeated at least twice. Parametric (ANOVA followed by the post hoc Dunnett test) and nonparametric  on NAMPT. Preincubation of HGF with specific inhibitors against MEK1/2 and NF-κB signaling reduced the F. nucleatum-induced upregulation of NAMPT by 64% and 83%, respectively.First, we sought to examine whether HGF express NAMPT and, if so, whether the constitutive expression of NAMPT is modulated by inflammatory or microbial signals. As shown in of IL-1β . By contucleatum  and no dβ, P. gingivalis, and F. nucleatum. Our experiments demonstrated that HGF also express constitutively adiponectin, leptin, and resistin (β, P. gingivalis, and F. nucleatum had no significant effects on these adipokines except for the P. gingivalis-induced upregulation of resistin at 12 h (We also sought to study whether HGF produce additional adipokines and, if so, whether their expression can be regulated by IL-1resistin . However at 12 h .β, P. gingivalis, and F. nucleatum was paralleled by increased NAMPT protein levels in the supernatants of stimulated cells, as compared to control cells, at 24 h and 48 h (β- and F. nucleatum-stimulated cells by immunocytochemistry at 48 h ( P. gingivalis-treated cells at this time point (The significant upregulation of NAMPT expression by IL-1and 48 h . Enhance at 48 h . By contme point .Next we studied the expression of NAMPT as well as other adipokines and their receptors in gingival biopsies from periodontally healthy, gingivitis, and periodontitis subjects. As demonstrated in As shown in Figures β and the periodontopathogens P. gingivalis and F. nucleatum. These findings suggest that local synthesis of NAMPT in the inflamed gingiva may contribute to the enhanced gingival and serum levels of NAMPT, as observed in patients with periodontitis. The local production of NAMPT by periodontal cells may represent a possible mechanism whereby periodontitis may impact on systemic diseases, such as diabetes mellitus and cardiovascular diseases. Moreover, since NAMPT stimulates the synthesis of proinflammatory and matrix-degrading molecules, increased NAMPT production by HGF at inflamed sites may result in the amplification of periodontal inflammation and destruction.The present study provides original evidence that HGF produce NAMPT, and this synthesis is stimulated by the proinflammatory cytokine IL-1In a subset of experiments, we also studied the expression of adiponectin, leptin, and resistin in HGF. Although these adipokines could also be detected by real-time PCR, their expressions were very slight and barely modulated. A few studies have reported that HGF express AdipoR1 and AdipoR2, but not adiponectin, which seems to be in contrast to our findings , 29. Howβ, which was used to mimic inflammatory conditions in vitro, as in our previous studies [P. gingivalis and F. nucleatum. The suspensions were exposed to intensive ultrasonication and contained disrupted cell wall particles with a high amount of lipopolysaccharide. Nevertheless, other microbial components may also have been present in the suspensions. P. gingivalis, which is a gram-negative bacterium and strongly linked to periodontitis, possesses various virulence factors, such as gingipains and fimbriae. This bacterium has been shown to invade host cells and evade the host defense system [F. nucleatum is also a gram-negative, anaerobic microorganism. This bacterium acts as a bridge bacterium between early and late colonizers during plaque development and is associated with both gingivitis and periodontitis. Like P. gingivalis, F. nucleatum has also been demonstrated to invade host cells [β, P. gingivalis, and F. nucleatum were applied at the same doses as in previous studies [In the present study, HGF were exposed to IL-1 studies –27. This studies –33. In oe system –36. F. nst cells –42. None studies , 23.β and the periodontopathogens P. gingivalis and F. nucleatum caused increased NAMPT levels in the supernatants of the stimulated cells. In general, the ELISA results were also in agreement with findings from the immunocytochemistry analysis, which demonstrated increased NAMPT protein levels in IL-1β- and F. nucleatum-stimulated cells, as compared to control. However, in contrast to the ELISA data, only slight differences in NAMPT protein levels were found between P. gingivalis-treated and control cells by immunocytochemistry. Whether P. gingivalis leads to a fast and almost complete secretion of NAMPT in HGF or whether other mechanisms play a role needs to be determined in further studies.Our findings for NAMPT at transcriptional levels were paralleled by the findings obtained by ELISA. IL-1F. nucleatum-induced NAMPT upregulation was dependent on MEK1/2 and NFκB signaling. These results are in line with our previous findings on PDL cells, in which the NFκB pathway was also activated by F. nucleatum [β and P. gingivalis for their stimulatory effects on NAMPT expression.We also sought to unravel the intracellular mechanisms underlying the upregulation of NAMPT in HGF. Our experiments revealed that the ucleatum . FurtherIn order to verify the results from our in vitro experiments, in which inflammatory and infectious conditions were simulated, we also studied the expression and protein levels of NAMPT in gingival biopsies from periodontally healthy, gingivitis, and periodontitis subjects. To our