Open Access Case Report

Renal Oncocytoma: Report of Two Cases and Review of the Literature

E. O. Ofori, B. A. Bin Alhassan, K. Akakpo, E. G. Imbeah, A. Asante-Asamani, P. Maison, G. A. Rahman

Journal of Advances in Medicine and Medical Research, Page 16-23
DOI: 10.9734/jammr/2020/v32i530412

Introduction: Renal oncocytomas are benign tumours arising from the intercalated cells of the collecting ducts and account for 3% to 7% of primary renal tumours. It was first described by Zippel in 1942. Oncocytomas are mostly asymptomatic and often discovered incidentally. They are often diagnosed postoperatively due to clinical and radiographic challenges in differentiating them from renal cell carcinoma.

Presentation of Case: The present study reports two cases of renal oncocytoma in a 61‑year‑old man who was asymptomatic and a 73‑year‑old woman who was symptomatic. Relevant clinical and imaging data on the two patients were reviewed. Both patients underwent nephrectomy via flank incisions.

Discussion: The typical morphologic features of oncocytoma were observed on histological examination of the excised kidney speci­mens. The postoperative course of each patient was uneventful and they were discharged 14 and 6-days post‑surgery, respec­tively. In addition, the present study reviews the literature regarding the clinical, radiological and pathological characteristics of renal oncocytoma.

Conclusion: Renal oncocytoma though is benign and has an excellent prognosis, the preoperative diagnostic challenges invariable warranted radical nephrectomy.

Open Access Original Research Article

Hepatotoxic Effect of Port Harcourt Eliozu Landfill Leachate in Wistar Rats

I. I. Weleh, O. A. Georgewill, L. C. Barizoge, D. V. Dapper

Journal of Advances in Medicine and Medical Research, Page 1-8
DOI: 10.9734/jammr/2020/v32i530410

Studies have reported deleterious effect of landfill leachate and their surrounding water sources around the world. None has been reported on the Port Harcourt (Eliozu) landfill. This therefore necessitates this study that evaluated the hepatotoxic effects of Port Harcourt (Eliozu) landfill in wistar rats. 25 wistar rats were grouped into five of five rats each. Group 1 served as the control and received 1 ml of commercial non-carbonated bottled water; Group 2 served as negative control and received 1 ml of water obtained from borehole about 1 km from the landfill; while Groups 3, 4 and 5 received 1 ml of 10% of leachate concentration, 1 ml of 50% of leachate concentration and 1 ml of 100% of leachate concentration respectively once daily for 90 days. After the treatment period, the rats were sacrificed and 5 ml of blood was collected via cardiac puncture. The blood samples were prepared and used for the determination of serum concentrations of liver enzymes. The rats were also dissected and the liver harvested for histochemical analysis using the periodic acid Schiff stain. Result showed the serum concentrations liver enzymes significantly increased in the rats exposed to the leachate and water from a nearby borehole. Also histochemistry examination showed a marked distortion of the hepatic cells and cirrhotic change in the test groups compared to control. This study therefore concludes that exposure to Port Harcourt Eliozu landfill leachate (PELL) may cause significant hepatotoxicity in rats.

Open Access Original Research Article

Revisiting Puerperal Sepsis in Obsteric Referal Centres in Port Harcourt, Southern Nigeria

Oranu Emmanuel Okwudili, Owolabi Ayodeji Oluwaseun, I. Nonye-Enyindah Esther

Journal of Advances in Medicine and Medical Research, Page 9-15
DOI: 10.9734/jammr/2020/v32i530411

Background: As the frontier of knowledge expands, surgical skills improve; and with the advent of increasingly potent antibiotics, it is expected that puerperal sepsis and its complications as captured in the literature of studies will be on the down turn. With this in mind, we decided to find out what is current as par risk factors and complications of puerperal sepsis in these obstetric referral centres in Port Harcourt.

Objective: To determine the risk factors and complications of puerperal sepsis at the University of Port Harcourt Teaching Hospital(UPTH), Port Harcourt and the River State University Teaching Hospital (RSUTH), Port Harcourt, Nigeria.

