Clinical Utility of 24-h Ambulatory Blood Pressure Monitoring in Hospitalized Patients with Chronic Kidney Disease.

INTRODUCTION: Hypertension leads to rapid progression of kidney disease. Hypertension (HTN) is the second most common cause for CKD after diabetes. Ambulatory blood pressure monitoring (ABPM) helps in accurate and early diagnosis of HTN along with measurements of other variables, namely nondippers, reverse dippers, hyperbaric index (HBI), percentage time elevation (PTE), and early morning surge. METHODOLOGY: After obtaining the institution ethics committee approval total 192 cases, of 12-80 years age group, who were diagnosed with CKD were included in the study. ABPM was done for patients using Meditech ABPM-05 machine. RESULTS: Study showed male predominance. Maximum patients were in the age group of 41-60 years. Prevalence of Hypertension in patients with CKD was 88.02%. The systolic BP, diastolic BP, and mean arterial pressure (MAP) were significantly higher by clinic BP measurement than ABPM in all stages of patients with CKD especially in stage IV than stage V CKD. Systolic, diastolic, MAP, HBI and PTE at nighttime were significantly higher than daytime in all patients with CKD, especially in patients with resistant hypertension. Prevalence of whitecoat HTN (4.1%), whitecoat effect (16.1%), resistant hypertension (39.6%), masked HTN (1%), and masked uncontrolled HTN (10.4%) was noted. Systolic and diastolic HBI was lower in patients on hemodialysis as compared to those not on hemodialysis. Non-dippers were more than dippers. CONCLUSION: Apart from mean systolic and diastolic BP, ABPM gives the extent of end-organ damage and insights into the need for control of 24 h BP in patients of CKD.

Preliminary Observations and Experiences of Physiotherapy Practice in Acute Care Setup of COVID 19: A Retrospective Observational Study.

BACKGROUND: The rapid outbreak of coronavirus disease 2019 (COVID-19), a public health emergency of grave concern, warranted hospital admissions with almost 90,000 cases in June 2020 in city of Mumbai. 3-10% of the patients with moderate to severe involvement required intensive care unit (ICU) admission with respiratory support. Patients admitted in ICU with an acute COVID event present with respiratory dysfunction and are more likely to have critical illness myopathy and neuropathy (CIMN). Physiotherapy services being integral part of non-pharmacological management of any ICU was implemented for patients with COVID 19; a novel viral disease. OBJECTIVE: This retrospective study was undertaken to explore the physiotherapy practices that could be implemented in patients admitted with COVID 19 in the ICU and its effect on mobility and oxygen requirement as an outcome. METHODOLOGY: Following ethical permission of institute, the data was extracted from electronic data record sheet in which daily parameters for physiotherapy intervention were recorded. Data from a single ICU and step down unit (SDU) from 5th June to 5th July 2020 was analysed. Records of patients diagnosed with COVID 19 and admitted in ICU or SDU were studied. Those in the age group of 18 to 90 years, of either gender were included. Demographic characteristics, disease severity, oxygen requirement, mobility status, physiotherapy intervention were studied. RESULTS: 278 record sheets (110 ICU and 168 SDU) were retrospectively analysed for demographics. 44.55% of patients improved with side lying position, 37.27% with prone position and 10.91% with quarter prone position. 4.55% of patient maintained oxygenation in propped up sitting. 2.73% could not be positioned. Chest physiotherapy techniques applied were deep breathing, ACBT, paced breathing and diaphragmatic breathing. Deep intercostal pressure on NIV along with vibrations was given to 12.72% of patients in the ICU. Group therapy sessions were conducted in SDU where 50.59% patients participated. ICU mobility score showed significant improvement on Wilcoxon Signed Ranks test status on day 7 in the ICU (z=-5.99, p=0.00) and SDU (z= 7.676, p=0.00) compared to day 1. Descriptive analysis showed a definitive reduction in oxygen support requirement. CONCLUSION: Most common form of physiotherapy interventions in patients with Covid 19 were therapeutic positioning, early mobilization and breathing exercises. Physiotherapy intervention appears promising in facilitating early patient ambulation and discharge. This study shows that it is safe and feasible to provide early physiotherapy treatment techniques in patients with COVID-19 using appropriate measures of infection prevention and cross contamination.

Clinical Utility of Ambulatory Blood Pressure Monitoring (ABPM) in Newly Diagnosed Hypertensive Patients.