knowledge, this is the first study which demonstrates that the gingival expression of NAMPT is increased at sites of periodontitis as compared to healthy sites. This finding is in accordance with our in vitro results, which revealed that NAMPT expression and protein levels are increased under inflammatory and infectious conditions. However, gingival biopsies contain various cell types, such as fibroblasts, epithelial, endothelial, and inflammatory cells, and each of them might be a possible source of NAMPT. We therefore also studied the production of NAMPT in gingival tissue by immunohistochemistry. Whereas no or only very low levels of NAMPT were found in the subepithelial connective tissue of healthy gingival biopsies, high amounts of NAMPT were observed in the connective tissue of gingiva from periodontitis patients. Immunostaining for NAMPT was detected in the cytoplasm of fibroblasts and endothelial cells as well as in the extracellular space. Interestingly, NAMPT was also present in epithelial cells in both healthy and diseased tissues. These results confirm our in vitro data on the increased NAMPT production in gingival fibroblasts under inflammatory and infectious conditions. Furthermore, our data provide first evidence that gingival epithelial cells produce NAMPT.We also sought to examine the expression of other adipokines in gingival biopsies. Our study shows for the first time that the proinflammatory adipokine resistin is also significantly upregulated in inflamed gingival tissue as compared to healthy gingiva. By contrast, the leptin and adiponectin expressions were decreased in gingiva from periodontitis patients. The downregulation of these two adipokines was paralleled by the upregulation of their receptors in periodontitis. In a recent study, the expression of both adiponectin receptors was lower in periodontal tissues from patients with severe periodontitis than in healthy periodontal tissues . It was In summary, the present study provides original evidence that gingival fibroblasts produce NAMPT and that this synthesis is increased under inflammatory and infectious conditions. Local synthesis of NAMPT in the inflamed gingiva may contribute to the enhanced gingival and serum levels of NAMPT, as observed in periodontitis patients. Moreover, local production of NAMPT by gingival fibroblasts may represent a possible mechanism whereby periodontitis may impact on systemic diseases.


Nigella sativa or Black seed (N. sativa L.) is traditionally used for several ailments in many Middle Eastern countries. It is an annual herbaceous plant that belongs to the Ranuculacea family with many beneficial properties as antitumor, antidiabetic, antihypertensive, antioxidative and antibacterial. This work attempted to study the effect of N. sativa seeds powder and oil on atherosclerosis in diet-induced hypercholesterolemic (HC) rabbits in comparison with simvastatin (ST). Twenty-five adult New Zealand male white rabbits, weighing 1.5–2.5 kg, were divided into five groups; normal group  and four hypercholesterolemic groups (n = 20): a positive control (PC) and three HC groups force fed diet supplemented with 1000 mg Kg−1 body weight of N. sativa powder (NSP), 500 mg Kg−1 body N. sativa oil (NSO) and 10 mg Kg−1 ST for 8 weeks. Feeding HC rabbits with N. sativa either in powder or oil forms was shown to significantly reduce (P < .05) total cholesterol (TC) and low-density lipoprotein cholesterol (LDLC) levels and enhance high-density lipoprotein cholesterol (HDL) levels after treatment for 2, 4, 6 and 8 weeks compared to the PC group. Plaque formation was significantly inhibited while the intima: media ratio was significantly reduced in the NSP and NSO supplemented groups compared to the PC group. In conclusion, treatment of HC rabbits with N. sativa seeds powder or oil showed hypocholesterolemic and antiatherogenic cardioprotective properties. Nigella sativa L., commonly known as black seeds have been used for nutritional and medicinal purposes in many Middle Eastern countries and other parts of the world [N. sativa and Neem has been used traditionally in Asia and the Middle East to treat many diseases and several viral diseases [N. sativa seed and its oil have provided scientific support for the traditional use of the seed and its oil for treatment of rheumatism, immune stimulation, diabetes, cancer and related inflammatory diseases [Nigella sativa seeds active constituents, for example volatile oil and thymoquinone, showed protection against nephrotoxicity and hepatotoxicity induced by either diseases or chemicals [N. sativa seeds in animals and human is inconclusive.Complementary and Alternative Medicine (CAM), including herbal medicine, is popular in the general population worldwide . Nigellahe world , 3. Seeddiseases , 5. Recediseases . Nigellahemicals . The seehemicals . Evidencin vivo to investigate the hypocholesterolemic properties of N. sativa seeds and their oil. Nigella sativa seeds oil and thymoquinone have been shown to have a hypocholesterolemic activity in rats [N. sativa in powder form and as a part of the diet on hypercholesterolemia. Furthermore, to our knowledge, no published study has investigated the antiatherogenic benefits of N. sativa seeds and oil. Therefore the aim of this study was, to investigate the hypocholesterolemic and antiatherogenic properties