Methods: The case notes of these patients were retrieved from the medical records departments and relevant data extracted using a well-structured proforma.  Data collected included the demographic characteristics, booking status, background immune suppression (HIV/AIDS or DM), labour characteristics, place and mode of delivery, fetal outcome, length of hospital stay. Morbidities like septicaemia, pelvic abscess, disseminated intravascular coagulopathy among others; and the presence of mortality was also noted. The data was analyzed using SPSS version 23.0. Statistical analysis of data was done by Chi-square test. A p-value less than 0.05 was considered significant. The result is presented in tables of frequencies and percentages.

Results: The prevalence of puerperal sepsis was 1.7%. Risk factors were low parity, unbooked status (84.35%) and wound infection (29.9%), among other intrauterine foetal death (22.8%), obstructed labour (14.2%) and perineal tear (11.0%). The main complications of puerperal sepsis noticed were prolonged hospital stay (58.3%) and septicaemia (13.4%); pelvic abscess (10.2%) and intestinal obstruction (4.7%) while (1)3.1% ended in mortality.

Conclusion: Complications of puerperal sepsis were still high in these centres. Worrisomely, a huge number of these patients were unbooked.

Open Access Original Research Article

Prevalence and Risk Factors of Urolithiasis in Children with Cerebral Palsy

Ghazal Elsayed Eissa, Mohamed Abd El-Aziz El-Gamasy, Azza Kamal Al-Shahawy, Amira Hamed Darwish

Journal of Advances in Medicine and Medical Research, Page 24-39
DOI: 10.9734/jammr/2020/v32i530414

Introduction: Cerebral palsy (CP)is due to damage occurring to the developing brain. This damage can occur during pregnancy, delivery, the first month of life, or less commonly in early childhood. Cerebral palsy is one of the most common causes of physical disability in childhood. Rates of cerebral palsy appear to be similar in both the developing and developed world.  The overall CP morbidity rate will automatically increase unless a substantially improved outcome in survivors can be achieved. Children with CP are predisposed to many complications including renal stones.

Aim of the Study: The aim of this study was detection of prevalence and risk factors of urolithiasis in children with cerebral palsy.

Subjects and Methods: This cross sectional case control study was conducted on forty children suffering from cerebral palsy who were attending the Pediatric Neurology Unit of Tanta University Hospital through the period from March 2018 to March 2019. Forty age and sex matched children were taken as a control group.

Inclusion Criteria: Children suffering from different types of cerebral palsy at any age.

Exclusion Criteria: Children whose parents refuse to participate in the study, children receiving drugs that can cause renal stones.

A- Hematological Investigations:  Total serum calcium, serum uric acid, serum creatinine.

B- Urinary: Complete urine analysis, urine culture,and urinary chemistry.

C - Imaging Study: Plain X-ray of abdomen.  Pelvic and renal ultrasonography.

Results: Renal stone were detected in 12.5% of children with CP. Urinary tract infection, immobilization, hypercalcemia, hypercalciuria and hyperuricemia were the risk factors detected in this study.

Conclusion:Children with CP are liable to develop renal stones more than normal children.

Open Access Original Research Article

Hyperbaric Oxygen Therapy Ameliorates the Harmful Effects of Dexamethasone Induced Diabetes on Liver and Pancreas of Adult Male Albino Rats

Nehal Farid El-Helbawy, Alhaz Abd Al-Hai Abd Al-Salam, Manal El -Sayed El-Sawaf, Safwat Abd El-Aziz El-Deeb

Journal of Advances in Medicine and Medical Research, Page 40-54
DOI: 10.9734/jammr/2020/v32i530415

Aims: This study was done to clarify the effects of hyperbaric oxygen therapy on the harmful changes of liver and pancreas of adult male albino rats after dexamethasone induced diabetes.

Place of Study: Faculty of medicine, Tanta University, Egypt.

Methodology: Thirty two adult male albino rats were divided into; group I (control), group II (Hyperbaric oxygen treated), Group III (induced diabetes - non treated group) and Group IV (induced diabetes + Hyperbaric oxygen treated group). Induction of diabetes was done by dexamethasone injection for ten days. Hyperbaric oxygen was given once per day for 5 sessions in group II and IV. The rats of all groups were sacrificed after the 20th day. Specimens of liver and pancreas were subjected to microscopic examination.

