Thirty-day readmission rate of COVID-19 patients discharged from a tertiary care university hospital in Turkey: an observational, single-center study.

BACKGROUND: The 30-day readmission rate is an important indicator of patient safety and hospital's quality performance. In this study, we aimed to find out the 30-day readmission rate of mild and moderate severity coronavirus disease of 2019 (COVID-19) patients discharged from a tertiary care university hospital and to demonstrate the possible factors associated with readmission. METHODS: This is an observational, single-center study. Epidemiological and clinical data of patients who were hospitalized with a diagnosis of COVID-19 were retrieved from a research database where patient information was recorded prospectively. Readmission data were sought from the hospital information management system and the National Health Information System to detect if the patients were readmitted to any hospital within 30 days of discharge. Adult patients (≥18 years old) hospitalized in COVID-19 wards with a diagnosis of mild or moderate COVID-19 between 20 March 2020 (when the first case was admitted to our hospital) and 26 April 2020 were included. RESULTS: From 26 March to 1 May, there were 154 mild or moderate severity (non-critical) COVID-19 patients discharged from COVID-19 wards, of which 11 (7.1%) were readmitted. The median time of readmission was 8.1 days (interquartile range [IQR] = 5.2). Two patients (18.1%) were categorized to have mild disease and the remaining 9 (81.9%) as moderate disease. Two patients who were over 65 years of age and had metastatic cancers and hypertension developed sepsis and died in the hospital during the readmission episode. Malignancy (18.7% vs. 2.1%, P = 0.04) and hypertension (45.5% vs. 14%, P = 0.02) were more common in those who were readmitted. CONCLUSIONS: This is one of the first studies to report on 30-day readmission rate of COVID-19 in the literature. More comprehensive studies are needed to reveal the causes and predictors of COVID-19 readmissions.

Evaluation of the effect of COVID-19 pandemic on anxiety severity of physicians working in the internal medicine department of a tertiary care hospital: a cross-sectional survey.

BACKGROUND: Internists who have an important role in the global response to the COVID-19 pandemic are under both physical and psychological pressures. AIMS: To assess the anxiety among physicians working in the internal medicine department of a tertiary care hospital who are on the frontline of the COVID-19 pandemic. METHODS: This single-centre, non-intervention, cross-sectional descriptive study was conducted using an online survey questionnaire from 1 April to 14 April 2020. Physicians of the Department of Internal Medicine were invited to participate with a self-administered questionnaire. The degree of symptoms of anxiety was assessed by the Turkish versions of the 7-item Generalised Anxiety Disorder scale and Beck Anxiety Inventory, respectively. RESULTS: A total of 113 participants consented for the study and completed the questionnaire. The median age was 29 (IQR = 5) years and 53.1% were male. A total of 72 internists (63.7%) worked as 'frontline' healthcare workers directly engaged in diagnosing, treating or caring for patients with or suspected to have COVID-19. Female gender was significantly associated with high scores and levels in all scales compared to the male gender (P < 0.005). Having family members over 65 years old and with chronic diseases were significantly associated with high anxiety scores and levels (P < 0.005). CONCLUSIONS: In this survey of internists in a university hospital equipped with clinics, wards and intensive care unit for patients with COVID-19, female gender and having family members over 65 years old and with chronic diseases were associated with increased anxiety levels.

A comprehensive framework identifying readmission risk factors using the CHAID algorithm: a prospective cohort study.

OBJECTIVE: To identify frequency of readmission after discharge from internal-medicine wards, readmission risk factors, and reasons and costs of readmission. DESIGN: Prospective cohort study. SETTING: A tertiary-care hospital in Turkey. PARTICIPANTS: 2622 adult patients discharged from internal-medicine wards of the hospital between 1 February 2015 and 31 January 2016. MAIN OUTCOME MEASURES: Thirty day all-cause readmission rates, reasons and costs of readmission. To identify readmission risk factors Chi-square Automatic Interaction Detector (CHAID) analysis was conducted. RESULTS: The same hospital readmission rate was 17.9%, while the same hospital or different-hospital readmission rate was 21.3%. Receiver operating characteristic (ROC) curve analysis showed that the predictive performance of the CHAID algorithm was high. According to the CHAID algorithm, the most significant readmission risk factor was the main diagnosis of neoplasm at the index admission. In other diagnosis groups, higher Charlson comorbidity score, higher level of education, having a regular physician, and three dimensions of Readiness for Hospital Discharge Scale were significant risk factors for readmission. The most frequent reason for readmission was neoplasm, and the total cost of readmissions was ~$900 000. CONCLUSIONS: The CHAID algorithm for readmissions had a high predictive strength and provided details that aid physicians in decision-making. Measures must be taken from initial diagnosis to post-discharge follow-up, to minimize readmissions, especially in patients with neoplasm.