of N. sativa seeds and the extracted oil on diet-induced hypercholesterolemic in rabbits.Heart diseases remain one of the leading causes of death worldwide . Several in rats , 9. TherNigella sativa seeds were purchased from a local herbal grocery from Taiz—a city— in the Republic of Yemen. The seeds were cleaned and kept at 4°C in the Laboratory of Molecular Biomedicine, Institute of Bioscience, University Putra Malaysia, Malaysia. The seeds were ground using an electric grinder . Homogenized and ground samples (100 g) were soaked overnight with an n-hexane  at a ratio of 1 :  5 (w/v) and filtered using the Whatman paper (Fisher Scientific Co Ltd). The solvent was evaporated in a vacuum rotary evaporator  at 40°C. The crude oil samples were combined, weighed, and stored at −30°C until analysis.Twenty-five male New Zealand white rabbits weighing 1.25–2.5 kg were used for this study. They were housed individually in stainless steel mesh-bottomed cages and were fed initially standard rabbits chow pellets for 1 week for adaptation. All rabbits were maintained at almost constant environmental conditions throughout the study at 21–24°C and 12 h 1ight : dark cycle. This study was carried out according to the guidelines approved by the Animal Care and Use Committee (ACUC) of Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.3), (0.5%) and calcium phosphate (CaHPO4) (0.5%) , containing: soybean meal (15%), corn (30%), palm kernel meal (36%), soybean oil (2%), starch (10%), molasses (2%), mineral mixture (3.5%), vitamins mixture (0.3%), DL-methionine (0.2%), calcium carbonate (CaCO) (0.5%) . Diet waCholesterol and Sudan 1V were purchased from Sigma-Aldrich, St Louis, Missouri, USA and Simvastatin was purchased from Ranbaxy, Pharmaniga Logisttics Sdn Bhd 260790-T, while TC, LDL, HDL and triglycerides (TG) estimation kits were supplied by Roche Diagnostic GmbH, d-68298 Mannheeim, Germany. Formalin was obtained from BHD Chemicals and Xylene from Ajax Chemicals, Auburn, Australia, whereas Hematoxylin and Eosin (H&E) were purchased from Merck, Amsterdam, The Netherlands. Absolute alcohol was bought from R&M Chemicals, Essex, UK.n = 20) in which rabbits were fed normal diet supplemented with 1% cholesterol for 3 weeks. Hypercholesterolemic rabbits were further subdivided into four groups: a positive control (PC) nontreated group, a cholesterol diet supplemented with 1000 mg kg−1 N. satvia seeds in powder form (NSP), a cholesterol diet supplemented with 500 mg kg−1 N. sativa seeds oil (NSO) and a group force-fed cholesterol diet supplemented with 10 mg kg−1 day−1 simvastatin (ST)  for 8 weeks. The amount of food and water was recorded daily, while the body weight was recorded every 2 weeks.The rabbits were randomly assigned to five groups of five animals each; negative control (NC), received a normal diet prepared and used as reference and four groups induced with hypercholesterolemia . The tissues were blocked, and cut using a microtome (Letiz Wetzlar 1512) to 4-t-test. One-way ANOVA followed by Dunnet's Post hoc test was used to compare the means of the PC and the treatment groups .Data were presented as group means ± SD and were analyzed using SPSS program version 11.0. The differences between NC and hypercholesterolemic groups were tested by independent sample P < .05) in body weight compared to NC. Body weight of the PC and the NC groups were shown to be increased until the end of the experiment. On the other hand, after 2 weeks of treatment the body weight of NSO and NSP groups were shown to be slightly decreased and this phenomenon was continued until the end of experiment. Similar effect on body weight was observed when animals treated with ST, but this effect started after 4 weeks of treatment.Feeding rabbits with 1% cholesterol-supplemented diet for 3 weeks resulted in a significant increase (P < .05) in the thickness of the intima and the intima : media ratio in cholesterol group as compared with the NC group. Feeding rabbits 1% cholesterol supplemented diet resulted in a significant increase in plasma TC and LDL levels and slightly decreased HDL levels Tables . In addiP < .05) in plasma TC, LDL and TG levels of NSP-, NSO- and ST-treated groups were observed at 2, 4, 6 and 8 weeks of treatment compared to PC group (Tables P > .05) in plasma HDL levels as compared to the PC group at Weeks 4, 6 and 8 of treatment. However, throughout the treatment period no significant differences were noticed in plasma HDL and TG levels obtained from ST and PC groups. Plaque formation was significantly inhibited and the intima : media ratio was significantly reduced (P < .05) in N. sativa treatment groups and ST group as compared to the PC group. It should be mentioned that treatment with ST-induced mortality in rabbits (two rabbits) after 10 days of treatment and increased liver weight and its percentage to body weight. A significant reduction (P < .05) by N. sativa and ST treatments as compared to the PC group. There was no significant difference (P > .05) in the whole area examined between treatment groups . Feeding rabbits 1% cholesterol supplemented diet-induced plaque formation in the abdominal aorta. The plaque area exceeded 10.63 ± 1.44%, 2.53 ±  1.06%, 2.19 ±  0.88% and 3.97 ± 0.47% in the PC, NSP, NSO and ST groups, respectively . Lipid dP < .05) when compared to NC group (P < .05) in the intima thickness of the NSP and the NSO groups in comparison with that result obtained from the ST-treated group. The new findings showed that there were no significant differences observed among all the treated groups compared to the NC group. Thickness of the intima in the PC group was significantly higher  compared to the NC group, (P < .05) between the PC group (71%) and the treatment groups . However, the intima : media ratio was observed to be significantly reduced in the NSP and NSO groups (P < .05) compared to the ST group, while there was no significant difference (P < .05) in intima : media ratio observed between the NSO and the NSP group. The intima : media ratio in the animals fed cholesterol was significantly higher  has gained a worldwide popularity over the past 20 years , 13. Nighe world , 15. Thehe world . Thus, rN. sativa treatment groups (NSO and NSP) showed slight decrease in the body weight during the 8 weeks of the treatment time. These results are similar to what was found by Zaoui et al. [P < .05) in body weight of normal rats that received a daily dose of 1 mg kg−1 of N. sativa fixed oil by oral gavage for 12 weeks. Nigella sativa treatment of rats  reported to cause a reduction in the body weight accompanied by significant and sustained reduction in food intake [Our results showed that body weight of the PC group was significantly increased until the end of the experiment compared to the NC, whereas the i et al. , who obsd intake . ST groud intake , where tN. sativa treatments (NSO and NSP), are in agreement with the previous studies as reported by El-Dakhakhani et al. [N. sativa oil (800 g kg−1 day−1) orally for 4 weeks caused significant decreases in the serum LDL and TG levels, and an elevation of serum HDL levels. Recently, it was reported that the petroleum ether extract of N. sativa significantly reduced plasma TG and increased HDL cholesterol [N. sativa was observed to be as efficient as the cholesterol-reducing drug ST [N. sativa oil decreased serum TC, TG and LDL levels [−1 body weight of N. sativa seeds fixed oil for 12 weeks showed a significant decrease in total serum TC and TG [Significant elevation in plasma TC and LDL levels and slight decrease in plasma HDL levels were used as indicators of hypercholesterolemia resulted from feeding rabbits cholesterol supplemented diet. These findings were in the same line as with those results reported by Prasad . In addii et al. , 14, wholesterol . The vol drug ST . FurtherL levels . AdditioC and TG .N. sativa seeds oil is rich in vitamin E and total antioxidant activity, which may explain the significant reduction in plasma TC, LDL levels. As shown by Jorge et al. [N. sativa seeds is rich in unsaturated fatty acids, which could be responsible for the decrease of TC and LDL cholesterol levels as reported by other researchers [N. sativa seeds and their oil could be attributed to the seeds contents of total dietary fiber (TDF), insoluble dietary fiber (IDF) and soluble dietary fiber (SDF) as observed by Al-Nageeb et al. [−1 day−1) significantly decreased TC and LDL levels when compared to the PC group over the treatment period and these findings are in agreement with those results obtained by other researchers [On the other hand, our previous results  showed te et al.  vitamin e et al. . It was earchers . The hypb et al. . In addib et al. . The preearchers , 24.N. sativa seeds could be attributed to their high content of vitamin E, since increased consumption of vitamin E is inversely correlated with the development of the coronary heart diseases [N. sativa treatment (NSP and NSO) may also be attributed to the active constituent of N. sativa seeds (Thymoquinone) as reported recently by Ragheb et al. [The results obtained from this study showed that feeding rabbits with 1.0% of cholesterol supplemented to their diet induced a significant increase in the lesions as compared to normal rabbits. In addition, our results showed that the plaque formation in all treatment groups was significantly inhibited as compared to the PC group. The reduction in atherogenesis caused by diseases . Furtherdiseases . In addib et al.  as well b et al. .N. sativa fed rabbits revealed a significant inhibition of aortic atherosclerotic changes when compared with the aorta of the PC group. In general N. sativa treatment (NSP and NSO) showed significant decrease in intima : media ratio compared to ST group. It was reported that, ST-reduced atherosclerotic plaque size and significantly increased the plaque content of vascular smooth muscle cells and collagen and reduced inflammation contributing to atherosclerotic plaque [N. Sativa powder and oil in preventing the development of atherosclerosis. Feeding rabbits with 1% cholesterol supplemented diet-induced atherosclerosis; however, the histological examination of normal rabbit revealed that the aorta wall has a uniform thickness with no bulging in the lumen, and the intima was intact without any interruption in contrast to the hypercholesterolemic rabbits. Data from histopathological examination of c plaque . ST decrc plaque . The relN. sativa seeds and oil in reducing the arterial wall lipid deposition, total cholesterol and LDL levels and consequently the atherogenesis indicating its potential health value.In conclusion, this study points out to the importance of University Putra Malaysia (grant number 62166).


