Morning hypertension for stroke and cardiovascular: clinical pearls for primary care

Hypertension is the world’s leading cause of mortality and morbidity. One of the phenomena that commonly occur in hypertensive as well as normotensive patients, is morning hypertension. Blood pressure (BP) follows a diurnal rhythm, reaching its highest level during the morning hours and dropping to the lowest level at midnight. Transient increases in BP in morning hypertension plus persistent stressors within 24 hours are thought to increase target organ damage and trigger cardiovascular events. Therefore, ambulatory BP monitoring or morning home BP monitoring is recommended as a strong predictor of cardiovascular events. There are two types of morning hypertension according to its underlying mechanisms; the first one is called nocturnal hypertensive morning hypertension, and the other one is morning-surge hypertension. Numerous studies have proved that this phenomenon often leads to several acute cardiovascular events, such as stroke, coronary artery disease, and peripheral artery disease. To prevent these complications, cost-effective management is needed, especially for identifying accurate diagnostic tools, as well as creating specific regimens. Therefore, to achieve appropriate management of hypertension, including morning hypertension, long-acting antihypertensive drugs should be used, at full doses and in the form of combination therapy. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. More studies are needed, especially looking for other clinical evidence of the benefits of lowering BP in the morning. Home BP monitoring is recommended as a good choice for BP measurements, especially in the primary care setting.

Obesity is the most influential risk factor of cardiopulmonary endurance in older women

BackgroundPulmonary function decreases with age. Similarly, physical exercise capacity measured by maximal oxygen uptake, which is one indicator to measure the level of cardiac and pulmonary vascular resistance, decreases by >1% per year. This results in many respiratory diseases that occur in older persons, especially in obese older persons. Pulmonary function is a basic component of cardiopulmonary endurance, besides other factors such as age, hemodynamics, metabolism, and lifestyle. The objective of this study was to determine whether body mass index (BMI) and pulmonary function have a significant association with cardiopulmonary endurance in older women. MethodsThe study used a cross-sectional design involving 66 subjects aged 60 years and older in South Jakarta. Data was collected by measuring body mass index (BMI), pulmonary function (FEV1, FVC, FEV1/FVC) and maximal oxygen uptake (VO2 max) for cardiopulmonary endurance. Data analysis used simple and multiple linear regression tests in SPSS v.25, with p<0.05. ResultsOf the 66 older persons, 57.6% was obese. Pulmonary function of subjects showed restriction (33.3%), obstruction (6.1%) and a combination of restriction and obstruction (1.5%). Furthermore, mean VO2 max was 12.2 mL/kg/min. Multiple linear regression analysis showed a significant association of BMI and FEV1/FVC with VO2 max (â =-0.56; 95% CI=-0.81 - (-) 0.31; p=0.000; â =0.09; 95% CI=0.01-0.18; p=0.028). BMI was the most influential risk factor of VO2 max (Beta = -0.46). ConclusionsThere was a significant association of BMI and FEV1/FVC with VO2 max, BMI being the most influential risk factor of cardiopulmonary endurance in older women.

Viral load as a risk factor of reverse transcriptase inhibitor drug resistance mutation in antiretroviral-treated people living with HIV/AIDS

Background The human immunodeficiency virus type 1 (HIV-1) is a major contagion faced by the population of Indonesia. The success of antiretroviral treatment (ART) is threatened by the emergence of drug resistance mutations (DRM). The aim of this study was to determine the association between CD4 count, CD4 count changes, viral load, adherence to therapy, and therapy history in the presence of DRM in people living with HIV/AIDS (PLWHA). MethodsThis was a cross-sectional study involving 269 adults who underwent antiretroviral (ARV) therapy for at least 6 months. The frequencies of DRM and polymorphisms were measured by partial amplification of the reverse transcriptase (RT) gene using RT-nested PCR on samples with viral loads of >1000 copies/mL. Sequencing was performed using the Sanger method, and edited by BioEdit. The edited sequences were submitted to http://hivdb.stanford.edu for DRM determination. Respondents’ medical data, CD4 count, viral load, and DRM were analyzed by simple and multiple logistic regression. ResultsThe multiple logistic regression analysis showed a significant association of CD4 count (aOR=12.47; 95% CI: 1.45 -107.39; p=0.023) and viral load at the time of study (aOR=29.56; 95% CI: 3.47-251.52; p=0.002) with the presence of DRM in respondents. ARV substitution history was not associated with the presence of DRM. There were 17 respondents (6.3%) carrying HIV-1 DRM, with M184V/I (11 sequences) as the most frequent pattern of NRTI resistance, and K103 (9 sequences) as that of NNRTI resistance. ConclusionThis study demonstrated that viral load at the time of the study was the most influential determinant factor for the presence of DRM in PLWHA.

