Diffusion-weighted imaging in hyperacute haemorrhagic stroke patients presenting within thrombolysis window

INTRODUCTION

Diffusion-weighted imaging (DWI) in magnetic resonance imaging (MRI) has been proposed as the first line of neuroimaging for acute ischaemic stroke. The reliability of DWI in detecting intracranial haemorrhage, however, is still unproven, compared with susceptibility-weighted imaging (SWI) and CT scan which being considered the gold standard. This study seeks to establish the reliability of DWI as a first-line imaging modality to detect the intracranial haemorrhage in the patients present within the thrombolysis window.

MATERIALS AND METHODS

A retrospective cross-sectional analysis was performed on patients who presented to our institution from April 2020 until July 2021 for acute stroke and had MRI brain as first-line neuroimaging. A total of 31 subjects were included in this study. Two radiologists assessed the signal patterns in DWI sequence and compared them with SWI and CT Brain, whenever available, as the gold standard for observing the presence of intracranial haemorrhage.

RESULTS

The majority of patients with hyperacute bleed proven to be revealed on SWI or CT, thus showed characteristics of central hyperintensity and peripheral hypointense rim, on DWI. Slightly more than half (51.6%) presented with mild to moderate NIHSS scores (1-15). The sensitivity, specificity, positive predictive value and negative predictive value of DWI in detecting intracranial intra-axial haemorrhages were exceptionally high. There is strong interobserver level of agreement in identifying central haemorrhagic signal intensity [kappa = 0.94 (0.06), p < 0.05].

CONCLUSION

This study supported the DWI sequence as a reliable sequence in MRI, to detect intracranial haemorrhage in hyperacute stroke.

The reliability and process capability assessment of suspended growth sewage treatment plant in Melaka, Malaysia

This paper presents the promising method of synchronizing the Six Sigma and reliability analyses at 15 sewage treatment plants (STPs) operating in Melaka, Malaysia. Five different suspended growth treatment technologies in various capacities were investigated. The sequential batch reactor (SBR) and extended aeration activated sludge (EAAS) processes, conventional activated sludge (CAS), aerated lagoon (AL), and oxidation pond (OP) were compared using innovative Niku's treatment reliability and Six Sigma process capability method for biological oxygen demand (BOD₅), chemical oxygen demand (COD), total suspended solids (TSS), oil and grease (O&G), and ammoniacal nitrogen (NH₃-N) effluent parameters and justified the importance of understanding the lognormal behavior of the effluent parameters in interpreting the performance monitoring results and discharge compliance. The results showed that the SBR and EAAS systems relatively fulfilled the highest performance (>95%) compared to conventional systems to ensure the high quality of effluent discharge. Although the whole system is incapable of removing nutrients efficiently, ranging between 42.31% and 90.48%, may lead to eutrophication issues. Process modification and treatment control should become a critical priority in order to reduce variability, improve stability, and increase the efficiency of nutrient removal. These initiatives promote global sustainable development goals (SDGs) 2030 and the domestic water sector transformation (WST) 2040 by treatment cost reduction, improving environmental sustainability and guaranteeing social and health benefits.

Abstract P019: Clinical Impact Of A 3 Versus 5-minute Delay On Automated Office Blood Pressure Measurement

Background: Recent studies suggest that a reduced delay during automated office blood pressure (AOBP) measurement may be as accurate as a 5-minute delay. The clinical impact of this change compared to gold-standard assessments (i.e. 24-hour ambulatory BP monitoring, ABPM) has not been reported.

Objective: To compare the impact of a 3- vs 5-minute delay on AOBP and its relation with average awake-time ABPM.

Methods: Patients referred to a single hypertension (HTN) center had BP measurements with ABPM and one of two non-randomized, unattended AOBP protocols. Half of patients underwent AOBP with a 5-minute delay; the other half underwent AOBP with a 3-minute delay. All measurements were compared to the average awake-time ABPM. HTN was defined as SBP≥140 or DBP≥90 mmHg. We used linear regression adjusted for age, sex, and race to assess whether the 3-minute protocol was associated with a difference between mean AOBP and average awake-time ABPM.