The cholesterol lowering efficacy of plant stanol ester yoghurt in a Turkish population: a double-blind, placebo-controlled trial.

BACKGROUND: We evaluated the cholesterol lowering efficacy of low-fat spoonable yoghurt with 1.9 g/d plant stanols as esters on plasma lipid profiles of Turkish subjects with mild to moderate hypercholesterolemia. METHODS: Using a randomised, double-blind, placebo-controlled study design, intervention (n = 35) and control (n = 35) groups consumed either 115 g low-fat yoghurt with 1.9 g/d plant stanols as esters or placebo yoghurt, respectively, for 4 weeks. Seventy subjects with untreated mild to moderate hypercholesterolemia (aged 23-65 years) were recruited. Changes in the lipid profile, including lipoproteins, apolipoproteins, and triglycerides, and anthropometric measurements were monitored at screening, baseline, and at the end of the second, third, and fourth weeks of intervention. The general linear model repeated measures procedure was used to test differences in the repeated continuous variables between study groups. RESULTS: Serum total cholesterol (4.6%), LDL cholesterol (6.3%), and non-HDL cholesterol (6.2%) concentrations were reduced significantly from baseline in the plant stanol group compared to the control group (p = 0.007, p = 0.005 and p = 0.005, respectively). A variation in the response of serum total and LDL cholesterol between the subjects in plant stanol group was obtained. No clinically significant change in anthropometrical measurements was observed during the intervention. CONCLUSIONS: The spoonable low-fat yoghurt with 1.9 g/d plant stanols as esters lowered total, LDL, and non-HDL cholesterol levels in Turkish subjects with mild to moderate hypercholesterolemia. Nevertheless variation in baseline cholesterol levels, genetic predisposition of the subjects and compliance may contribute to a large individual variability.

Mercury vapor inhalation and poisoning of a family.

Acute mercury vapor poisoning is a rare but fatal toxicological emergency. People are exposed to mercury in daily life by the way of foods, vaccines, antiseptics, ointments, amalgam or occupation. We present here, the clinical picture and management of four members of the same family who were exposed to elemental mercury. Three of the family members were seen in another hospital with malaise, fever, eritematous rash and pulmonary problems. Their questioning revealed the mercury exposure. Having a suspicion of heavy metal intoxication, blood and urine mercury levels were measured and mercury intoxication was diagnosed. On admission to our hospital, two patients already had chelation therapy. In three of them we found three distinct abnormalities: encephalopathy, nephrotic syndrome and polyneuropathy. The fourth family member had minor symptoms. This family is an example for the inhalation exposure resulting from inappropriate handling of liquid mercury. During the first days, flu like illness ensues. Then, severe pulmonary, neurological, renal, hepatic, hematological and dermatological dysfunctions develop. Blood and urine mercury levels should be tested on suspicion, but it must be kept in mind that blood level is unreliable in predicting the severity of mercury toxicity. The priority in the treatment should be removing the patient from the source of exposure. Then British anti-Lewisite, edetate calcium disodium, penicillamine, Sodium 2,3-dimercaptopropane-1-sulfhonate and 2,3-dimercaptosuccinic acid can be used for binding the mercury. We conclude that since mercury-containing devices are present in daily life, physicians must be able to recognize the clinical manifestations and treatment of mercury poisoning.

Independent predictors of in-hospital mortality and the need for intensive care in hospitalized non-critical COVID-19 patients: a prospective cohort study.