Detection of immunogenic protein from salivary gland of Aedes albopictus

BackgroundDengue virus is transmitted by several species of Aedes mosquitoes, with Aedes albopictus as secondary vector. During blood feeding, these vectors inject saliva into the vertebrate hosts. The saliva contains anticoagulant, anti-inflammatory and immunogenic factors. The objective of this research was to detect immunogenic proteins from Ae.albopictus salivary glands reacting with sera of people living in dengue endemic areas. MethodsThe identification of immunogenic proteins of Ae. albopictus salivary gland used one-dimensional gel electrophoresis (sodium dodecyl sulfate polyacrylamide gel electrophoresis), and western blot analysis, respectively. To determine the immunogenic nature of the candidate proteins, the antigens from the salivary gland of Ae. albopictus were reacted with sera from healthy persons, dengue hemorrhagic fever (DHF) patients, and neonates, each of the groups comprising 10 samples. ResultsThe protein profiles of Ae. albopictus salivary glands showed 13 bands with molecular weights from 16 kDa up to 97 kDa, i.e. 16, 17, 26, 28, 31, 32, 45, 55, 60, 67, 73, 76, and 97 kDa. According to western blot analysis result, the 31 kDa proteins were recognized in all endemic population sera, both in DHF patients and healthy persons. In contrast, protein bands of 47 and 67 kDa were only recognized by the sera of DHF patients. ConclusionThree immunogenic proteins of 31, 47 and 67 kDa were detected from Ae. albopictus salivary glands. These immunogenic proteins may be developed as candidate biomarkers for bite exposure to Ae. albopictus and as vector-based DHF vaccines.

Breastfeeding self-efficacy and related factors during early postpartum period

BACKGROUNDBreastfeeding self-efficacy (BSE) could be an indicator of the performance of mothers in breastfeeding during the immediate postpartum time period. The factor most affecting the duration and success of breastfeeding is the self-efficacy perception of the mothers. This study was carried out to determine the BSE and the factors related to it in the early postpartum period. METHODSA cross-sectional study was performed involving 264 mothers. Data were collected by using a questionnaire and the BSE scale (BSES). The questionnaire consisted of questions regarding descriptive characteristics (age, educational status, family type, income level, etc.) and obstetric characteristics regarding pregnancy, delivery and breastfeeding status (number of pregnancies, number of births, type of delivery, planned and desired pregnancy, birth weight, first breast-feeding time after birth, etc.). Simple and multiple linear regression were performed to examine factors related to BSE. RESULTSThe mean BSE score of the mothers participating in the study was 65.20 ± 9.3. Simple and multiple linear regression models indicated that significant determinants of BSE score include having nuclear family type, having social security, a greater number of pregnancies, a greater number of births, the status of antenatal visits in pregnancy, the status of getting information about breastfeeding, and short first breastfeeding time. Getting information about breastfeeding was the most influential factor of BSE (Beta=3.432; 95% CI : 32.771-51.626; p=0.000). CONCLUSIONSIn this study, getting information about breastfeeding was the most influential factor of BSE in the early postpartum period. A woman's level of breastfeeding self-efficacy should be determined during the early postpartum period.

Outcomes of ureteral stent placement for hydronephrosis in patients with ureteral stone

BackgroundRoutine ureteral stent placement after ureteroscopy (URS) for ureteral stone treatment is arguable due to the possible stent-related symptoms. Several studies claimed that its use is necessary, while others reported that its use is excessive. Hydronephrosis occurs when urine cannot drain out from the kidney to the bladder due to blockage or obstruction. We aimed to evaluate the role of ureteral stents in hydronephrosis resolution in ureteral stone patients following URS lithotripsy. MethodsThis was a prospective observational study using secondary data involving 130 ureteral stone patients undergoing URS lithotripsy [99 patients (76.2%) with stent placement and 31 patients (23.8%) without stent]. Data consisting of baseline characteristics, pre-operative status, intraoperative characteristics, and postoperative complications were collected from the medical record database and presented descriptively. The patients were divided into two groups based on stent placement. Comparison of hydronephrosis resolution between the groups was analyzed with Chi-square. ResultsUreteral lesions were the most common indication of ureteral stent placement following URS lithotripsy (28.3%). The most bothersome symptoms were dysuria in 18 patients (18.2%); followed by frequency in eight patients (8.1%) and low back pain in six patients (6.1%). All symptoms were successfully treated with oral medications. There were 41 patients (91.1%) with pre-operative hydronephrosis significantly resolved after stent placement compared to 5 (62.5%) patients without stent placement (p=0.027). ConclusionUreteral stenting significantly resolves pre-operative hydronephrosis after URS lithotripsy in patients with ureteral stone. Ureteral stent placement is the preferred method for the treatment of pre-operative hydronephrosis.