Results: Among 100 participants (mean age 59.7±15.5 years, 58% women, 26% Black), the average awake-time BP was 132.6±14.8/77.4±11 for the 5-minute protocol and 134.4±17/78.2±11 for the 3-minute protocol. HTN misclassification between groups based on awake-ABPM was similar (14% for 5- versus 12% for 3-minute delay, p=0.51). Compared to 5-minute delay, 3-minute delay was not associated with a significant difference between mean AOBP and mean awake-time ABPM for SBP (2.3 mm Hg; 95% CI: -3.7, 8.2) or DBP (1.2 mm Hg; 95% CI: -2.5, 4.8).

Conclusion: Measuring AOBP with a 3-minute delay did not result in statistically different accuracy compared with average awake-time ABPM. However, this finding should be confirmed in a larger, clinic-based sample.

Effects of Antihypertensive Deprescribing Strategies on Blood Pressure, Adverse Events, and Orthostatic Symptoms in Older Adults: Results From TONE

BACKGROUND

The Trial of Nonpharmacologic Interventions in the Elderly (TONE) demonstrated the efficacy of weight loss and sodium reduction to reduce hypertension medication use in older adults. However, the longer-term effects of drug withdrawal (DW) on blood pressure (BP), adverse events, and orthostatic symptoms were not reported.

METHODS

TONE enrolled adults, ages 60-80 years, receiving treatment with a single antihypertensive and systolic BP (SBP)/diastolic BP <145/<85 mm Hg. Participants were randomized to weight loss, sodium reduction, both, or neither (usual care) and followed up to 36 months; ~3 months postrandomization, the antihypertensive was withdrawn and only restored if needed for uncontrolled hypertension. BP and orthostatic symptoms (lightheadedness, feeling faint, imbalance) were assessed at randomization and throughout the study. Two physicians independently adjudicated adverse events, masked to intervention, classifying symptomatic (lightheadedness, dizziness, vertigo), or clinical events (fall, fracture, syncope).

RESULTS

Among the 975 participants (mean age 66 years, 48% women, 24% black), mean (±SD) BP was 128 ± 9/71 ± 7 mm Hg. Independent of assignment, DW increased SBP by 4.59 mm Hg (95% confidence interval [CI]: 3.89, 5.28) compared with baseline. There were 113 adverse events (84 symptomatic, 29 clinical), primarily during DW. Compared with usual care, combined weight loss and sodium reduction mitigated the effects of DW on BP (β = -4.33 mm Hg; 95% CI: -6.48, -2.17) and reduced orthostatic symptoms long term (odds ratio = 0.62; 95% CI: 0.41, 0.92), without affecting adverse events (hazard ratio = 1.81; 95% CI: 0.90, 3.65). In contrast, sodium reduction alone increased risk of adverse events (hazard ratio = 1.75; 95% CI: 1.04, 2.95), mainly during DW.

CONCLUSIONS

In older adults, antihypertensive DW may increase risk of symptomatic adverse events, highlighting the need for caution in withdrawing their antihypertensive medications.

CLINICAL TRIALS REGISTRATION

Trial Number NCT00000535.

Abstract MP71: Impact Of 30 Versus 60 Second Time Interval Between Automated Office Blood Pressure Measurements On Measured Blood Pressure

Background: Guidelines advocate for the use of automated office-based blood pressure (AOBP) measurement to improve accuracy of blood pressure (BP) measurement in the outpatient clinical setting. Current recommendations include a 5-minute period of quiet rest prior to obtaining 3 readings, each separated by 1-2 minutes. As a result, AOBP requires a minimum of 7 minutes of rest time in addition to proper patient positioning plus cuff inflation and deflation, adding nearly 10 minutes to an office visit. Reducing this by even 1 minute has broad implications for the widespread use of AOBP.

