Borderline Blood Pressure Research Articles

7668 Rhabdomyolysis Associated with Severe Hypothyroidism

Abstract Disclosure: H. Soe: None. P. Mikkilineni: None. Background: Over 70% of the patients with newly diagnosed hypothyroidism can present with muscle complaints such as weakness, fatigability, cramps, myalgia. However, rhabdomyolysis, which is the rapid breakdown of skeletal muscle cells, is the rare presentation. Clinical Case: A 70-year old male patient with history of rheumatoid arthritis, hyperlipidemia, prior CVA (left hemispheric subcortical stroke) 6 months ago without residual deficit presented to the hospital with poor oral intake and generalized muscle weakness for 3 weeks. He was unable to get out of bed without assistance and also needed adult diapers. Found to have new-onset severe hypothyroidism with TSH 228 uIU/ml (Ref: 0.350-4.940) and FT4 <0.40 ng/dL (Ref: 0.70-1.50), positive TPO antibody 197 IU/ml (Ref: 0-34). No prior thyroid labs were available and no known history of thyroid disorder was recorded. He has never been on Amiodarone or Lithium before. On physical exam, he was alert and oriented. There was no goiter or palpable thyroid nodule. There was no focal neurological deficit and no peripheral edema. There were no other signs and symptoms pertinent to hypothyroidism except mild bradycardia (HR 56-60) and borderline low blood pressure. AM cortisol was 10.1 ug/dL (Ref: 3.7-19.4). EKG showed low-voltage sinus bradycardia. Echocardiogram was normal. Urinalysis was positive for large blood but only 3 RBCs were present which raised the suspicion of rhabdomyolysis. Creatinine kinase (CK) was 15,584 IU/L (Ref: 30-200). Other laboratory studies were significant for acute renal failure with mild hyperkalemia and mild hypocalcemia, also transaminitis; BUN 130 mg/dl (Ref: 8-26), Creatinine 9.51 mg/dl (Ref: 0.72-1.25), eGFR 5 ml/min/1.73 m2 (Ref: >59), AST 435 IU/L (Ref: 5-34), ALT 269 IU/L (Ref: <55), ALP 171 IU/L (Ref: 40-150). On medication review, he was started on Atorvastatin 80 mg daily during prior admission for CVA 6 months ago. He received IV fluids, s/p 1 dose of Hydrocortisone 100 mg IV, Levothyroxine IV 200 mcg, followed by Levothyroxine IV 50 mcg daily x 3 days and switched to Levothyroxine PO 100 mcg daily (weight-based dose). Atorvastatin was on hold. He became anuric during the hospital course and received 2-3 sessions of hemodialysis. 3-4 days later, CK was trending down to 3000 IU/L, FT4 improved to 0.54 ng/dl and there was also significant improvement in kidney and liver functions. The patient was diagnosed with acute renal failure secondary to rhabdomyolysis associated with severe hypothyroidism caused by Hashimoto's thyroiditis, in the setting of high dose statin use. Conclusion: Clinicians should raise the suspicion of rhabdomyolysis in a patient with severe hypothyroidism, especially in patients with recent high dose statin use as rhabdomyolysis can be a rare and fatal complication of severe hypothyroidism, in the presence of precipitating factors. Presentation: 6/2/2024