Results: Rats from group III showed a highly significant increase of blood glucose compared to the controls. Treated rats in group IV showed highly significant decrease in blood glucose compared to group III. Hepatic steatosis and histopathological changes of pancreatic acini and islets of Langerhans were noticed in untreated diabetic rats. Group IV after Hyperbaric oxygen therapy revealed partial improvement of histological and ultrastructural effects of diabetes on the liver and pancreas.

Conclusions: HBOT is partially effective in reducing blood glucose level and improving the hazardous effect of untreated diabetes on the histological and ultrastructural architecture of the liver and pancreas of male albino rats.

Open Access Original Research Article

Computer Technologies in Spectral Analysis of Uzbek Speech on the Steps of Development of Speech Audiometry for Children

V. S. H. Khamrayeva, S. A. Khasanov, B. Videke

Journal of Advances in Medicine and Medical Research, Page 55-70
DOI: 10.9734/jammr/2020/v32i530416

The presented article is devoted to the stages of development of speech audiometry in the Uzbek language. The capabilities of Praat computer technology made it possible to conduct a frequency-spectral analysis of Uzbek speech, which formed the basis of speech tables and used in assessing the quality of hearing of school-age children with various hearing impairments. Accordance with the spectral analysis there was revealed: The male voice for the given parameters of sound strength was characterized by the main tone within 80-100 Hz, while the female voice when pronouncing the same words and phrases amounted to 160-175 Hz. Consequently, this fact confirmed that the main tone of the Uzbek language is characterized by a lower basic tone than the Romance and Slavic languages. A qualitative assessment of hearing at the children according to developed speech audiometry in the Uzbek language showed that in cases of sensorineural and conductive, as well as with mixed hearing loss, the influence of the speaker’s gender on speech intelligibility is noted. So, when tested with a male voice, it reaches 100% of the result, but when tested with a female voice in children with III degrees of hearing impairment of 100%, the intelligibility threshold is not observed.

Open Access Original Research Article

Community Perspectives on Worm Infections in a Peri-Urban Area of Lusaka, Zambia

H. Halwiindi, O. Hatwiinda, M. Lisulo

Journal of Advances in Medicine and Medical Research, Page 83-96
DOI: 10.9734/jammr/2020/v32i530418

Soil transmitted helminths (STH) known as worm infections are more than a technical or biomedical problem. They can be linked directly to specific human behaviour in relation to sanitation and hygiene practices. Although these infections are prevalent in Zambia, There is paucity of data on community perceptions and beliefs with respect to STH infections. Therefore, this study sought to understand this aspect from a peri-urban point of view. Qualitative interviews were conducted on fifty-seven participants from Ngombe compound; a peri-urban area within Lusaka, Zambia. The study was carried out between August and December 2015 using semi-structured interviews and analysed by means of question analysis. Wide spread knowledge about the various types of worms was found in the community, although most of it was generally folk knowledge. However, this did not mean that the study population recognized STH as serious health problem as some participants considered having worms as normal. While consumption of food was commonly cited as cause of STH, most participants failed to give empirical evidence linking soil or faecal contaminated food items as direct cause of STH. Although the findings cannot be generalized, the study provides informative reference in understanding beliefs and perceptions regarding STH in Zambian peri-urban communities. There is need for concentrated efforts that are bio-medically relevant as well as beneficial to the targeted population.

Open Access Original Research Article

Lymphocyte Transformation of Hepatitis B Virus Infected Pregnant Women, Attending Specialist Hospital Sokoto

C. O. Onwuliri, C. C. Onyenekwe, M. H. Yeldu, A. A. Panti, A. B. Shuaibu, M. Kalgo

Journal of Advances in Medicine and Medical Research, Page 97-107
DOI: 10.9734/jammr/2020/v32i530419

Hepatitis B virus (HBV) is a major public health problem in sub-Saharan Africa with high morbidity and mortality. Vertical transmission is a significant contributor of new cases. The aim of this study was to determine the prevalence of HBV infection, to assess the immune competence of Hepatitis B (HB) viral infected pregnant women using lymphocyte transformation. It was a cross sectional comparative observational study. Simple random sampling technique was applied. One hundred HB infected pregnant women and one hundred controls were recruited. Data were analysed using SPSS (version 23) software. A P-value ≤ 0.05 was considered statistically significant. The results recorded showed a prevalence of 6.6%. The percentage lymphocyte transformation was significantly lower (p < 0.05) for HBV infected subjects compared with control. The rate of lymphocyte transformation with Phytohaemagglutinin was significantly lower (p < 0.05) when compared with Concanavalin A. Conclusively HB infection affects the adaptive immune response. Pregnant women should be screened for Hepatitis B surface Antigen (HBsAg) during routine Antenatal clinic and Concanavalin A based drugs should be recommended for HB infected pregnant women.