Methods: Patients from a single hypertension center underwent a 3-day evaluation that included a 24-hour ambulatory BP monitor (ABPM) and one of two, non-randomized, unattended AOBP protocols. Half of patients underwent 3 BP measurements separated by 30 seconds and the other half underwent 3 BP measurements separated by 60 seconds. All measurements were compared to the average awake-time BP from ABPM as well as the first AOBP measurement.

Results: Among 102 patients, the average awake-time BP was 128.6±13.6/76.5±12.5 mmHg for the 30-second protocol and 132.5±15.6/77.7±12.2 mmHg among those who underwent the 60-second protocol . Mean BP was lower with the 2nd and 3rd AOBP measurement by -0.5/-1.7 mmHg and -1.0/-2.3 mmHg for the 60-second protocol versus -0.8/-2.0 mmHg and -0.7/-2.7 mmHg for the 30-second protocol ( Figure ). Differences between AOBP measurements (1st, 2nd, or 3rd) and awake-time ABPM were nearly identical across protocols.

Conclusion: A 30-second interval between AOBP measurements was as accurate and reliable as a 60-second interval.

Antimicrobial properties and sensorial acceptability of edible antimicrobial films from seaweed (Kappaphycus alvarezii) and cinnamon (Cinnamomum zeylanicum) essential oil

Packaging of foods by using edible antimicrobial films (EAF) incorporated with essential oils is able to reduce the spoilage of food due to surface contamination. Essential oils are highly volatile and have strong aromas that can affect their function and consumer acceptance. This paper discussed the effect of cinnamon essential oil (CEO) concentrations on the antimicrobial activity and sensory acceptability of EAF produced from seaweed through a casting method. The CEO was added into the formulations at 10, 20, 30, 40 and 50 g/kg levels. The EAF showed antimicrobial activity against the tested microorganisms with the highest antimicrobial activity at the concentration of 40 g/kg CEO. However, based on the results obtained from a sensory evaluation using a 7-points hedonic scale, the overall acceptability was 3.23 which was lower than the minimum acceptability score of 4. Hence, the highest acceptable level of CEO in the EAF was 30 g/ kg. It is recommended that the CEO of 30 g/kg could be incorporated into edible film and act as an alternative method to extend the shelf life of packaged foods.

Abstract MP59: Effects Of Sodium Reduction And Weight Loss On Lightheadedness And Falls In Older Adults: Results From TONE

Background: The Trial of Nonpharmacologic Interventions in the Elderly (TONE) demonstrated the efficacy of sodium reduction and weight loss to reduce hypertension medication use in older adults. However, adverse events related to lightheadedness and falls have not been reported.

Objective: To determine whether sodium reduction and weight loss are associated with greater risk of lightheadedness and falls among older adults.

Methods: TONE was a randomized trial of 60-80 year-old adults with systolic BP (SBP) and diastolic BP (DBP) below 145 and 85 mm Hg, respectively, while receiving treatment with a single antihypertensive medication. Participants were randomized to behavioral interventions focused on sodium reduction, weight loss, both, or neither (usual care); 3 months after randomization, the antihypertensive medication was withdrawn and only restored later during the study if needed for uncontrolled hypertension. Total follow-up was 36 months post-randomization. Two physicians independently adjudicated adverse event logs, masked to intervention assignment. The primary outcome was a composite of the first occurrence of adverse event related to falls (total N=95): 72 involved orthostatic symptoms (lightheadedness, dizziness, vertigo), while 23 involved hard events (fall or syncope). Hazard ratios were determined via Cox proportional hazards models.

Results: Among the 975 participants (mean age 66 yrs, 48% women, 24% black), mean SBP and DBP were 128 and 71 mm Hg. The cumulative incidence of adverse events at 30 months was 0.08, 0.13, 0.11, and 0.14 for usual care, reduced sodium, weight loss, or both, respectively ( Figure ). In adjusted multi-variable analyses, sodium reduction was associated with higher risk of an adverse event (HR 1.52; 95% CI: 1.02, 2.27), while weight loss was not associated with adverse events (HR 1.18; 0.77, 1.79).