Although most deaths among patients with type 2 diabetes (T2D) are attributable to cardiovascular disease, modifiable cardiovascular risk factors appear to be inadequately treated in medical practice. The aim of this study was to describe hypertension, dyslipidemia and medical treatment of these conditions in a large population-based sample.The present analysis was based on the DIAB-CORE project, in which data from five regional population-based studies and one nationwide German study were pooled. All studies were conducted between 1997 and 2006. We assessed the frequencies of risk factors and co-morbidities, especially hypertension and dyslipidemia, in participants with and without T2D. The odds of no or insufficient treatment and the odds of pharmacotherapy were computed using multivariable logistic regression models. Types of medication regimens were described.The pooled data set comprised individual data of 15, 071 participants aged 45–74 years, including 1287 (8.5%) participants with T2D. Subjects with T2D were significantly more likely to have untreated or insufficiently treated hypertension, i.e. blood pressure of > = 140/90 mmHg  and dyslipidemia i.e. a total cholesterol/HDL-cholesterol ratio > = 5  than participants without T2D. Untreated or insufficiently treated blood pressure was observed in 48.9% of participants without T2D and in 63.6% of participants with T2D. In this latter group, 28.0% did not receive anti-hypertensive medication and 72.0% were insufficiently treated. In non-T2D participants, 28.8% had untreated or insufficiently treated dyslipidemia. Of all participants with T2D 42.5% had currently elevated lipids, 80.3% of these were untreated and 19.7% were insufficiently treated.Blood pressure and lipid management fall short especially in persons with T2D across Germany. The importance of sufficient risk factor control besides blood glucose monitoring in diabetes care needs to be emphasized in order to prevent cardiovascular sequelae and premature death. Atherosclerosis accounts for most deaths in people with type 2 diabetes (T2D) and the age adjusted relative risk of coronary artery disease and peripheral arterial disease has been reported to be threefold higher than in the general population -3. In a Hypertension and dyslipidemia are often associated with insulin resistance, frequent in T2D and enhance the risk of macrovascular complications like coronary artery disease and stroke as well as microvascular sequelae like retinopathy and nephropathy .Thus, subjects with T2D particularly profit from lifestyle modifications and medication therapy aiming at a normotensive blood pressure and low lipid concentrations in the blood .Nevertheless, several studies in Germany and other countries have shown that patients in primary care -11 and pWhile patient-related data from primary care and patients-registries are available demonstrating an under-treatment of T2D patients in clinical practice, results from population-based studies are scarce. Such data, however, are important to generalize knowledge on the treatment status of specific populations and to identify regional differences in the quality of health care. Moreover, studies using clinical practice data probably underestimate frequencies since well-treated patients are more likely to be recruited.In the current analysis, we used pooled data from the DIAB-CORE data set to assess the frequencies of risk factors associated with cardiovascular disease (CVD), co-morbidities, medication intake, adequate and insufficient treatment in participants with and without T2D from Germany. Our pre-specified hypothesis based on current literature was that blood pressure and lipid levels are not sufficiently controlled, particularly in patients with T2D.The DIAB-CORE Consortium has been launched in order to establish a joint pool of population-based data on persons with and without diabetes. Six studies covering regions in Germany were combined (from north to south): the Study of Health in Pomerania , the Dortmund Health Study , the Cardiovascular Disease, Living and Ageing  Study, the Heinz Nixdorf-Risk Factors, Evaluation of Coronary Calcification, and Lifestyle  Study, the Cooperative Health Research in the Region of Augsburg  Study, and the nationwide German National Health Interview and Examination Survey 1998 , see Table All studies were conducted between 1997 and 2006 and used similar instruments, questionnaires and medical measurements to collect data. Detailed descriptions of study designs, samples and procedures are available elsewhere . EthicalOnly participants aged 45 to 74 years were included in the pooled data set, representing the common intersection of all studies.A binary variable was created contrasting individuals with high and middle educational graduation  versus low educational graduation (no school certificate or junior high school only).Participants were asked to choose their appropriate income class. The midpoints of these classes were used to define the variable household net income separately for each regional study. The lowest income group was defined as less than 60% of the median income in the individual study and was compared to the other groups.Two categories (current vs. ex- and never smoker) were defined to differentiate