Biomedical subjects
Publications and source records attributed to S S Rastogi.
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In a randomized, double-blind, placebo-controlled trial, the effects of combined treatment with the antioxidant vitamins A (50,000 IU/day), vitamin C (1,000 mg/day), vitamin E (400 mg/day), and beta-carotene (25 mg/day) were compared for 28 days in 63 (intervention group) and 62 (placebo group) patients with suspected acute myocardial infarction. After treatment with antioxidants, the mean infarct size (creatine kinase and creatine kinase-MB gram equivalents) was significantly less in the antioxidant group than in the placebo group. Serum glutamic-oxaloacetic transaminase decreased by 45.6 IU/dl in the antioxidant group versus 25.8 IU/dl in the placebo group (p < 0.02). Cardiac enzyme lactate dehydrogenase increased slightly (88.6 IU/dl) in the antioxidant group compared with that in the placebo group (166.5 IU/dl) (p < 0.01). QRS score in the electrocardiogram was significantly less in the antioxidant than in the placebo group. The following levels increased in the antioxidant group versus the placebo group, respectively: plasma levels of vitamin E increased by 8.8 and 2.2 mumol/L (p < 0.01), vitamin C increased by 12.6 and 4.2 mumol/L (p < 0.01), beta-carotene increased by 0.28 and 0.06 mumol/L (p < 0.01), and vitamin A increased by 0.36 and 0.12 mumol/L (p < 0.01). Serum lipid peroxides decreased by 1.22 pmol/ml in antioxidant versus 0.22 pmol/ml in the placebo group (p < 0.01). Angina pectoris, total arrhythmias, and poor left ventricular function occurred less often in the antioxidant group. Cardiac end points were significantly less in the antioxidant group (20.6% vs 30.6%, respectively). These results suggest that combined treatment with antioxidant vitamins A, E, C, and beta-carotene in patients with recent acute myocardial infarction may be protective against cardiac necrosis and oxidative stress, and could be beneficial in preventing complications and cardiac event rate in such patients.
OBJECTIVE: To test whether a fat modified and fruit and vegetable enriched diet in conjunction with moderate physical activity reduces the cardiac event rate in patients with coronary artery disease (CAD) and its risk factors in an urban setting in India. SUBJECTS AND METHODS: 480 patients either with CAD or with risk factors. Those with definite or possible CAD including angina pectoris (n = 210) based on World Health Organization criteria and patients with risk factors were assigned to diet A (n = 231) or diet B (n = 232) for a period of 3 years. Both groups were advised to follow a fat modified diet. Group A was also advised to consume at least 400 g/day of fruits, vegetables and legumes according to World Health Organization advice and include moderate physical activity. RESULTS: Waist-hip ratios, fasting and post-prandial blood glucose, plasma insulin levels, blood pressure and weight fell significantly in patients in group A compared with those in group B. While triglycerides in group A showed a significant decrease, high density lipoprotein cholesterol showed a significant increase. Both groups showed a significant reduction in total and low density lipoprotein cholesterol, although the decrease was greater in group A than group B. Central obesity decreased by 6.2% in group A vs. 1.2% in group B, 95% confidence interval of difference 2.3 to 7.8. The incidence of cardiac events was significantly lower in group A than group B (29 vs. 43 patients, p < 0.01). All-cause mortality also significantly declined in group A compared with group B (16 vs. 24 died, p < 0.05). The group A patients with better adherence to exercise and diet showed greater reduction in central obesity and greater decline in cardiac event rates and total mortality compared to control group B. CONCLUSIONS: It is possible that moderate physical activity in conjunction with dietary changes in patients with CAD may cause substantial reductions in central obesity and associated disturbances corresponding to a significant decrease in cardiac events and mortality during the follow-up of 3 years.