Conclusions: In the context of antihypertensive medication withdrawal, sodium reduction was associated with a higher risk of fall-related adverse events, predominantly symptoms.

Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis

BACKGROUND

Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH).

PURPOSE

To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions.

STUDY SELECTION

Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing.

DATA EXTRACTION

2 investigators independently abstracted articles and rated risk of bias.

DATA SYNTHESIS

5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged.

LIMITATIONS

Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available.

CONCLUSION

Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).

Abstract MP36: Effects Of Intensive Blood Pressure Treatment On Orthostatic Hypotension: An Individual-level Meta-analysis

Background: Intensive blood pressure (BP) treatment reduces the risk of cardiovascular disease, but there are ongoing concerns that it also might be harmful by increasing the risk of orthostatic hypotension (OH). However, individual trials have been inconclusive.

Methods: In this individual participant data meta-analysis, we systematically reviewed MEDLINE, EMBASE, and CENTRAL databases through October 7, 2019 for randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) on measured OH. OH was defined as a drop in SBP ≥20 mmHg or DBP ≥10 mmHg after changing positions from seated to standing. Ultimately, five trials of BP treatment goal were identified. Effects were examined overall and in subgroups of baseline characteristics, including diabetes, standing BP pre-randomization (<110 vs ≥110 mm Hg), and pre-randomization OH.

Results: There were 18,466 participants with 127,998 follow-up visits. Most trials demonstrated low risk of bias with minimal heterogeneity of effects across trials ( I 2 = 0.0%). Intensive BP treatment significantly lowered risk of OH (OR 0.93; 95% CI: 0.86, 0.99). Effects were strongest among adults without diabetes (OR 0.90 vs 1.10; P -interaction = 0.015) and adults with lower standing SBP (OR 0.66 for <110 mmHg vs 0.96 for ≥110 mmHg; P -interaction = 0.02). Effects did not differ by pre-randomization OH ( P -interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged ( Figure ).

Conclusion: OH prior to or in the setting of more intensive BP treatment should not be viewed as a reason to avoid or to de-escalate treatment for hypertension.

Abstract P168: A Novel Protocol Using Ambulatory Blood Pressure Monitoring To Assess The Impact Of Prescription Stimulants On Blood Pressure In Adults

Background: Prescription stimulant medications are an important cause of secondary hypertension (HTN) and use is increasing in US adults. Although stimulants are known to increase blood pressure (BP), a systematic approach to assess impact in individual patients is lacking. Further, treating HTN secondary to stimulant use may differ from treatment of essential HTN.

Objective: To develop a protocol using ambulatory blood pressure monitoring (ABPM) to differentiate HTN secondary to stimulant use from essential HTN.

Methods: We used ABPM to evaluate pre- and post-stimulant systolic blood pressure (SBP) and diastolic blood pressure (DBP) for patients referred to the BIDMC Hypertension Center. Patient charts were reviewed by a clinical pharmacist to ensure the safety of holding the stimulant medication and to determine the duration of action. Average daytime BP on day 1 (off stimulant) was compared to day 2 (on stimulant) to assess the impact of stimulant on BP. We defined normotension as BP <135/<85 on both days, sustained HTN as BP ≥135/≥85 on both days and stimulant-induced HTN as BP <135/<85 on Day 1 and ≥135/≥85 on Day 2. We also defined an increase of SBP≥10 and/or DBP≥ 5 while taking the stimulant as a clinically significant effect on BP.

Results: Eleven patients were assessed (see Table). Four had sustained normotension, six had sustained HTN, and one had stimulant-induced HTN. In addition, four of the patients had a clinically significant increase in their BP while on a stimulant. Overall, average increase in SBP was 6.7 mmHg and average increase in DBP was 3.2 mmHg.

Conclusion: This novel ABPM protocol was useful for differentiating secondary HTN from stimulant use from essential HTN.