risk types. A current smoker smoked at least one cigarette per day. An ex-smoker had quit smoking at least one year ago, otherwise he or she was regarded as a current smoker.2).Body mass index was calculated as weight in kilograms divided by height in square meters  conducted at the study centres with systolic blood pressure > =140 and/or diastolic blood pressure > =90 mmHg, or intake of anti-hypertensive medication in participants with physician’s diagnosis of hypertension (“awareness”). Participants with hypertension were categorized into one of the following four subgroups: (1) aware (with physician’ diagnosis) and controlled treated to target levels of < 140/90 mmHg, (2) aware and treated, but not reaching target blood pressure values of < 140/90 mmHg, i.e. insufficiently treated, (3) aware, but not treated, (4) unaware of hypertension. Thus, “awareness” of hypertension applied to participants in categories 1, 2 and 3, “treatment” applied to those in categories 1 and 2 and “control” to those in category 1.Hypertension guidelines -31 launcTotal cholesterol, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol levels were measured from random blood samples. Dyslipidemia was defined analogous to hypertension using information on lipid-lowering medication intake, self-reported information on physician's diagnoses and a total cholesterol to HDL cholesterol ratio (TC/HDL) of  > = 5 . AccordiSelf-reported data on myocardial infarction and stroke  was assessed identically in all studies. Information on angina pectoris (Rose questionnaire reference) and intermittent claudication was also collected, although the questions were not identical across the studies. However, we tried to achieve the best possible harmonization by using all available information. Prevalent CVD was defined as presence of self-reported MI, stroke, angina or claudication.All study participants were asked to bring original packaging of their medications used during the last seven days to the examination. Unique pharmaceutical identifiers, names etc. were recorded and ATC  codes were assigned accordingly. The variable “anti-hypertensive medication” included any prescription of medication belonging to the ATC subgroups C02 (antihypertensives), C03 (diuretics), C04 , C07 (beta blocking agents), C08  and C09 (agents reacting on the renin-angiotensin system).Medications of the ATC subgroup C10 (lipid modifying agents) were included in the variable “lipid-lowering medication”.Our pooled data set included 1287 participants with T2D and 13784 participants without T2D aged 45 to 74 years from major regions in Northeast, Middle, West- and South-Germany. Two-stage cluster sampling or stratified random sampling were used. In the nationwide survey GNHIES98, 3% non-German but German speaking citizens were included. KORA, SHIP, CARLA and HNR focused on participants of German nationality, in DHS nationality was not used as an inclusion criterion. Overall response ranged between 56% and 69%.Since physician's diagnosis of dyslipidemia had not been assessed in DHS, the study was not included in analyses using the combined variable of medication intake, laboratory measurements and physician's diagnosis to classify participants with dyslipidemia. Because of missing values, participants had to be excluded from the hypertension sub-analyses (n = 358), and from the dyslipidemia sub-analyses (n = 1460) using these combined variables. Participants were excluded from the logistic regressions on current hypertensive measurements (n = 26) and current dyslipidemia (n = 337), due to missing information on blood pressure or lipid measurements. Participants (n = 4612) with complete variable information on the combined hypertension variable, who had a positive physician’s diagnosis and used anti-hypertensive medication were included to assess the frequencies of medication classes.Men and women with diabetes and participants without diabetes were compared with respect to their lifestyle factors, cardiovascular burden, clinical measurements and medications. For continuous variables means and standard deviations (SD) were calculated, while categorical variables were described as percentages. Differences between groups were tested using t-tests and Wilcoxon tests (continuous variables) or chi-square tests and univariate logistic regression models . Logistic regression models were calculated to identify the effects of a basic set of variables that influence odds of hypertension, dyslipidemia and medication intake, respectively.A two-sided alpha level of 0.05 was chosen as criterion for statistical significance. All analyses were carried out using SAS, version 9.1 .The pooled sample included 15071 participants (47.1-51.7% women across studies) aged 45–74 years .Participants with T2D were older than participants without T2D , 82.5% had hypertension compared to 59.0% in non-T2D participants. Considering the four subgroups, 18.9% of all participants with T2D were controlled treated (1) with mean blood pressure: 125/77 mmHg, 40.9% were insufficiently treated (2) with mean blood pressure: 159/91 mmHg, 6.7% were aware of the disease but not treated 3) with mean blood pressure: 159/95 mmHg and 16.0% were not aware (4) with mean blood pressure: 151/91 mmHg. Anti-hypertensive medications were taken by 69.7% of subjects, by 59.8% of subjects with