In a randomised, double-blind placebo-controlled trial, the effects of the administration of oral L-carnitine (2 g/day) for 28 days were compared in the management of 51 (carnitine group) and 50 (placebo group) patients with suspected acute myocardial infarction. At study entry, the extent of cardiac disease, cardiac enzymes and lipid peroxides were comparable between the groups, although both groups showed an increase in cardiac enzymes and lipid peroxides. At the end of the 28-day treatment period, the mean infarct size assessed by cardiac enzymes showed a significant reduction in the carnitine group compared to placebo. Electrocardiographic assessment of infarct size revealed that the QRS-score was significantly less in the carnitine group compared to placebo (7.4 +/- 1.2 vs 10.7 +/- 2.0), while serum aspartate transaminase and lipid peroxides showed significant reduction in the carnitine group. Lactate dehydrogenase measured on the sixth or seventh day following infarction showed a smaller rise in the carnitine group compared to placebo. Angina pectoris (17.6 vs 36.0%), New York Heart Association class III and IV heart failure plus left ventricular enlargement (23.4 vs 36.0%) and total arrhythmias (13.7 vs 28.0%) were significantly less in the carnitine group compared to placebo. Total cardiac events including cardiac deaths and nonfatal infarction were 15.6% in the carnitine group vs 26.0% in the placebo group. It is possible that L-carnitine supplementation in patients with suspected acute myocardial infarction may be protective against cardiac necrosis and complications during the first 28 days.
In a population survey of 162 rural and 152 urban subjects aged 26-65 years at Moradabad, the findings are compared with existing data on Indian immigrants to Britain and United States. In comparison with rural subjects, urban subjects had a higher prevalence of coronary artery disease (8.6 vs. 3.0%) and diabetes (7.9 vs 2.5%), higher blood pressures, total and low density lipoprotein cholesterol, triglycerides and postprandial 2-h blood glucose and plasma insulin similar to observations made in UK in immigrants compared to Europeans. Fasting plasma insulin and high density lipoprotein cholesterol levels in urban subjects were comparable with rural subjects. Mean body weights were significantly higher in urban women, but not in men, than in rural subjects. However the body mass index (22.9 +/- 4.2 vs. 21.6 +/- 2.4 kg/m2) and waist-hip girth ratio (0.89 +/- 0.10 vs. 0.86 +/- 0.07) were significantly higher in urban men compared to rural men without such differences in women. Underlying these differences in risk factors, urban subjects had three times better socioeconomic status than rural subjects and were eating higher total and saturated fat, cholesterol and refined carbohydrates and lower total and complex carbohydrates compared to rural men and women. Energy expenditure during routine and spare time physical activity was significantly higher in rural compared to urban subjects. Those patients who had risk factors, showed lesser physical activity and had greater adverse factors in the diet compared to subjects without risk factors. Body mass index and waist-hip girth ratio in patients with risk factors were significantly higher than in subjects without risk factors. The findings suggest that decreased consumption of total and saturated fat and increased physical activity may be useful for prevention of coronary artery disease among urbans as well as in immigrants.
OBJECTIVE: To determine whether a fat- and energy-reduced diet rich in antioxidant vitamins C and E, beta carotene, and soluble dietary fiber reduces free-radical stress and cardiac enzyme level and increases plasma ascorbic acid level 1 week after acute myocardial infarction. DESIGN: Randomized, single blind, controlled study. SETTING: Primary- and secondary-care research center for patients with myocardial infarction. SUBJECTS: All subjects with suspected acute myocardial infarction (n = 505) were considered for entry to the study. Subjects with definite or possible acute myocardial infarction and unstable angina (according to World Health Organization criteria) were assigned to either an intervention diet (n = 204) or a control diet (n = 202) within 48 hours of symptoms of infarction. INTERVENTIONS: Intervention and control groups were advised to consume a fat-reduced, oil-substituted diet. The intervention group was also advised to eat more fruits, vegetable soup, pulses, and crushed almonds and walnuts mixed with skim milk. MAIN OUTCOME MEASURES: Reduction in plasma lipid peroxide and lactate dehydrogenase cardiac enzyme levels, increase in plasma ascorbic acid level, and compliance with diet, especially with vitamin C intake as determined by chemical analysis. STATISTICAL ANALYSIS: A two-sample t test using one-way analysis of variance for comparison of data. RESULTS: Plasma lipid peroxide level decreased significantly in the intervention group compared with the control group (0.59 pmol/L in the intervention group and 0.10 pmol/L in the control group; 95% confidence interval of difference = 0.19 to 0.83). Lactate dehydrogenase level increased less in the intervention group than in the control group (427.7 vs 561.2 U/L; confidence interval of difference = 82.9 to 184.7). Plasma ascorbic acid level increased more in the intervention group than in the control group (23.38 vs 7.95 mumol/L; confidence interval of difference = 12.85 to 26.13). APPLICATIONS/CONCLUSIONS: Consumption of an antioxidant-rich diet may reduce the plasma levels of lipid peroxide and cardiac enzyme and increase the plasma level of ascorbic acid. Antioxidant-rich foods may reduce myocardial necrosis and reperfusion injury induced by oxygen free radicals.