Open Access Original Research Article

Lewis Blood Group Percentage Distribution among Indigenes of Ogoni Ethnicity in Rivers State, Nigeria

Serekara Gideon Christian, Evelyn Mgbeoma Eze, Beatrice Wobiarueri Moore-Igwe

Journal of Advances in Medicine and Medical Research, Page 108-113
DOI: 10.9734/jammr/2020/v32i530420

Aim: We attempted to determine the frequency and percentage distribution of Lewis blood group antigens among indigenes of Ogoni ethnicity in Rivers State, Nigeria.

Study Design: The study consisted of 101 Ogoni people, who were apparently healthy and free from transfusion transmissible infections confirmed by serological screening. Ogoniland is located along the Niger Delta Eastern edge, and to the north-east of the Imo River and Port Harcourt city. All subjects were recruited and their blood samples were collected. The presence of Lewis-a and -b (Lea/Leb) blood group was examined using Anti-Lea and Leb monoclonal antibody, respectively (Lorne Laboratories).

Results: Lea and Leb blood group was observed in 17.8% and 11.9%, respectively.

Conclusion: Lea and Leb in this population was observed less frequently than those in other population previously reported. The Lewis antigen was reported to be associated with thrombotic disorders and Helicobacter pylori infection. Further studies may be directed to examine the association between Lewis blood group antigens and the risk of these conditions in Ogoni subjects.

Open Access Original Research Article

Correlation between Neutrophil Gelatinase-Associated Lipocalin and Endoscopic, Histopathologic and Clinical Activities of Ulcerative Colitis

Mohammed G. Flefel, Heba A. Mourad, Eiman A. Hasby, Sherif E. Ezzat, Waleed S. Mohamed

Journal of Advances in Medicine and Medical Research, Page 136-144
DOI: 10.9734/jammr/2020/v32i530422

Introduction: Detection of activity of ulcerative colitis (UC) is vital for predicting treatment outcome. The assessment depends on clinical, serologic, and endoscopic findings. One of the noninvasive biomarkers for disease activity detection is serum Neutrophil Gelatinase-Associated Lipocalin (NGAL).

Aim: To assess the relationship between NGAL and endoscopic, histopathologic and clinical activity of UC.

Methods: This study was conducted on 50 cases with definitive diagnosis of UC and 15 cases with normal colonoscopy examination as controls. UC cases were considered active if Geobes score was ≥3.1. Complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and liver and kidney function tests were done. Serum NGAL was estimated using ELISA technique.

Results: UC cases were classified into active group (n = 36) and inactive group (n = 14). In active UC cases, median value (IQR) of serum NGAL was significantly increased (101.15 (67.53 – 156.40) ng/mL) compared to inactive cases (63.35 (60.98–65.20) ng/mL) and control group (24.80 (15.50 – 31.50) ng/mL). Serum NGAL was well correlated with Geobes score, Mayo score, CRP and ESR. Serum NGAL at cut-off ≥ 63 can predict activity with sensitivity 88.89%, specificity 85.71%, PPV 94.12% and NPV 75%.

Conclusion: Serum NGAL is valuable noninvasive marker for assessment of UC disease activity.

Open Access Original Research Article

PRE-EQC: A Proficiency Testing Program for Pre-Analytical and Analytical Monitoring Using Pooled Samples without Preservatives

Shyamali Pal

Journal of Advances in Medicine and Medical Research, Page 145-152
DOI: 10.9734/jammr/2020/v32i530423

Aim: External Quality Assurance (EQA) is basic requirement of a medical laboratory to assess the quality assurance and achieve the accreditation. The available EQA schemes evaluate the analytical performances of the laboratory but neither evaluate pre analytical factors nor mimic actual laboratory process. PRE-EQC has combined both performances in single scheme and assisting the participant laboratories to take appropriate corrective action and interpretations.