One of the most helpful strategies to deal with ongoing coronavirus pandemics is to use some prudence when treating patients infected with SARS-CoV-2. We aimed to evaluate the clinical, demographic, and laboratory parameters that might have predictive value for in-hospital mortality and the need for intensive care and build a model based on them. This study was a prospective, observational, single-center study including non-critical patients admitted to COVID-19 wards. Besides classical clinic-demographic features, basic laboratory parameters obtained on admission were tested, and then new models for each outcome were developed built on the most significant variables. Receiver operating characteristics (ROC) analyses were performed by calculating each model's probability. A total of 368 non-critical hospitalized patients were recruited, the need for ICU care was observed in 70 patients (19%). The total number of patients who died in either ICU or wards was 39 (10.6%). The first two models (based on clinical features and demographics) were developed to predict ICU and death, respectively; older age, male sex, active cancer, and low baseline saturation were noted to be independent predictors. The area under the curve values of the first two models were noted 0.878 and 0.882 (p < .001; confidence interval [CI] 95% [0.837-0.919], p < .001; CI 95% [0.844-0.922]). Following two models, the third and fourth were based on laboratory parameters with clinic-demographic features. Initial lower sodium and lower albumin levels were determined as independent factors in predicting the need for ICU care; higher blood urea nitrogen and lower albumin were independent factors in predicting in-hospital mortality. The area under the curve values of the third and fourth model was noted 0.938 and 0.929, respectively (p < .001; CI 95% [0.912-0.965], p < .001; CI 95% [0.895-962]). By integrating the widely available blood tests results with simple clinic demographic data, non-critical patients can be stratified according to their risk level. Such stratification is essential to filter the patients' non-critical underlying diseases and conditions that can obfuscate the physician's predictive capacity.

A retrospective observational cohort study of the clinical epidemiology of bloodstream infections due to carbapenem-resistant Klebsiella pneumoniae in an OXA-48 endemic setting.

This study aimed to characterize the epidemiology and clinical outcomes of patients with bloodstream infections (BSIs) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) in an OXA-48-predominant environment. This was a retrospective single-centre cohort study including all consecutive patients with CRKP BSIs treated between 1 January 2014 and 31 December 2018. Multivariate analysis, subgroup analysis and propensity-score-matched analysis were employed to analyse 30-day mortality as the primary outcome. Clinical cure at day 14 was also analysed for the whole cohort. In total, 124 patients with unique isolates met all the inclusion criteria. OXA-48 was the most common type of carbapenemase (85.5%). Inappropriate therapy was significantly associated with 30-day mortality [70.6% vs 39.7%, adjusted odds ratio (aOR) 4.65, 95% confidence interval (CI) 1.50-14.40, P=0.008] and 14-day clinical failure (78.5% vs 56.2%, aOR 3.14, 95% CI 1.09-9.02, P=0.033) in multivariate analyses. Among those treated appropriately, the 30-day mortality rates were similar in monotherapy and combination therapy arms (OR 2.85, 95% CI 0.68-11.95, P=0.15). INCREMENT CPE mortality score (aOR 1.16, 95% CI 1.01-1.33, P=0.029), sepsis at BSI onset (aOR 2.90, 95% CI 1.02-8.27, P=0.046), and inappropriate therapy (aOR 4.65, 95% CI 1.50-14.40, P=0.008) were identified as independent risk factors for 30-day mortality. Colistin resistance in CRKP had no significant impact on 30-day mortality. These results were also confirmed in all propensity-score-matched analyses and sensitivity analyses. Appropriate regimens were associated with better clinical outcomes than inappropriate therapies for BSIs with CRKP predominantly possessing OXA-48.

Altered tryptophan absorption and metabolism could underlie long-term symptoms in survivors of coronavirus disease 2019 (COVID-19).

The global pandemic of COVID-19 has been lasting for more than one year and there is little known about the long-term health effects of the disease. Long-COVID is a new term that is used to describe the enduring symptoms of COVID-19 survivors. Huang et al. reported that fatigue, muscle weakness, sleep disturbances, anxiety, and depression were the most common complaints in COVID-19 survivors after 6 months of the infection. A recent meta-analysis showed that 80% of COVID-19 survivors have developed at least one long-term symptom and the most common five were fatigue, headache, attention deficit disorder, hair loss, and dyspnea. In this paper, we discuss the hypothesis that altered tryptophan absorption and metabolism could be the main contributor to the long-term symptoms in COVID-19 survivors.

Effect of gastric acid suppression on Clostridioides difficile-induced diarrhea and appropriateness of gastric acid suppressors in hospitalized patients: A matched case-control study.