OBJECTIVE: In view of the rapid increase in the prevalence of coronary artery disease (CAD) in developing countries, our aim was to determine the prevalence of CAD and its risk factors and lifestyle factors in an elderly population from north India. METHODS: A random sample of 595 elderly subjects between 50 to 84 years of age was obtained from the urban population of Moradabad. The response rate was 90.1%. The survey methods included a questionnaire containing information on 7-day food intake, other lifestyle factors, Rose questionnaire for diagnosis of angina pectoris, a standard 12-lead electrocardiogram, blood pressure measurements and blood examination. RESULTS: The total prevalence of CAD based on clinical history and electrocardiogram was 121/1000 (95% CI 72 to 165). The prevalence rate was slightly higher in males (130/1000) than in females (110/1000). The prevalence of CAD based on the Rose questionnaire was 57/1000 and based on electrocardiogram in 561 asymptomatic subjects was 67/1000. CAD was significantly higher in the elderly (65 to 84 years) group than in the middle-aged (50 to 64 years) group (168 vs. 97 per 1000), respectively. While the prevalence of hypertension was significantly higher in the elderly than middle-aged group respectively (214 vs. 168 per 1000), the prevalence of central obesity was significantly higher in the middle-aged than elderly group (674 vs. 632 per 1000). Other risk factors including smoking were comparable in the two subgroups. Prevalence of major risk factors and central obesity were significantly higher among patients with CAD than in the rest of the subjects. Prevalence of CAD was significantly higher in the middle and higher socio-economic groups compared to the lower income group. These higher income groups were also eating significantly higher amounts of visible fat and had a higher prevalence of physical inactivity (93.3%) compared to the lower income group. CONCLUSIONS: CAD and its risk factors such as hypertension, hypercholesterolemia, diabetes and central obesity are of sufficient magnitude in the elderly population of India to be a major public health problem. The findings also indicate that CAD is more commonly associated with middle and higher socio-economic status which may be due to greater consumption of dietary fat and more sedentariness compared to lower socioeconomic groups.
Obesity, especially central, increases the risk of hypertension, hypertriglyceridaemia and diabetes to a significant extent. To determine whether dietary weight reduction can reduce blood pressure (BP) and other cardiovascular risk factors, 217 hypertensives were randomised to receive either 1600 Kcal/day diet (group A, n = 108) or the usual 2100 Kcal/day diet (group B, n = 109). Sodium intake and physical activity were kept similar in both groups. After 16 weeks of follow-up, patients in group A received significantly less energy leading to a 2.8 kg net reduction in mean weight in association with a significant net decrease in mean SBP and DBP (7.5/6.5 mm Hg) compared with nonsignificant changes in group B. There was a significant net decrease in mean total cholesterol (7.0%), low-density lipoprotein (LDL)-cholesterol (7.9%) and triglycerides (8.0%), with a significant net increase in high-density lipoprotein (HDL)-cholesterol (4.0%) in group A compared with group B. New risk factors such as glucose intolerance (8.0%) and central obesity (waist-hip girth ratio, 0.021) showed a significant net reduction compared with group B. Patients with central obesity and other associated disturbances showed maximal reduction in BP and other cardiovascular risk factors with a significantly greater increase in HDL-cholesterol. Mean doses of drugs were similar at entry to the study as well as after 16 weeks in both groups. It is possible that weight reduction due to a low caloric diet can moderate central obesity and associated disturbances in hypertensive subjects.