Design: Pre-Analytical monitoring evaluates transport condition, correlation of the stability of samples and temperature, storage condition and environment of the laboratory of the participants and its effect on the results. A sample is specially prepared to estimate haemolysis, lipemic and icteric index.

Clinical Biochemistry: Serum, fluoride and biological fluid (CSF exempted) samples are pooled from the routine collection of specimens. Pooled fractions are homogenized in a rotary shaker for 10 minutes. The clear samples are poured in individual double pack primary containers, which are placed between two gel packs in a “biohazard” labelled plastic bag. Temperature is recorded, kept in insulated thermocol box and sent to the destination.

Urine Routine & Microalbumin, Creatinine Examination: Urine sample is stabilized using preservative.

Methods: The process of sample pool to result submission has been completed within 6 days as samples are without preservative. Stability mimicking the transport, homogeneity and validation of assigned values were done.

Statistical Calculations: As per ISO 13528:2015.

Results and Discussion: The SD of the assigned values showed better performance than existing schemes and within the range of CLIA recommended SD.

Conclusion: The PRE-EQC sample from direct and microalbumin from direct specimen has achieved good reproducibility than lyophilized material.

Open Access Original Research Article

Haemostatic Alterations after Sildenafil and Tramadol Administration in Rats

Evelyn Mgbeoma Eze, Ransom Baribefii Jacob

Journal of Advances in Medicine and Medical Research, Page 153-158
DOI: 10.9734/jammr/2020/v32i530424

Haemostatic parameters constitute measurable indices in the haemostatic system used to assess the functionality of the coagulation system of an individual to establish a state of health or disorder. This study evaluated haemostatic parameter such as platelets count, mean platelet volume (MPV), platelets distribution width (PDW), prothrombin time (PT) and activated partial thromboplastin time (APTT) in 22 Male Albino Rats grouped and orally treated daily for three weeks with Sildenafil (4 mg/200 g.bwt), Tramadol(6 mg/200 g.bwt) and Sildenafil/Tramadol combination (4+6 mg/220 g.bwt). Rats were sacrificed by cardiac puncture and 5 mls of blood collected for the analysis of the parameters using Sysmex haematology analyser and Agape Diagnostic reagents kits. Results obtained shows a statistically significant increase in platelet count, PT and APTT compared with control across the various groups (p<0.05). A statistically significant decrease was observed in MPV, PDW in Sildenafil+tramadol group, significant decrease in platelets distribution width for Tramadol group when compared with control (p<0.05). No significant difference was observed in the mean platelets volume and platelet distribution width in Sildenafil group. A comparison of Sildenafil+tramadol and Sildenafil groups shows no statistically significant difference in all the parameters analysed. There was also no significant difference in the mean platelets count, PDW, PT and APTT when Sildenafil+tramadol and Tramadol groups were compared (p<0.05). However, a statistically significant increase was seen in platelets count when Sildenafil+tramadol and tramadol were compared (p<0.05). Sildenafil and tramadol causes significant increase in platelets count, prolonged PT and APTT following single/combined daily administration in rats. Further research on these parameters, assessment of liver function, and measurement of intrinsic and extrinsic pathway coagulation factors in human taking this medication is recommended.

Open Access Original Research Article

Effects of the Hydroalcoholic Extract of Passiflora edulis on Anxiety Induced by Sub-acute Immobilization Stress

Ayissi Mbomo Rigobert Espoir, Kandeda Kavaye Antoine, Moto Okomolo Fleur Clarisse, Nanga Léopold Didier, Djangou Siebatcheu Sandrine Linda, Dimo Théophile

Journal of Advances in Medicine and Medical Research, Page 159-169
DOI: 10.9734/jammr/2020/v32i530425

Aims: This study was carried out to assess the anxiolytic effects of the hydroalcoholic extract of P. edulis.

Place and Duration of Study:  Animal Physiology Laboratory of the Higher Teachers’ Training College, Animal Physiology Laboratory of the Faculty of Sciences , University of Yaoundé I, from November 2017 to August 2018.

Methodology: Anxiety was induced to mice by the sub-acute immobilization stress. After 11 days treatment, behavioural parameters were assessed using Elevated Plus Maze (EPM) and Open Field (OF), then biochemical parameters (MDA, GSH, SOD, catalase, GABA, GABA-T and 5-HT) were estimated.