Severe Dengue with Hemophagocytosis Syndrome

Dengue is known to cause high morbidity and mortality worldwide. In recent years, there have been increasing cases of dengue fever associated with a rare complication: hemophagocytic syndrome (HPS), which is a dangerous disorder that carries high mortality. It is associated with infections, autoimmune disorders, and malignancies. Prolonged duration of fever and cytopenia together with multi-organ dysfunction out of proportion to the plasma leakage phase should alert clinicians to consider this condition. In this case study, we highlight a 45-year-old woman with underlying diabetes who was admitted due to dengue fever with warning signs. Her conditions deteriorated quickly: she had spontaneous bleeding, evidence of plasma leakage, severe hepatitis, and coagulopathy on the 11th day of illness. With the support of other blood results, such as raised serum ferritin and lactate dehydrogenase, she was diagnosed with severe dengue with hemophagocytosis syndrome. She responded well to intravenous dexamethasone and recovered on the 19th day of illness.

The effects of antihypertensive class on gout in older adults: secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

OBJECTIVES

Gout is a common complication of blood pressure management and a frequently cited cause of medication nonadherence. Little trial evidence exists to inform antihypertensive selection with regard to gout risk.

METHODS

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial on the effects of first-step hypertension therapy with amlodipine, chlorthalidone, or lisinopril on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). Trial participants were linked to CMS and VA gout claims (ICD9 274.XX). We determined the effect of drug assignment on gout with Cox regression models. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) with gout.

RESULTS

Claims were linked to 23 964 participants (mean age 69.8 ± 6.8 years, 45% women, 31% black). Atenolol use was reported by 928 participants at the 1-month visit. Over a mean follow-up of 4.9 years, we documented 597 gout claims. Amlodipine reduced the risk of gout by 37% (hazard ratio 0.63; 95% CI 0.51--0.78) compared with chlorthalidone and by 26% (hazard ratio 0.74; 95% CI 0.58--0.94) compared with lisinopril. Lisinopril nonsignificantly lowered gout risk compared with chlorthalidone (hazard ratio 0.85; 95% CI 0.70--1.03). Atenolol use was not associated with gout risk (adjusted hazard ratio 1.18; 95% CI 0.78--1.80). Gout risk reduction was primarily observed after 1 year of follow-up.

CONCLUSION

Amlodipine lowered long-term gout risk compared with lisinopril or chlorthalidone. This finding may be useful in cases where gout risk is a principal concern among patients being treated for hypertension.This trial is registered at clinicaltrials.gov, number: NCT00000542.

Impact of Clinic-Based Blood Pressure Approaches on Blood Pressure Measurement

BACKGROUND

Clinic-based blood pressure (BP) is a closely-tracked metric of health care quality, but is prone to inaccuracy and measurement imprecision. Recent guidelines have advocated for automated office blood pressure (AOBP) devices to improve clinic-based BP assessments.

METHODS

Patients from a single hypertension clinic underwent a 3-day evaluation that included a 24-hour ambulatory blood pressure monitoring (ABPM), 2 manual clinic-based BP measurements (over 2 visits), and an unattended AOBP measurement (single visit). All measurements were compared to the average wake-time systolic BP (SBP) and diastolic BP (DBP) from ABPM.

RESULTS

Among 103 patients (mean age 57.3 ± 14.8 years, 51% women, 29% black) the average wake-time SBP was 131.3 ± 12.3 mm Hg and DBP was 78.3 ± 9.2 mm Hg. The average of 2 manual BPs was significantly higher than wake-time ABPM with mean differences of 5.5 mm Hg (P < 0.001) for SBP and 2.7 mm Hg (P = 0.002) for DBP. In contrast, the averages of the last 2 AOBP measurements did not significantly differ from ABPM with mean differences of 1.6 mm Hg (P = 0.21) for SBP and -0.5 mm Hg (P = 0.62) for DBP. The estimated prevalence of SBP ≥ 140 or DBP ≥ 90 mm Hg based on wake-time ABPM was 27.2% vs. 49.5% based on the average of 2 manual measurements (difference 22.3%; P < 0.001) and 31.1% based on the average of the last 2 AOBP measurements (difference 3.9%; P = 0.57).