Central obesity in association with insulin resistance is a strong predictor of coronary artery disease (CAD) in South Asians; however the prevalence of central obesity and insulin resistance in Indians are unknown. Anthropometric measurements, dietary intakes, physical activity and prevalence of risk factors and CAD were obtained in 152 adults between 26-65 years of age (80 males, 72 females) selected by random sampling from urban population of Moradabad. The overall prevalence of central obesity was 539 per 1000 adults including 56.2% in males and 51.3% in females. The prevalence of glucose intolerance, diabetes mellitus, hypertension, hypertriglyceridemia and CAD were significantly higher in the higher quintiles of WHR above 0.88 compared to lower quintiles. Fasting and postprandial glucose, plasma insulin and triglycerides as well s total cholesterol and blood pressure were significantly higher in each of the upper quintile of WHR with increase in WHR compared to lowest quintile of WHR below 0.81. These findings indicate the existence of a modest degree of insulin resistance with a modest tendency to central obesity in the urban population of North India. The prevalence of CAD was significantly (p < 0.01) higher among subjects with central obesity than in non-obese subjects (21.5 vs 3.2%). Underlying these findings, the prevalence of central obesity was significantly greater among sedentary and mild activity group compared to moderate and heavy activity group and per day energy expenditure during activity in the upper quintiles with WHR > 0.88 was significantly less compared to energy expenditure in lower quintiles of WHR. Similarly dietary fat intake in the upper quintiles of WHR was also significantly higher than in the lower quintiles of WHR. These findings suggest that populations with higher prevalence of central obesity and CAD may be benefited with an aim to decrease central obesity.
OBJECTIVE: To study the relation of dietary and serum levels of magnesium (Mg) in acute myocardial infarction (AMI) and its complications in relation to noncardiac diagnoses. METHODOLOGY: Case control study in a primary and secondary care center for AMI patients. The study included 460 subjects with definite AMI (n = 335, group A), possible AMI (n = 64, group B), unstable angina (n = 19, group C) and controls with noncardiac chest pain (n = 42, group D). Demographic variables, dietary intake, and clinical and biochemical data were compared. Mean age, sex, body weight, and body mass index were comparable in all the groups. RESULTS: Dietary fat and cholesterol intakes were significantly higher and carbohydrate intakes were lower in group A, B and C patients with coronary artery disease compared to control group D. Dietary consumption of Mg was comparable in all groups; however, in 85 patients in group A (272.5 mg/day) and 17 in group B (280.4 mg/day) in whom ventricular arrhythmias were present, Mg intake was relatively lower compared to control group D (316.6 mg/day). Serum Mg levels in group A (1.66 mEq/L), B (1.65 mEq/L), and C (1.66 mEq/L) were within normal (1.74 mEq/L) limits, but were significantly lower than in control group D. CONCLUSIONS: Lower serum Mg in group A, B and C patients was attributed to increased demand during AMI, although in patients with complications (ventricular arrhythmias), Mg deficiency may in part result from relatively lower Mg intake, a hypothesis which requires further study.
The prevalence of coronary artery (CAD) disease in the Indian urban population is comparable to British population. Dietary intakes, antioxidant vitamins, prevalence of risk factors and CAD, were studied in a random sample of 152 adult urban subjects between 26-65 years of age (80 males, 72 females) from Peerzada street, Moradabad and compared with Indian immigrants to U.K. and a British comparison group. There was no significant relation with vitamin A. Smoking and diabetes were the confounding factors. Plasma antioxidant vitamin C (21.6 +/- 3.3 vs 42.5 +/- 4.5 mumol/L), vitamin E (15.2 +/- 2.8 vs 21.4 +/- 3.2 mumol/L) and beta-carotene (0.33 +/- 0.6 vs 0.55 +/- 0.08 mumol/L) were significantly lowered and lipid peroxides higher (2.82 +/- 0.22 vs 1.3 +/- 0.20 nmol/ml) in patients with CAD compared to subjects without any risk factors. The relation between low plasma level of vitamin C and E levels and carotene remained independently and inversely related after adjustment for smoking, diabetes and other risk factors. Regression analysis showed that after adjustment. Odd's ratio for carotene (1.82, 95% C.I. 0.50 to 3.72), vitamin C (2.23, 95% C.I. 1.14 to 5.26) and vitamin E (2.35, 95% C.I. 1.29 to 5.30) were significantly related to CAD. Underlying these changes, dietary intake of vitamin A, E, C and beta-carotene was significantly less in patients with CAD. Vitamin C and beta-carotene intake were less in smokers and diabetes. Compared with British population, the Indian urbans consumed less total and saturated fat and cholesterol and more polyunsaturated fat and complex carbohydrates. The plasma total and low density lipoprotein cholesterol levels were less in Indian urbans compared to Britons and so were mean body weight, body mass index and waist-hip ratio. Plasma insulin levels were comparable. The fatty acid composition of the diet, blood lipids, central obesity and insulin levels do not appear to account for high rates of CAD among Indians. The findings suggest that urban population in India may benefit from eating diets rich in antioxidant vitamin C, E and beta-carotene.