known hypertension, i.e. 9.9% probably used these medications for a different indication. On site measurements of  > =140/90 mmHg, e.g. untreated or insufficiently treated hypertension was recorded in 63.6%. In comparison, the percentage of participants without T2D with untreated or insufficiently treated hypertension was 48.9% of 13443 subjects with complete variable information , 54.8% were classified as having dyslipidaemia. The four subgroups displayed the following frequencies: 12.3% were controlled treated (1) with mean TC/HDL: 3.7, 7.2% were insufficiently treated (2) with mean TC/HDL: 6.3, 17.1% were aware of the disease but not treated (3) with mean TC/HDL: 6.4 and 18.1% were not aware (4) with mean TC/HDL: 6.1. Currently elevated lipids (TC/HDL > =5), i.e. untreated or insufficiently treated dyslipidemia was recorded in 42.5%. Lipid lowering medications were taken by 23.2% of participants . In non-T2D study participants, 35.7% of 12450 with complete cholesterol, physician and medication variables had dyslipidemia, 28.8% were untreated or insufficiently treated. Lipid lowering medications were used by 10.7% of non-T2D participants (by 9.3x% with diagnosed dyslipidemia) , we found that participants with diabetes had significantly higher odds of failing to reach the blood pressure target   was also positively associated with diabetes status  and male sex . All regional studies reported a significantly lower number of participants with TC/HDL > = 5 than GNHIES98. Interaction of diabetes and sex showed that women with diabetes had a much higher odds of dyslipidemia  than men with diabetes . Moreover, in women the odds increased with increasing age, while in men, the odds decreased slightly.The odds of anti-hypertensive treatment in hypertensive patients (n = 8982) were clearly higher in subjects with T2D , older and female participants (Table In persons with dyslipidemia (n = 5083), lipid-lowering preparations were also used more often by participants with T2D , older participants  and women . CARLA, HNR and SHIP had higher rates of lipid-lowering medication than GNHIES98. DHS was not included in this model. The odds of taking lipid-lowering medications increased significantly with increasing age in participants without T2D, but not in participants with T2D.Some interaction terms involving the ‘individual study’ variable were also statistically significant Tables  and 5.Anti-hypertensive treatment regimens were assessed in participants who were aware of their condition  only, assuming that individuals who received medications without having a physician’s diagnosis of hypertension used these preparations for different indications (e.g. cardiac insufficiency). Participants with T2D received preparations of the ATC groups: C03 (diuretics), C08  and C09 , more frequently than non-T2D hypertensive participants . GNHIES98, as the oldest study, had the greatest percentage of participants with hypertension.Our study confirms that there is a clear gap between measured blood pressure and blood lipid recommendations and the actual management in 45 to 74 years old T2D and non- T2D subjects in the general German population. More than 60% of participants with T2D did not reach the conservative blood pressure target of 140/90 mmHg and about 40% had prevalent dyslipidemia . The analysis showed that about 70% of all T2D participants received anti-hypertensive medication, but 40% were insufficiently controlled. About 20% of the participants with T2D used lipid-lowering medication but 7% did not reach a total cholesterol/HDL-ratio of <5 despite medication intake. Approximately 80% of T2D subjects with currently elevated lipid levels were untreated. T2D patients had a worse cardiovascular profile compared to non-T2D subjects.The choice of anti-hypertensive drugs differed between participants with and without diabetes, reflecting current recommendations . Many stThe odds of having blood pressure values  > =140/90 mmHg decreased significantly over time. However, since the single studies differed in the frequency of hypertension and the individual study periods overlapped only in part, the effect was difficult to separate from the study effect and will be studied in more detail using longitudinal data.We did not especially stress the differences between the individual studies, since they do not necessarily reflect regional differences in health care. The studies were not conducted simultaneously and data assessment and laboratory measurements were not standardized from the outset. The nationwide GNHIES98, SHIP and DHS had more unfavourable outcomes than the other studies which might be due to the fact that GNHIES98 and SHIP were the oldest studies and DHS had the smallest number of participants and only two blood pressure measurements.The essential strength of our study is the large population-based sample drawn from the general German population aged 45 to 74 years and the fact that both, laboratory measurements and information on medication intake were available.Due to the pooling process only similarly collected and coded data of all six studies could be used and the least common denominator had to be found. Therefore, the definition of diabetes was based on self-report of physician’s diagnosis and treatment with anti-diabetic agents rather than on clinical diagnosis and medical