BACKGROUND AND STUDY AIMS: The effects of gastric acid suppressors (GASs) on Clostridioides difficile infection remain controversial. Moreover, studies have shown that GASs are overused. This study was designed to evaluate the effects of GAS use on the risk of C. difficile-induced diarrhea (CDID) development and to investigate the appropriate use of GASs. PATIENTS AND METHODS: In this observational case-control study, patients hospitalized between January 2010 and December 2016 who had diarrhea after 3 days of hospitalization were included. The study (n = 122) and control (n = 122) groups were matched according to the patients' hospitalization dates and departments. RESULTS: No significant difference in CDID development was observed between the study and control groups. However, GAS use was excessive in the study and control groups (usage rates were 90.2% and 91.8%, respectively) (p > 0.05). Most proton pump inhibitors and histamine-2 receptor antagonists were used without an appropriate indication. Surprisingly, the use of nonsteroidal anti-inflammatory drugs for 7 days and longer showed a significant difference between the study and control groups (p < 0.05). Additionally, significant differences in enteral feeding, oral nutritional support products, carbapenem, penicillin, glycopeptide antibiotics, antifungals, hypoalbuminemia, and increased leukocyte levels were observed between the study and control groups (p < 0.05). CONCLUSION: A significant difference in CDID development was not detected. The use of non-steroidal anti-inflammatory drugs for 7 days and longer was a risk factor for CDID development. Additionally, an excessive inappropriate use of GASs was observed. Clinicians should be cautious of all these factors, which may increase the risk of CDID development.

Can Levamisole be used in the treatment of COVID-19 patients presenting with diarrhea?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China, on Jan 7, 2020. Over the following months, the virus rapidly spread throughout the world. Coronavirus Disease 2019 (COVID-19) can involve the gastrointestinal tract, including symptoms like nausea, vomiting and diarrhea and shedding of the SARS-CoV-2 in feces. Angiotensin-converting enzyme 2 (ACE2) protein, which has been proven to be a cell receptor for SARS-CoV-2, is expressed in the glandular cells of gastric, duodenal, and rectal epithelia, supporting the entry of SARS-CoV-2 into the host cells. According to the literature, rates of COVID-19 patients reporting diarrhea were between 7 - 14%. Diarrhea in the course of COVID-19 disease can cause dehydration and hospitalization. Although no antiviral drug was specifically designed for the treatment of diarrhea, several molecules could have beneficial effects by reducing viral replication. In this letter, we discussed the Levamisole, which is an anthelmintic agent with immunomodulatory effects, could be used effectively both for antiviral therapy and especially in COVID-19 patients with diarrhea.

Spontaneous subepithelial hemorrhage of renal pelvis and ureter (Antopol-Goldman lesion) in hemophilia A patient with inhibitor: Case report and review of the literature.

INTRODUCTION: The Antopol-Goldman lesion (AGL), which expresses subepithelial hemorrhage in the renal pelvis, was first defined by Antopol and Goldman in 1948. The objective of this study is to report the first case of AGL in patients with congenital hemophilia and review the relevant literature. PATIENT CONCERNS: A 32-year-old male patient diagnosed with congenital hemophilia A (FVIII = %4) with high responding inhibitors (7.4 BU) was admitted to our emergency department with gross hematuria and sudden onset flank pain. DIAGNOSIS: Abdominal computed tomography (CT-scan) presented a hyperdense lesion in the left ureteropelvic junction with Hounsfield Units of 56 compatibles with hemorrhage. INTERVENTIONS: The patient was given 4500 IU of factor eight inhibitor bypass activity (FEIBA) intravenously twice daily for 5 days. Subsequently, 4500 IU of FEIBA was administrated once a day for 2 days. OUTCOMES: The patient's complaints disappeared on the fourth day of treatment. Macroscopic and microscopic hematuria was not seen in the following days. Follow-up CT was done 3 months after discharge and showed normal left renal pelvis without hyperdenosis. Follow-up CT was performed 3 months after discharge and presented normal left renal pelvis with no hyperdense lesion. CONCLUSION: Although very rare, AGL should be kept in mind in the differential diagnosis of renal pelvic hemorrhage. In the patient who has an underlying history of coagulopathy nephrectomy can be avoided when there is awareness of AGL.

An unusual complication: prolonged myopathy due to an alternative medical therapy with heat and massage.