Results: The results show that treatment with P. edulis at doses 100 and 200 mg/kg significantly increased open arms entries and time, while reducing closed arms entries and time in the EPM test. Lines crossed as well as passages through the centre and the centre time were significantly increased in the OF test. It is suggested that P. edulis would protect against anxiety and this effect probably linked to its ability to fight oxidative stress and counteract hyperexcitability by potentiating the GABA action. The more effective dose, 100 mg/kg significantly (P<0.01) increased to 4.44 ± 0.24 µmol/g the activity of GSH. In mice treated with dose 100 mg/kg, the extract induced a significant decrease of three oxidative stress markers including MDA, catalase and SOD to 0.22 ± 0.01 µmol/g, 1.05± 0.15 mmol H2O2/min/g; and 19.46±0.00 unit/min/mg respectively when compared to the negative control. Animals treated with P. edulis 100 mg/kg presented a significant increase level (P<0.001) of GABA and 5-HT up to 4.62 ± 0.28 and µg/g and 31.47 ± 1.58 ng/ml respectively. GABA-T activity was also impacted by the treatment with P. edulis, since the value of GABA-T activity of 1.27 ± 0.10 in the negative control significantly (P<0.001) decreased to 0.37± 0.00 in the group treated with dose 100 mg/kg.

Conclusion: The beneficial effects of this extract observed in this study justify the empirical use of P. edulis in the treatment of head ache and insomnia.

Open Access Review Article

The Role of PET/CT in the Investigation of Fever of Unknown Origin

Ioanna Kotsiri, Charalampos Panotopoulos, E. Magiorkinis

Journal of Advances in Medicine and Medical Research, Page 71-82
DOI: 10.9734/jammr/2020/v32i530417

Aims: Fever of unknown origin (FUO) remains a diagnostic challenge for clinicians. The current diagnostic approach includes a detailed medical history, physical examination, laboratory tests and imaging techniques (chest X-ray, ultrasound, CT, MRI). 18F-FDG PET/CT (18fluoro-deoxyglucose PET/CT) is a non-invasive diagnostic imaging technique, which is widely used in oncology. The purpose of our narrative review was to summarize the knowledge for the diagnostic role of 18F-FDG PET/CT in the diagnostic approach of patients with FUO, as reported in the literature.

Methodology: We undertook a search of literature published in PubMed until February 2019.

Results: Various studies showed that 18F-FDG PET/CT could play an important role as a second-line explorative technique in the diagnosis of patients with FUO. 18F-FDG PET/CT presents high diagnostic accuracy in large vessel vasculitis, in orthopedic prosthetic infections, in chronic osteomyelitis and in prosthetic valve endocarditis. However, 18 -FDG/PET has some limitations such as the assessment of urine tract due to the excretion into the urine but also become of the high glucose metabolism in some organs such as the brain.

Conclusions: Overall, PET/CT gains increasing interest in the diagnosis of FUO and should be considered by the clinicians in the exploration of those patients.

Open Access Review Article

Treating Dyslipidemia in Adults: An Update

Sheikh Salahuddin Ahmed

Journal of Advances in Medicine and Medical Research, Page 114-135
DOI: 10.9734/jammr/2020/v32i530421

Dyslipidemia is an important risk for the promotion of atherosclerosis and the development of cardiovascular disease (CVD). Currently available drugs can effectively lower the increased levels of blood cholesterol in most patients and prevent the development and progression of CVD. This paper focuses on the adverse cardiovascular effects produced by high blood cholesterols and the overall management of dyslipidemia in adults. Relevant guidelines and research papers published mainly after the year 2000 on the management of dyslipidemia were reviewed. High levels of low density lipoprotein cholesterol (LDL-C), or low levels of high density lipoprotein cholesterol (HDL-C), combined or independently are associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). Apolipoprotein B (ApoB), an atherogenic lipoprotein has emerged recently as the key factor in the pathogenesis of atherosclerosis. High triglyceride (TG) levels are associated with acute and recurrent pancreatitis. The purpose of treating lipid disorders is to prevent the development of ASCVD and pancreatitis. The treatment of dyslipidemia includes multifactorial life style intervention and pharmacotherapy with lipid modifying drugs. Reduction of LDL-C is substantially associated with reduction of risk of ASCVD and evidences show that “lower is better” for LDL-C reduction.