7443 Severe Hypothyroidism and Adrenal Insufficiency in a 27-Year-Old Male with Klippel-Feil Syndrome: A Case Report

Abstract Disclosure: S. Almardini: None. F. Haddadin: None. L. Aoun: None. F. Saliba: None. J. Zaidan: None. Background: Klippel-Feil syndrome (KFS) is a rare congenital disorder characterized by improper segmentation of the cervical vertebrae. The classical clinical triad consists of short neck, low posterior hairline, and limited neck mobility. It is uncommonly associated with endocrine abnormalities. We present a rare case of KFS with severe primary hypothyroidism. Case Presentation: A 27-year-old male with KFS presented for evaluation of profound fatigue and lack of energy. His vital signs revealed a heart rate of 50 and a borderline low blood pressure. On physical exam patient was noted to be lethargic and icteric, thyroid exam was limited due to patient short neck. Labs were consistent with severe hypothyroidism TSH of 825 mIU/L, total T4 <0.4 mcg/dL, low 8 AM cortisol of 4.3 mcg/dL, elevated LDL at 333 mg/dL, elevated liver enzymes AST 491 U/L, ALT 294 U/L, neutropenia with WBC 2.69 x10^3/uL 20% neutrophils and anemia Hb 12 g/dL. TPO and thyroglobulin antibodies were positive at 149.0 and 109.0 IU/mL respectively, 21 hydroxylase antibodies were negative. Thyroid Ultrasound showed small and diffusely heterogenous thyroid. Patient was started on Levothyroxine 125 mcg daily and hydrocortisone with improvement in his symptoms as well as normalization of his lipid panel, liver enzymes and neutropenia. The patient was continued on levothyroxine 125 mcg, hydrocortisone was tapered and repeat cortisol levels were normal. Discussion: This case demonstrates an unusual association between KFS and hypothyroidism secondary to Hashimoto thyroiditis, likely representing an incidental finding rather than a causative relationship. The cervical spinal abnormalities and short neck characteristic of KFS could potentially lead to compression of neurological and vascular structures in the neck. However, this is unlikely to fully explain our patient's hypothyroidism. There are few published case reports of KFS with endocrine disorders in the literature that describe incidental findings like autoimmune thyroiditis and hypoparathyroidism, but there is no known biological mechanism linking KFS and endocrine dysfunction. Moreover, there is no evidence in either our patient's case or in existing literature to suggest a higher occurrence of autoimmune disorders like Hashimoto in such individuals. Conclusion: we present a novel case of KFS found incidentally with primary hypothyroidism. While these endocrine disorders could compound the growth delay and developmental issues typically seen in KFS, they do not appear to be causally related. This case highlights the need to monitor endocrine function in KFS patients and serves as a reminder that common conditions may co-occur simply by chance. Presentation: 6/3/2024

Abstract 09: The Diagnostic Accuracy of Using Borderline High Office Blood Pressure Thresholds to Diagnose Masked Hypertension According to the 2017 American College of Cardiology / American Heart Association Blood Pressure Guideline

Background: Compared to adults with sustained normotension (i.e. those with neither high office blood pressure [BP] nor high out-of-office BP), adults with masked hypertension (i.e. those with high out-of-office BP but not high office BP) have an increased risk of cardiovascular disease events. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline recommends using ambulatory BP monitoring (ABPM) to detect masked hypertension among adults with an office BP close to the high BP threshold (i.e. office systolic BP [SBP] 120 to <130 mmHg or diastolic BP [DBP] 75 to <80 mmHg) and not taking antihypertensive medication (Class IIa recommendation). Limited data exist on the diagnostic accuracy of using this approach to detect masked hypertension. Methods: We analyzed data from the Improving the Detection of Hypertension Study, a community-based study of adult participants, from Upper Manhattan, not taking antihypertensive medication. Office BP was measured using a validated Omron oscillometric device (Model HEM-790IT or HEM-791IT) and ABPM was performed using a validated Spacelabs device (Model 90207). Sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), false positive rate (FPR), and false negative rate (FNR) of having an office SBP 120 to <130 mmHg or DBP 75 to <80 mmHg for the diagnosis of high BP on ABPM were determined among 263 participants who had a mean SBP <130 mmHg and mean DBP <80 mmHg based on 6 SBP and 6 DBP readings from the first 2 visits (i.e. 3 SBP and 3 DBP readings per visit), and a sufficient number of ABPM readings (i.e. ≥10 awake and ≥5 asleep readings). High BP on ABPM was defined as mean awake SBP ≥130 mmHg or mean awake DBP ≥80 mmHg as per the 2017 ACC/AHA BP guideline. In a sensitivity analysis, high BP on ABPM was defined as mean 24-hour SBP ≥125 mmHg or mean 24-hour DBP ≥75 mmHg. Results: Mean (SD) age was 39.2 (12.8) years, 62.4% were female, 16.7% were non-Hispanic White, 14.4% were non-Hispanic Black, 6.8% were non-Hispanic Asian, 60.8% were Hispanic, and 1.3% were Other race/ethnicity. Of the 263 participants, 101 (38.4%) had an office SBP 120 to <130 mmHg or DBP 75 to <80 mmHg, and 69 (26.2%) had high BP on ABPM (awake SBP/DBP ≥130/80 mmHg). SN, SP, PPV, NPV, FPR, and FNR were 75.4%, 74.7%, 51.5%, 89.5%, 25.3%, and 24.6%, respectively. When using mean 24-hour SBP/DBP to define high BP on ABPM, SN, SP, PPV, NPV, FPR, and FNR were 72.7%, 75.8%, 55.4%, 87.0%, 24.2%, and 27.3%, respectively. Conclusions: The 2017 ACC/AHA BP guideline currently would require only 38.4% of participants with mean office BP <130/80 mmHg to be screened with ABPM for masked hypertension using a screening office BP threshold of SBP 120 to <130 mmHg or DBP 75 to <80 mmHg. However, this approach had a substantial rate of false positives and false negatives. Investigation of alternative diagnostic screening approaches for masked hypertension is needed.