A 66-year-old male presented with swelling of the neck and arms, which was limiting his daily activities. Serum muscle enzymes were increased. A detailed history revealed that the patient received 10 cycles of infrared heat and massage therapy approximately 1 month before his first visit to the outpatient clinic. The swelling of the extremities began on day 11 of therapy, and the pain became unbearable. He was followed up with analgesics. There was a significant decrease in the muscle enzymes and a subjective improvement of 60-70% one month after discharge. Alternative therapies may have serious complications, and patients usually do not report them unless asked specifically.

Fenofibrate improves endothelial function and decreases thrombin-activatable fibrinolysis inhibitor concentration in metabolic syndrome.

Procoagulant state, inflammation, and endothelial dysfunction have been documented in metabolic syndrome. Endothelial dysfunction is a strong predictor of cardiovascular events. Studies on the association of thrombin-activatable fibrinolysis inhibitor and thrombosis are still controversial, but substantial evidence suggests that increased thrombin-activatable fibrinolysis inhibitor or thrombin-activatable fibrinolysis inhibits or protects against arterial thrombosis. This study aimed to assess concomitantly the effects of fenofibrate therapy on thrombin-activatable fibrinolysis inhibitor concentrations and endothelial functions in patients with metabolic syndrome. Twenty-five patients (16 women; mean age 50.4 +/- 7.0) were enrolled in the study. Plasma thrombin-activatable fibrinolysis inhibitor, C-reactive protein, and fibrinogen levels were measured before fenofibrate administration and after 8 weeks of fenofibrate treatment. Endothelial function was assessed by endothelial-dependent flow-mediated dilatation from brachial artery. Pretreatment (baseline) thrombin-activatable fibrinolysis inhibitor level was 52.3 (1.2-119.7) decreasing to 7.7 (0.9-51.2; P < 0.001) after 8 weeks of fibrate treatment. Endothelial functions, which were measured with flow-mediated dilatation, were significantly improved after treatment (mean flow-mediated dilatation was 6.76 +/- 2.21 at baseline and 10.66 +/- 1.17% after 8 week of fenofibrate treatment, P < 0.001). Fenofibrate decreases thrombin-activatable fibrinolysis inhibitor levels and improves endothelial function in metabolic syndrome and, thus, suggests a potential for protection against cardiovascular effects. Further studies are warranted to confirm the effects of fibrates on thrombin-activatable fibrinolysis inhibitor and for conclusive evidence on the association between thrombin-activatable fibrinolysis inhibitor and thrombosis.

Decrements in the thrombin activatable fibrinolysis inhibitor (TAFI) levels in association with orlistat treatment in obesity.

Obesity and its associated metabolic complications can impair the physiologic regulation of fibrinolysis, leading to a hyper coagulable state. We aimed to assess circulating thrombin activatable fibrinolysis inhibitor (TAFI) levels in obese female patients and to test the effects of orlistat-induced weight loss on basal TAFI concentrations. Obese female outpatients age 18 and older, with a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of at least 30, were included into the study. Thirteen nonobese (median BMI, 22.60 kg/m(2)) age-matched females were taken as controls. Plasma TAFI levels were measured before orlistat administration and after 6 months of orlistat treatment in the obese group and only one measurement was done in the control group. Twenty-seven obese patients were recruited into the study. The median TAFI level of the control group was 124.00; this value was significantly lower than the basal TAFI level of the obese group (p < 0.001). TAFI levels after orlistat therapy were statistically significantly lower than basal TAFI levels (p < 0.001) in the obese group. Hemostatic abnormalities including TAFI alterations represent a link between obesity and vascular thrombosis. Effective interventions should be considered in improving the obesity-associated prothrombotic risk profile.

Evaluation of bone metabolism and bone mass in patients with type-2 diabetes mellitus.

The objectives of this study were to determine whether type-2 diabetes was associated with a higher bone mineral density (BMD) in men and women and to evaluate the differences in mineral metabolism between diabetic and normal subjects by using biochemical bone turnover markers. In this study, 52 patients (37 females/15 males) aged 41-64 with type-2 diabetes mellitus and 48 nondiabetic control subjects (34 females/14 males) were evaluated. In men, BMD was significantly higher in diabetics at the forearm (p <0.05), whereas in women tended to be higher at the hip (p=0.002). Serum osteocalcin (p<0.0001), bone alkaline phosphatase (BAP) (p<0.05) and carboxyterminal telopeptide (CTx) (p<0.05) were higher in the control group than in diabetics. In men, serum osteocalcin (p<0.05) and CTx (p<0.005) and, in women, serum osteocalcin (p<0.0001) and BAP (p<0.05) were lower in diabetic subjects. In conclusion, our findings suggest that although bone formation is decreased in type-2 diabetes, diabetic patients are not susceptible to bone resorption. This low bone turnover can slow the rate of bone loss and cause a higher bone density than expected for their age.