BACKGROUND: Ambulatory Blood Pressure Monitoring (ABPM) has an upper hand in diagnosing hypertension accurately. Parameters obtained by ABPM helps us in diagnosing white coat hypertension, BP variability, dipping status and blood pressure load on organs (Hyperbaric Index) reflecting possible end organ damage. OBJECTIVES: To evaluate clinical utility of ABPM in stage 1 newly diagnosed hypertensive subjects, to compare ABPM readings with clinic blood pressure (Clinic BP), to study dipping pattern and White Coat Hypertension (WCH) in newly labeled hypertensives. METHODOLOGY: After institutional ethics committee approval and written informed consent from participants, an observational cross sectional prospective study was conducted in hypertension clinic of tertiary care hospital over a period of one and half years on 138 newly diagnosed stage I hypertensive patients. ABPM results were analyzed and compared with clinic BP. RESULTS: 86/138 (62.32%) patients were diagnosed to have true HT by ABPM. WCH was detected in 52/138 (37.68%) which is higher than that reported in international studies (21%). The mean pulse, mean systolic/diastolic BP, mean pulse pressure and MAP were significantly higher (p<0.0001) by clinic BP than ABPM. True hypertensive patients were having higher weight (p <0.001), had higher fasting blood sugar values (p=0.008) and BUN levels (p=0.034) than WCH patients. Hyperbaric Index was significantly higher for systolic and diastolic BP in true hypertensive patients as compared to WCH patients. Patients with WCH were predominantly males (71.15%), were younger (41.82 ± 12.77 years) than true hypertensives (46.45 ± 12.20years), (p =0.037). Dipping was detected in 33 (38.37%), non-dipping in 44 (51.16%) and reverse dipping in 9 (10.47%) patients. CONCLUSION: Our study reflects the clinical utility of ambulatory blood pressure monitoring not only for accurate diagnosis of hypertension but also for assessing the various parameters of blood pressure.

A Prospective, Observational Study to Determine the Prevalence and Clinical Profile of Patients of Hypertensive Crisis in a Tertiary Care Hospital.

BACKGROUND: Hypertension can present in crisis form as 'hypertensive urgency'(HU) or as 'hypertensive emergency' (HE). Both the conditions are associated with significant morbidity and mortality. AIM: To evaluate the clinical characteristics, course of illness, end-organ damage and survival outcome in patients with hypertensive crisis. METHODOLOGY: This prospective observational year-long study was conducted after due ethical considerations on 120 adult non-pregnant patients who presented with blood pressure of >180/120 mm Hg in the emergency medical services of a tertiary care hospital. The available data was statistically analyzed using the t-test for continuous variables and chi-square test for categorical variables. RESULTS: Sixty two (51.67%) patients presented with hypertensive urgency and fifty eight (48.33%) with hypertensive emergency. Together they constituted 0.59% of total medical admissions and 18.04% of ICU admissions. Mean age of patients was 48.34 years and 52.48 years in HU and HE groups respectively. Headache (49.2%) and giddiness (43.3%) were the common presenting symptoms. Focal neurological deficit (p=0.001), psychomotor agitation (p=0.024), visual disturbances (p=0.048), oliguria (p=0.036) were noted significantly in patients with HE. Systolic and diastolic blood pressures were significantly elevated (p=0.001) in HE as compared to HU. Circadian peaks were noted between 2pm - 4 pm followed by 2am - 4 am and circannual peaks were noted in hot and humid months of May and October. Occurrence of HE was significantly linked with male gender (p=0.037), alcoholism (p<0.001), dyslipidemia (p<0.001) and diabetes mellitus (p<0.001). Cardiac and cerebrovascular end organ involvement was noted in 67.2% each and majority of subjects (69.9%) had more than one organ involvement. Out of total 120 study subjects, 19 (15.83%) died within first 72 hours of admission with mean age of 52.47 years. Negative survival outcome was associated with hypertensive emergencies (p=0.021), smoking (p=0.05), dyslipidemia(p=0.002), diabetes mellitus(p=0.003), cardiovascular (p=0.002) and cerebrovascular involvement(p=0.015). CONCLUSIONS: This study showcases the characteristic features of hypertensive crises in Indian subjects, thus allowing us a better understanding of the natural history of this medical emergency.

Left ventricular non-compaction with viral myocarditis: a rare presentation of a rarer disease.

We report an unusual case of a 22-year-old male who was incidentally diagnosed with isolated noncompaction of the left ventricle (LV) when he was admitted with viral myocarditis. Left ventricular noncompaction (LVNC) is a congenital cardiomyopathy which presents with ventricular dysfunction, cardioembolic manifestations or with arrhythmias. A diagnosis can be made with the commonly available modality of echocardiography but is still often overlooked. There is no specific treatment directed at isolated noncompaction. Treatment is focused on the cause of presentation, with medication aimed at improving ventricular dysfunction, as well as treating and preventing thrombosis and arrhythmia. This is, we feel, the first case report of isolated LVNC presenting with viral myocarditis.

HTLV infection and strongyloidal hyperinfection syndrome.

Strongyloides stercoralis can affect humans in the form of asymptomatic infections, Strongyloidal hyperinfection syndrome and disseminated Strongyloidiasis depending on the immune response of the host. We report a case of strongyloidial hyperinfection syndrome that subsequently tested positive for HTLV infection.