CONCLUSIONS

A single visit, unattended AOBP more precisely estimated BP and the prevalence of stage 2 and uncontrolled hypertension than even the average of 2 manual clinic visits, supporting guideline recommendations to use AOBP for clinic-based BP measurements.

Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Abstract 103: The Effects of s Lower Blood Pressure Treatment Goal on Orthostatic Hypotension in Adults With Recent Stroke

Background: Lower systolic blood pressure (SBP) treatment goals reduce risk of orthostatic hypotension (OH). Whether a lower goal also reduces orthostatic symptoms is unknown.

Methods: We examined the effect of SBP goal on OH in SPS3-BP (Secondary Prevention of Small Subcortical Strokes - Blood Pressure), an open label, randomized trial. Adults with a recent stroke (<6 months) were assigned to either a SBP goal of 130-149 mm Hg or <130 mm Hg. During follow-up, BP was measured 3 times in a seated position and once after 2 minutes of standing. OH was defined as a drop in SBP ≥20 mm Hg or DBP ≥10 mm Hg. We also examined extreme standing BP values (SBP ≥190 mm Hg or ≤90 mm Hg; DBP ≥110 mm Hg or ≤40 mm Hg). Participants were asked about dizziness and lightheadedness in the process of standing up. We used generalized estimating equations to account for repeat measurements.

Results: During 36,342 visits, involving 2,876 participants (mean age 62.8 ± 10.7 yrs, 37% women, 16% black) with a mean of 15 follow-up visits, OH was present 2,591 times in 1,165 participants. Similarly, dizziness was present 1,343 times (in 592 participants) and lightheadedness was present 941 times (in 893 participants). A lower SBP goal (compared to standard) was associated with a lower risk of OH (OR 0.86; 95% CI: 0.75, 0.99), a higher risk of SBP ≤90 mm Hg (3.79; 2.35, 6.11) or DBP ≤40 mm Hg (2.42; 1.41, 4.15), and a lower risk of SBP ≥190 mm Hg (0.40; 0.27, 0.60) or DBP ≥110 mm Hg (0.31; 0.19, 0.50) ( Table ). BP goal did not affect dizziness or lightheadedness.

Conclusions: A lower SBP goal decreased OH without affecting orthostatic symptoms. These findings support recent observations that more intensive SBP treatment does not increase risk of falls.

Young Lady with Bilateral Yellowish Lesions on Her Eyelids

A 26-year-old woman with an unknown medical illness presented with yellowish skin lesions around both eyes, visible for the past 4 years. The lesions were neither itchy nor tender and had increased gradually in size. She had neither constitutional nor hyperthyroidism symptoms. She is the youngest out of four siblings, and none of her family members have cardiovascular disease or similar problems. Upon examination, there were bilateral yellowish plaques over the periorbital region. Her body mass index (BMI) was 23.8 kg/m². Her vital signs were all normal at every visit.

Alopecia secondary to repaired occipital encephalocele - role of tissue expander in hair restoration

Partial scalp alopecia is a common problem that can lead to severe social and psychological problems. Tissue expansion, although an old concept, provides a surgical alternative to manage areas of alopecia. We describe a case of alopecia secondary to repaired occipital encephalocele that was successfully treated using tissue expansion technique.

Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta-analysis

Essentials Despite trial data, guidelines have not endorsed direct oral Xa inhibitors above other options. We provide profiles of venous thromboembolism and hemorrhage risk for 12 options. Direct oral Xa inhibitors had a favorable profile compared with low-molecular-weight heparin. Other options did not have favorable profiles compared with low-molecular-weight heparin.