Demographic, socioeconomic and educational aspects of obesity in an adult population.

Obesity as a disease is a yet-unidentified sum of genetic and environmental factors. Risky eating behavior and lifestyle may bring the disease. The aim of the study was to find out risk factors for obesity factors influencing definition of obesity. Participants (n = 1500) who filled out a questionnaire about eating habits are grouped according to their body mass indices as normal weight, overweight and obese (n = 500 in each group). According to our results, the prevalence of having obese first-degree relatives is significantly higher in obese individuals (p < 0.001). Sixty-two of normal weighing subjects were university graduates, whereas this ratio was only 31% in the obese group (p < 0.001). Incidence of obesity was higher in married participants when compared to the single or divorced/widowed persons (p < 0.001). Multinomial logistic regression analysis gave the following results: risk of obesity was 57% less in participants lacking a family history of obesity when compared to the ones with a positive family history (p = 0.005). Being married increases the risk of obesity 2.5 times; being a primary school graduate increases the risk about 1.5 times. Lower educational level, unemployment and lack of counseling seem to be risk factors associated with obesity. Diverging patterns of sociodemographic features, lifestyles and perception were evident even between overweight and obese populations.

Ovarian carcinoma in two patients with chronic liver disease.

Ascites is a common and debilitating complication of cirrhosis. However, patients with chronic liver disease are not spared from other causes of ascites and physicians should be careful not to miss an underlying malignancy. Ovarian cancer is an insidious disease, which is difficult to diagnose and it ranks first in mortality among all gynecological cancers. Here, we present two cases of patients with chronic liver disease that developed ascites not simply because of cirrhosis but as a manifestation of ovarian cancer. We would like to emphasize that the causes of ascites, other than the liver itself, should not be overlooked in patients with chronic liver disease.

How hematopoietic stem cells know and act in cardiac microenvironment for stem cell plasticity? Impact of local renin-angiotensin systems.

Bone marrow-derived hematopoietic stem cells (HSC) can exhibit tremendous differentiation activity in numerous non-hematopoietic organs. This enigmatic process is called as 'stem cell plasticity' (SCP). HSC may promote structural and functional repair in several organs such as heart, liver, brain, and skeletal muscle via the SCP. The differentiation capacity of HSC is dependent on the specific signals present in the local tissue microenvironment. Those specific molecular signals required for the interactions of HSC and host tissues are currently unknown. The aim of this report is to propose a hypothesis on how HSC reach, recognize, and function in cardiac tissues in the context of SCP. Locally signaling cardiac microenvironment is essential for the seeding, expansion, and 'cardiomyocyte differentiation' of the HSC in the heart. Our hypothesis is that the receptors, ligands, and signaling pathways of the tissue renin-angiotensin system (RAS) serve as the link between HSC and local cardiac microenvironment in SCP. The RAS is considered as a 'tissue-based system' exhibiting paracrine functions within many organs. The presence of local hematopoietic bone marrow RAS and local cardiac RAS have been suggested. Both local tissue RASs share similar angiotensin peptide-signaling pathways such as JAK-STAT and mitogen-activated protein kinases. HSC have angiotensin type I (AT1a) receptors for the binding of angiotensin II, the active component of the RAS. Binding of angiotensin II to AT1a can increase hematopoietic progenitor cell proliferation. Local cardiac RAS has critical (patho)biological functions in the cardiomyocyte survival, renewal, and growth, as well as in cardiac remodeling. Therefore, the components of the local cardiac RAS and hematopoietic RAS could interact with each other during the SCP through myocardial tissue repair. Activation of the local myocardial RAS after injury may be related to homing and engraftment of the HSC to the cardiac tissue. Regenerating myocardial tissue may exert regulatory functions on circulating or resident HSC via the locally active RAS. Understanding the exact molecular basis of SCP in relation to local tissue RAS could offer new frontiers in the better management of ischemic cardiac diseases.