In a randomized, single-blind, controlled trial, 621 patients were assigned either intervention diet A (group A, 310 patients) or control diet B (group B, 311 patients) for a period of 24 weeks. After 24 weeks as revealed by dietary questionnaires, group A patients received: (1) a diet with a higher percentage of calories from fruits and vegetables and complex carbohydrates; (2) a higher polyunsaturated/saturated fat ratio diet; and (3) a larger amount of soluble dietary fiber, antioxidant vitamins and minerals and low saturated fat and cholesterol than group B. Group A patients also did more physical and yogic exercises than group B. Adherence to diet and exercise was obtained through questionnaires and information obtained was quantified into a formula. After 24 weeks, the overall score of diet and exercises was significantly higher in group A than in group B. There was a significant decrease in serum total cholesterol (13.3%), low-density lipoprotein cholesterol (16.9%), triglycerides (19.2%), fasting blood glucose (19.5%) and blood pressures (11.5/6.2 mm Hg) in the intervention group compared with initial levels and changes in group B. The effect of exercise on the decrease in risk factors was additive. Within group A, overall score for diet and exercise was greater in 1 subset of 116 patients in the intervention group which had maximal lifestyle changes. A separate analysis of data in this subgroup revealed a greater decrease in risk factors compared with risk factor changes in the remaining 194 patients with less higher overall score; this indicated that the relation of lifestyle changes with reduction in risk factors may be of causal nature.(ABSTRACT TRUNCATED AT 250 WORDS)
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The effects of antioxidant-rich foods as adjuncts to a prudent diet were compared for 12 weeks in a randomized, single-blind and controlled trial in 204 (group A) and 202 (group B) patients with acute myocardial infarction. There was a significant decrease in cardiac end points in group A compared to group B (37 vs 58, p < 0.01) after 12 weeks. Within intervention group A, those 108 patients with greater adherence to the intervention program showed a greater reduction in cardiac end points (14 vs 58, p < 0.001), and a significant decrease in total mortality (6 vs 28, p < 0.001), including cardiac mortality (6 vs 25, p < 0.01) compared to group B. Underlying these beneficial effects, antioxidant-rich foods caused a significantly smaller rise in lactate dehydrogenase (LDH) cardiac enzyme in group A than in group B (427.8 vs 561.6 IU/dL), indicating that the protective influence of such a diet may be observed within 1 week. The subset of group A patients showing reduction in mortality also had a lesser rise in LDH and greater reduction in blood lipids, blood glucose and blood pressures. Antioxidant-rich foods also caused a significant decrease in blood lipids with a lower decrease in high-density lipoprotein cholesterol in group A than in group B. Assay of serum level of antioxidants and long-term follow-up may confirm our observations.
A randomized, single-blind, controlled trial was conducted to examine the effects of guava fruit intake on BPs and blood lipids in patients with essential hypertension. Of 145 hypertensives that entered the trial, 72 patients were assigned to take a soluble fibre and a potassium-rich diet containing 0.5-1.0 kg of guava daily (group A) and 73 patients to their usual diet (group B), while salt, fat, cholesterol, caffeine and alcohol intake were similar in both groups. Mean age, mean body weight and male sex, were similar, and so were risk factors, mean BPs, mean serum sodium, potassium, calcium, magnesium, triglycerides, cholesterol and HDL-cholesterol in both groups. Dietary adherence to guava intake was checked by a questionnaire. After four weeks of follow-up on an increased consumption of dietary potassium and low sodium/potassium ratio, group A patients were associated with 7.5/8.5 mmHg net decrease in mean systolic and diastolic pressures compared with group B. Increased intake of soluble dietary fibre (47.8 +/- 11.5 vs. 9.5 +/- 0.85 g/day) was associated with a significant decrease in serum total cholesterol (7.9%), triglycerides (7.0%) and an insignificant increase in HDL-cholesterol (4.6%) with a mild increase in the ratio of total cholesterol/HDL-cholesterol in group A patients compared with group B. It is possible that an increased consumption of guava fruit can cause a substantial reduction in BPs and blood lipids with a lack of decrease in HDL-cholesterol due to its higher potassium and soluble fibre content, respectively.
