Self-Measured Blood Pressure-Guided Pharmacotherapy: A Systematic Review and Meta-Analysis of United States-Based Telemedicine Trials.

BACKGROUND: The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS: We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS: Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mm Hg (95% CI, -9.4 to -5.2), -2.7 mm Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS: Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.

Heterogeneity of the Effect of Telemedicine Hypertension Management Approach on Blood Pressure: A Systematic Review and Meta-analysis of US-based Clinical Trials.

Background: Telemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown. Methods: We conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at ≥6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials (≥25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials. Results: Thirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP). Conclusions: TM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation. Clinical Perspective: What Is New?: In this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care.The BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses,Non-White patient predominant trials achieved lesser BP reductions than White patient predominant trials.What Are the Clinical Implications?: Before wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control.Without equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US.

'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair. MATERIAL AND METHODS: After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator. RESULTS: Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed. CONCLUSIONS: Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

Post COVID-19 pulmonary complications in outpatient setting: Insights from a cross-sectional study in a rural academic hospital.

OBJECTIVE: Post COVID-19 disease pulmonary complications are generally expected among the hospitalized or elderly patients with multiple comorbidities given the gravity of the disease among such patients. However, non-hospitalized patients with less severe symptoms from COVID-19 disease have also been experiencing significant morbidity and difficulty functioning their activities of daily living. Therefore, we aim to characterize post COVID-19 pulmonary complications (symptomatology, clinical and radiological findings) in patients who did not require hospitalization but had significant outpatient visits secondary to COVID-19 sequelae. METHODS: This is a two part cross-sectional study based on a retrospective chart review. Patients with COVID-19 disease not requiring hospitalization but followed up at pulmonology clinic with respiratory symptoms were analyzed twice in an interval of 12 months. 23 patients in first cross-section group (followed up from December 2019 to June 2021) and 53 patients in second group (followed up from June 2021 to July 2022) were included in the analyses. Differences in mean and percentage of baseline characteristics and clinical outcomes between the two groups are analyzed using unpaired t-tests and Chi-squared tests respectively. Post COVID-19 disease symptoms are classified in to 3 different groups (mild, moderate and severe) based on duration of symptoms and presence or absence of hypoxia. RESULTS: Dyspnea on exertion (DOE) was the common compliant in majority of patients in both cross-section groups (43.5% vs 56.6%). Mean age in years were 33 and 50 in first and second cross-section groups respectively. Majority of the patients had mild and moderate symptoms in both groups (43.5% vs 9.4%, P = 0.0007; 43.5% vs 83%, P = 0.005). Mean duration of symptoms in first cross-section group was 3.8 whereas 10.5 months (P = 0.0001) in second cross-section group. CONCLUSION: Our study outlines the burden of post COVID-19 disease pulmonary complications in patient group where these complications are less expected. Strategies for the implementation of multidisciplinary post COVID-19 care clinic along with mass vaccination awareness campaigns in rural US should be prioritized to mitigate this existing burden.

COVID-19 Vaccine-Induced Rapid Progression of Prediabetes to Ketosis-Prone Diabetes Mellitus in an Elderly Male.

Studies show a low progression rate of prediabetes to Type 2 diabetes mellitus (DM) that we commonly seek to reverse, but we don't associate prediabetes as a lead-up to the first presentation of ketosis. We present a prediabetic who, in less than a year, converted to GAD65 antibody-positive diabetes mellitus with a diabetic ketoacidosis presentation. A 69-year-old male presented with three weeks of fatigue, polyuria, polydipsia, abdominal pain, and weight loss. Vital signs and physical exam were normal except for abdominal tenderness and dry oral mucosa. Complete blood count (CBC) was normal; blood glucose was severely elevated with mild corrected hyponatremia; elevated anion gap metabolic acidosis with glucosuria and ketonuria. He received an insulin drip, normal saline, and potassium in the intensive care unit. His anion gap closed overnight and was switched to basal-bolus insulin. Hemoglobin A1c (HbA1c) came out to be higher than expected as compared to last year of low prediabetic value, decreased c-peptide levels, and positive anti-GAD65 antibody. His first abnormal HbA1c was 5.8% a year ago and no autoimmune marker was checked before. He was vaccinated with the messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccine a year ago with an mRNA vaccine booster two months earlier. He was not COVID-19 infected. We discharged him with a basal-bolus insulin regimen. Type I DM passes from autoimmunity-positive normoglycemia to dysglycemia to the symptomatic stage, typically progressing more rapidly in children than in older adults. A new Type I or dysglycemia in Type II DM is increasingly reported after COVID-19 vaccines/infection. Mechanisms could be cytokine-mediated beta-cell damage or autoimmunity after mRNA vaccines or as a part of autoimmune syndrome induced by vaccine adjuvants. This case reports the rapid progression of prediabetes to Type 1 rather than Type 2 DM and highlights the possibility of dysglycemia after COVID-19 vaccines and calls for measures to prevent or early management of these side effects.