records. Blood pressure was calculated using the mean of the second and third measurements in all studies except for DHS, where only two measurements were performed and used to calculate the mean. This might distort the frequency in DHS and contribute to the high proportion of participants with 64.2% having a blood pressure  > = 140/90 mmHg compared to 49.3% in the other studies.Moreover, measurements of blood pressure and lipids based on a single testing opportunity present evidence for the respective condition, but are not equal to a clinical diagnosis with repeated measurements. We cannot exclude cases of ‘white coat hypertension’, i.e. elevated blood pressure owing to the excitement of the unfamiliar situation.Finally, all study participants were asked to bring packages of their medications to the study centres. However, due to non-compliance and forgetfulness it is possible that fewer packages were documented than had actually been prescribed. We might thus have underestimated medication intake, consequently overestimated the number of participants without treatment and probably underestimated the number of participants with insufficient treatment.The results of our population-based study fortify the findings of patient-based German and international studies. Recently, Berthold et al.  describeA nationwide French survey conducted in 2001 and involving 410 diabetologists found that the target blood pressure of < 140/80 mmHg was attained by 29% of patients and 58% had LDL values of < than 1.3 g/l. Control of blood pressure and LDL was not considered to be optimal .Similarly, the authors of a Canadian study  concludeFinally, data from 9,167 participants of the US NHANES  survey  showed tThe scientific community engaged in health care management strongly postulates an aggressive treatment of dyslipidemia and hypertension and advocates the widespread use of drugs to effectively improve mortality and morbidity rates in patients at risk . A largeIn general, ACE inhibitors should be used first, accompanied by diuretics depending on the presence of co-morbidities. Yet diuretics alone are suspected to negatively influence blood glucose . Beta blFurther reductions of blood pressure target values seem not to be advisable though . RecentlStatins are usually prescribed to treat dyslipidemia. They are regarded as safe, provide significant cardiovascular benefits in different populations including the elderly and patients with diabetes, and may halt or slow atherosclerotic disease progression . RecentlOver and above, insufficient blood pressure and lipid control are not exclusively due to insufficient prescription of medication but to various factors related to the patient and the physician. Important aspects are insufficient awareness and motivation of the patient, reluctance to initiate lifestyle changes, poor compliance  and failure to modify therapy, when it is indicated such as use of combination therapy if monotherapy proves to be inadequate ,52.Thus, apart from medication and its design, to improve secondary prevention of cardiovascular disease in primary physician health care and especially in T2D patients, the following intervention programmes should be emphasized : educatiAccording to a small study by Asimakopoulou et al. , T2D patTherefore, individual counselling and risk communication between a health professional and the patient is essential.In conclusion, our analysis based on a large dataset from six population-based studies provides evidence that, among comprehensive lifestyle interventions, health care in T2D patients in Germany could be remarkably improved by focusing on cardiovascular risk factors, especially blood pressure and lipid concentration. Though numerous guidelines on the topic have been published, the transfer of theoretical knowledge to practical application appears to be very difficult. Physicians may stick to the “glucocentric view” of diabetes therapy and fail to recognise the severity of cardiovascular risk factors and co-morbidities. This approach may limit microvascular disease, but lacks the important focus on macrovascular complications.ATC, Anatomical Therapeutic Chemical Classification System; BMI, body mass index; BP, blood pressure; CARLA, Cardiovascular Disease Living and Ageing Study; CVD, cardiovascular disease; DHS, Dortmund Health Study; DMP, disease management program; GNHIES98, German National Health Interview and Examination Survey; HDL, high-density lipoprotein; KORA, Cooperative Health Research in the Region of Augsburg Study; LDL, low-density lipoprotein; OAD, oral anti-diabetic medication; HNR:, Heinz Nixdorf-Risk Factors Evaluation of Coronary Calcification, and Lifestyle Study; SD, standard deviation; SHIP, Study of Health in Pomerania; T2D, type 2 diabetes; TC, total cholesterol.The authors declare that they have no competing interests.I-M.R. performed the statistical analyses and wrote the manuscript. C.M. and M.S. worked on pooling of the data, contributed to the discussion and reviewed/edited the manuscript. R.H. contributed to the discussion and reviewed/edited the manuscript. T.T. and W.R. worked on pooling of the data and reviewed/edited the manuscript. S.S., H.V., A.K., K.H.G., K.B., G.M., U.E., H.N, S.M. and S.A. contributed data and reviewed/edited the manuscript. All authors read and approved the final manuscript.