There is evidence that inclusion of high fiber foods such as oats, fruits and vegetables in the diet can decrease fat intake and modulate blood lipids. To test this hypothesis, 61 group A and 59 group B patients with essential hypertension were administered guava fruit preferably before meals in a foods-to-eat approach rather than foods-to-restrict, in a randomized and single-blind fashion for 12 weeks. At entry into the study, mean age, male sex, mean body mass index, percentages of risk factors and mean levels of blood lipids were comparable between groups A and B. Adherence to guava consumption was assessed by questionnaires and weighing of guava intake by 24-hour recall after 12 weeks of follow-up. Nutrient intakes including saturated and total fat were significantly decreased; carbohydrates, total and soluble fiber and vitamins and mineral intakes were significantly higher in group A than in group B at 12 weeks. There was a significant net decrease in serum total cholesterol (9.9%), triglycerides (7.7%) and blood pressures (9.0/8.0 mm Hg) with a significant net increase in high-density lipoprotein cholesterol (8.0%) after 12 weeks of guava fruit substitution in group A than in group B. By adding moderate amounts of guava fruit in the usual diet, changes in dietary fatty acids and carbohydrates may occur, providing significant amounts of soluble dietary fiber and antioxidant vitamins and minerals without any adverse effects. There is a greater decrease in lipoprotein metabolism and blood pressures.
This study was designed to test the efficacy of the administration of fruits and vegetables for 12 weeks as an adjunct to a prudent diet in decreasing blood lipids in 310 (intervention; group A) and 311 (control; group B) patients with risk factors of coronary artery disease (CAD) in a parallel, single-blind fashion. At entry to the study, sex, mean age, body weight, body mass index, systolic and diastolic blood pressures, and blood lipoproteins were comparable between both groups. Tasty fruits and vegetables were given to patients to eat before major meals for better nutrient adherence and adequacy. Dietary intakes were determined by questionnaires and by weighing of fruit and vegetable intake. Fruits and vegetables decreased total cholesterol level by 6.5% and low-density lipoprotein cholesterol level by 7.3% in group A, whereas the levels were unchanged in group B. The high-density lipoprotein cholesterol levels that decreased during the diet stabilization period in both groups, increased by 5.6% in group A after 12 weeks. Serum triglycerides also decreased (7%) more in group A than B. Fasting blood glucose decreased by 6.9% in group A and by 2.6% in group B. The combined effect of a fat-modified diet plus fruits and vegetables was greater than these changes. Because tasty fruits were taken by the patients before meals (when they are hungry) and are easily available at reasonable cost in our marketing and buying capacity, the compliance was excellent.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: To test whether a fat reduced diet rich in soluble dietary fibre, antioxidant vitamins, and minerals reduces complications and mortality after acute myocardial infarction. DESIGN: Randomised, single blind, controlled trial. SETTING: Primary and secondary care research centre for patients with myocardial infarction. SUBJECTS: 505 patients with suspected acute myocardial infarction. Those with definite or possible acute myocardial infarction and unstable angina based on World Health Organisation criteria were assigned to diet A (n = 204) or diet B (n = 202) within 24-48 hours of infarction. INTERVENTIONS: Both groups were advised to follow a fat reduced diet. Group A was also advised to eat more fruit, vegetables, nuts, and grain products. MAIN OUTCOME MEASURES: Mortality from cardiac disease and other causes. Serum lipid concentrations and compliance with diet. RESULTS: Blood lipoprotein concentrations and body weight fell significantly in patients in group A compared with those in group B (cholesterol fell by 0.74 mmol/l in group A v 0.32 mmol/l in group B, 95% confidence interval of difference 0.14 to 0.70, and weight by 7.1 v 3.0 kg, 0.52 to 7.68). The incidence of cardiac events was significantly lower in group A than group B (50 v 82 patients, p less than 0.001). Group A also had lower total mortality (21 v 38 died, p less than 0.01) than group B. CONCLUSIONS: Comprehensive dietary changes in conjunction with weight loss immediately after acute myocardial infarction may modulate blood lipoproteins and significantly reduce complications and mortality after one year.