SUMMARY

Background There are numerous trials and several meta-analyses comparing venous thromboembolism (VTE) prophylaxis options after total hip and knee replacement (THR and TKR). None have included simultaneous comparison of new with older options. Objective To measure simultaneously the relative risk of VTE and hemorrhage for 12 prophylaxis options. Methods We abstracted VTE and hemorrhage information from randomized controlled trials published between January 1990 and June 2016 comparing 12 prophylaxis options. We then constructed networks to compute the relative risk for each option, relative to once-daily dosing with low-molecular-weight heparin (LMWH) Low. Results Main: Relative to LMWH Low, direct oral Xa inhibitors had the lowest risk of total deep vein thrombosis (DVT)-asymptomatic and symptomatic- (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.35-0.57), translating to 53-139 fewer DVTs per 1000 patients. Vitamin K antagonists (VKAs) titrated to International Normalized Ratio [INR] 2-3 predicted 56% more DVT events (OR, 1.56; 95% CI, 1.14-2.14). Aspirin performed similarly (OR, 0.80; 95% CI, 0.34-1.86), although small numbers prohibit firm conclusions. Direct oral Xa inhibitors did not lead to significantly more bleeding (OR, 1.21; 95% CI, 0.79-1.90). Secondary: Relative to LMWH Low, direct oral Xa inhibitors prevented 4-fold more symptomatic DVTs (OR, 0.25; 95% CI, 0.13-0.47). Conclusions Relative to LMWH Low, direct oral Xa inhibitors had a more favorable profile of VTE and hemorrhage risk, whereas VKAs had a less favorable profile. The profile of other agents was not more or less favorable. Clinicians should consider these profiles when selecting prophylaxis options.

Identification of psychosocial factors of noncompliance in hypertensive patients

This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.

Prevalence of HIV, syphilis and genital chlamydial infection among women in north-west Ethiopia

The prevalence of sexually transmitted diseases (STD) among women visiting antenatal (ANC) and gynaecological clinics in Gondar, north-west Ethiopia, was investigated. Between April and August 1995, 728 women consented to enter the study. Prevalence rates were 5.9% (41/693) for chlamydial antigen in cervix, 18.8% (113/600) for syphilis (Treponema pallidum haemagglutination assay [TPHA]) and 25.3% (150/593) for HIV. Active syphilis (RPR)+, TPHA+ was detected in 74% (44/597). HIV infection rate was higher among women with higher age of first marriage and low gravidity. It was significantly associated with young age, urban residence, and presence of genital ulcer (odds ratio [OR] = 6.3), and lymphadenopathy (OR = 2.8) on examination. Women seropositive for syphilis had married at an earlier age, were significantly older and had changed husbands. Low gravidity and age < 30 were independently significant risk factors for cervical chlamydial antigen positivity which was predominantly asymptomatic. Significant association was observed between HIV infection and syphilis (OR = 2.6). Active syphilis was associated with chlamydial (OR = 3.4) and HIV infection (OR = 4.1). The rate of 23.4% and 15.1% of HIV seropositivity among ANC attenders and rural women respectively is an indicator of the rapid progression of the HIV epidemic in the area.

Cholera outbreak in Tumpat, Kelantan-1990

Two episodes of El Tor cholera outbreak occurred in Tumpat, Kelantan between the 13th of January and the 16th of May 1990. Every case and carrier reported were investigated to determine the source and mode of transmission and to identify specific preventive measures to break the chain of transmission. There were 109 cases and 85 carriers involved in this study. The first episode of one case only was of Inaba serotype while the second episode was caused by the imported Ogawa serotype. Two foci of spread were identified from cluster occurrence but the majority of infection had no discernible link between them. The outbreak became both explosive and protracted indicating poor basic sanitation and personal hygiene. Person-to-person transmission via food and water was the main mode of spread. The Kelantan river water and river clams were confirmed sources of reservoir during the outbreak. Recommendations for prevention are intensified surveillance throughout the year,urgent upgrading of potable water supply and concerted effort in public health education especially against the use of river water and the consumption of raw food.