COVID-19-Induced Left Sciatic Neuropathy Requiring Prolonged Physical Medicine and Rehabilitation.

A growing number of case reports and series have described a wide spectrum of neurological manifestations of COVID-19 disease including encephalopathy, cerebrovascular disease, and Guillain-Barre syndrome (GBS). However, peripheral neuropathy associated with COVID-19 disease has been uncommonly reported. Here, we describe a young patient with a COVID-19 infection who developed unilateral sciatic neuropathy during the course of treatment requiring prolonged physical medicine and rehabilitation stay. She was treated in the intensive care unit (ICU) for hypoxic respiratory failure for 22 days total, during which she was intubated, sedated, and paralyzed for 14 days. She received dexamethasone, convalescent plasma, and remdesivir for COVID-19; she also received ceftriaxone and azithromycin for possible superimposed bacterial pneumonia. The hypoxic respiratory failure was improved progressively, and she was extubated. On day 17 of ICU stay, she reported numbness and weakness in left leg and had 0/5 motor strength at the left ankle in all directions. She was able to move left hip and knee and had decreased sensation to light touch and pain from the level of the left knee to the toes. Imaging of the brain and spine showed no obvious findings that would explain the neurological symptoms. On electromyography (EMG), there was acute denervation in the left tibialis anterior muscle. She required prolonged physical medicine and rehabilitation care, greater than 60 days during which she had some improvement in sensation, but remained without ankle movement for two more months. This could be a rare manifestation of COVID-19-induced sciatic mono-neuropathy given her symptoms, EMG reports, clinical exam, and normal imaging studies.

Isolated Basilic Vein Thrombosis as a Rare Presentation of COVID-19 in a Young Patient.

COVID-19 has not spared a single system in the human body. Although acute respiratory failure culminating sometimes in death remains the most common manifestation of severe infection, hypercoagulability leading to deep vein thrombosis (DVT), pulmonary embolism (PE), and stroke have also been identified widely. Here, we describe a young patient with a COVID-19 infection who developed right basilic vein thrombosis. This case demonstrates how thrombosis can occur in uncommon sites and how clinicians should be vigilant for thrombotic complications in both the inpatient and outpatient settings.

Antioxidant, anticancer and antimicrobial effects of In vitro developed protocorms of Dendrobium longicornu.

In vitro seed germination and protocorms formation were successfully established in traditionally used Dendrobium longicornu. Fresh protocorms (178.34 g - 183.90 g) were produced on the elicitor of Alternaria sp, Bacillus subtilis and Fusarium solani supplemented MS-medium. Methanol extract of D. longicornu protocorms has scavenged 94.31 % of DPPH radicals at 1000 µg/mL. Its 117.56 µg/mL concentration has scavenged 50 % DPPH radical (IC50). Similarly, it inhibits 25.39 % and 27.80 % HeLa and U251 cells at 500 µg/mL. The IC50 was found as 350.06 µg/mL and 507.22 µg/mL for HeLa and U251 cells respectively. Further, it inhibited the growth of E. coli, K. pneumoniae and E. cloacae with the zone of inhibition 4, 2 and 2 mm respectively. In conclusion, protocorms developed through in vitro seeds culture have accumulated and synthesized bioactive secondary metabolites. Therefore, protocorms could be utilized to the isolation of compounds for formulation of herbal drugs without damaging natural populations.

Study, Design, and Rationale of Noncommunicable Diseases in Nepal (NCD Nepal) Study: A Community-Based Prospective Epidemiological and Implementation Study in Rural Nepal.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-to-middle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal. METHODS: We organize monthly mobile health clinics to screen NCDs among 40- to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling, pharmacotherapy or refer to higher level care, where appropriate; routinely follow participants with NCDs for continuity of care; and follow individuals without NCDs but with elevated glucose, prehypertension or other risk factors every year, and those without risk factors every 2 years. We will monitor participants in the community to reduce attrition and to track all-cause and disease-specific mortality. DISCUSSION: Understanding the community burden of NCDs in resource-limited setting and testing effectiveness of community-based screening and management of NCDs will provide insights to develop national policy to address NCD burden in LMIC like Nepal.

Herlyn-Weber-Wunderlich syndrome with ectopic ureter in prepubertal female.

We report a rare case of uterovaginal duplication in a prepubertal female. The patient also had a permeable ureter (ureter with urine passing through it) subtending a poorly functioning kidney with ectopic insertion in the obstructed hemivagina.