Marasmus and stunting in 2-month-old boy with pneumatocele

BackgroundNutrition is essential for humans and if inadequate may lead to undernutrition. Undernourished children are very susceptible to infections, such as pneumonia, one of its complications being pneumatocele, which is a more severe condition. Pulmonary pneumatoceles are thin-walled, air-filled cysts that develop within the lung parenchyma and have been found in 2.4 percent of 493 infants and children with pneumonia. However, in staphylococcal pneumonias, the frequency of pneumatocele can reach as high as 85 percent. Infants and young children are more likely to have pneumatoceles. It is critical to distinguish marasmus with pneumatocele from many other similar diagnoses. Failure to recognize can lead to incorrect diagnosis and treatment, causing more harm than good to patient care. This case highlights the importance of maintaining a high suspicion of pneumonia in neonates even with normal radiological findings and of searching for pneumatoceles. Case DescriptionWe report a case of marasmus and stunting accompanied by pneumatocele in a 2-month-old boy. The diagnosis was made based on history, physical examination, anthropometric examination using the WHO child growth standards, laboratory tests, and radiological imaging. Management of the patient was according to a multidisciplinary system including antibiotics administration and wasting management. ConclusionPneumatoceles are serious complications after pneumonia. Pneumonia is common in children with marasmus. Children with marasmus are caused by various underlying factors. The progression begins in the womb and continues through the first 1000 days of life.

Propranolol significantly reduced DNA polymerase β expression in patients with essential tremor

Background Essential tremor (ET) is the most common movement disorder. Propranolol is a first-line medication for ET. We aimed to evaluate the effect of propranolol on the expression of poly (ADP-ribose) polymerase 1 (PARP1) and DNA polymerase beta (POLB) genes, which are known to be related to neurodegenerative diseases, in patients with ET. MethodsThirty-five healthy volunteers and thirty-five patients followed up with essential tremors were included in a non-randomized control experimental study. Expressions of PARP1 and POLB genes were compared between the control group and the patient group. In addition, pre- and post-treatment gene expression levels and Fahn-Tolosa-Marin tremor scale values of the patient group were compared after 8 weeks of propranolol treatment. The Wilcoxon rank and Mann Whitney U tests were used to analyze the data. ResultsAt baseline, PARP1 expression was significantly lower in the ET group than in the control group. (p<0.001). POLB gene expression was significantly higher in the pre-treatment ET group than in the controls (p<0.05). There was no significant difference in PARP1 expression levels before and after 8 weeks of propranolol treatment. POLB gene expression was significantly higher in the pre-treatment group than in the post-treatment group (p<0.001). ConclusionPropranolol significantly decreased POLB gene expression but there was no significant difference in PARP1 gene expression levels in the patient group, after 8 weeks of propranolol treatment.

Comparison of matrix metalloproteinase-9 and E-cadherin expression in early- and late-onset preeclampsia

BACKGROUNDPreeclampsia (PE) is one of the most common pregnancy complications worldwide. Turnover of villous trophoblast is affected by impaired placental perfusion in preeclampsia. Among the various factors that influence pro and antiangiogenic factors in trophoblast invasion of PE are E-cadherin and matrix metalloproteinase-9 (MMP-9). The current classification scheme differentiates PE into two variants early-onset (EO) and late-onset (LO) PE. The aim of this study was to compare MMP-9 and E-cadherin expression between early- (EO) and late-onset (LO) PE. METHODSThis study used a cross-sectional design involving 26 women with gestational age <34 weeks (EO) and 38 women with gestational age ≥34 weeks (LO) from PE patients. Placentas born to preeclamptic mothers were taken in the form of small pieces of the maternal side to measure the levels of MMP-9 and E-cadherin by the ELISA method. Statistical analysis was assessed using the Mann Whitney and independent t-test with a significant p value <0.05. RESULTSSemiquantitative proteinuria levels were significantly higher in EO-PE group compared to LO-PE group (p=0.000). Mean E-cadherin levels were significant lower in the EO-PE group (125.94 ± 54.22 pg/mg) compared to LO-PE group (157.95 ± 54.12 pg/mg) (p=0.024). However, there was no significance difference in median MMP-9 levels between EO-PE group and LO-PE group (p=0.376). CONCLUSIONThis study demonstrate that E-cadherin had lower levels in preeclampsia patients who gave birth <34 weeks. This study indicated that lower levels of e-cadherin can lead to early delivery in preeclampsia patients.

Being aware of the neurological manifestations of COVID-19 infection

The novel coronavirus disease- 2019 (COVID-19) is first reported from China, and unfortunately, no longer restricted, and spreads in all geographies.(1) The main symptoms of COVID-19 infection are respiratory tract related. Infected patients usually have symptoms such as fever, sore throat, and fatigue, and they may have atypical symptoms like headache, seizure, anosmia, stroke, and even impaired consciousness. Strong evidence of an association between COVID-19 infection and neurological manifestations has been reported. Besides, the neurologic manifestations may be the initial presentation of COVID-19 infection.