Metabolic Syndrome and Positive Frailty Screening: A Cross-Sectional Study with Community-Dwelling Older Adults.

Metabolic Syndrome is a set of disorders that characterized by the association of three or more risk factors, like the obesity central, dyslipidemia, borderline blood pressure, hyperglycemia, and the increase of triglycerides. However, these factors also can be associated with pathophysiology of frailty. verifying whether the metabolic syndrome is associated to the positive frailty screening in the older people. Cross-sectional study. Participants: 443 older people living in Rio Branco, Brazil. Data collection was carried out in two stages: a personal interview and blood collection. The diagnosis of metabolic syndrome was based on the criteria of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. The frailty screening was performed using subjective questions validated in a previous study. Descriptive statistics and multinomial logistic regression were used for data analyses. There was a predominance of female older people (69.07%), aged between 60 and 79 years (87.13%), with an income greater than or equal to one minimum wage (72.09%), no cognitive decline (75.94%) and depressive symptoms (63.31%), independent for BADL (86.46%) and dependent for IADL (51.69%). From the total sample, 56.88% of the older people were identified as frail, 34.09% pre-frail and 9.03% non frail. The prevalence of metabolic syndrome was 51.69%. After adjusting by the independent variables, an association between metabolic syndrome and pre-frailty was observed, and older people with metabolic syndrome were more likely to be prefrail (RRR=2.36; 95%CI=1.08-5.18). The metabolic syndrome was associated to the increase chance of screening for prefrailty in the older people evaluated, which reinforces the needy to establish preventive measures in relation to the metabolic syndrome to avoid frailty in the older people.

HYPERTENSIVE URGENCY IN OLDER ADULT WITHOUT HYPERTENSION HISTORY: THE DANGERS OF OVERTREATMENT WITH LEVOTHYROXINE

Abstract A 72-yr old woman with well-controlled depression and active lifestyle was seen at urgent care for “nervousness.” She was found to have borderline tachycardia and blood pressure of 187/114 mmHg. There were no other associated symptoms. Physical examination and labs were unremarkable, with normal renal function. EKG showed sinus tachycardia at 110 bpm. Recheck of BP after 30 minutes was 135/80mmHg, and she was discharged home on Lisinopril. Two days later, she again had “nervousness” and was taken to the Emergency Department. Blood pressure was 200/105 mmHg. Again, she denied any other symptomatology, and had unremarkable physical exam and labs. Repeat BP was improved, and she was discharged home with instruction to follow up with PCP. Medication list included Bupropion for depression which she has been taking and tolerating well for years, and Levothyroxine 25 mcg daily, which was started by her PCP 8 weeks prior, for TSH of 5.43 mIU/L and FT4 of 1.1 ng/dL. Thyroid hormone therapy was stopped during recent ED visit, and she has had no recurrence of her anxiety symptoms. Her BP has been checked daily at home and has been at baseline level.

Daily trend of blood pressure in staff under conditions of shift work of railway transport

Introduction. The results of the study of features of the daily rhythm of blood pressure in people who constantly work in a rotational shift schedule, arising under the influence of night shift work, are discussed.
 The purpose of the study was to determine the modifying effect of working night wakefulness on the parameters of the daily rhythm of blood pressure in persons employed in work with a night shift schedule.
 Materials and methods. The analysis was carried out, in two cohorts of 19 years – 62 years employees of locomotive crews of Russian Railways. The study included drivers, assistant locomotive drivers, for at least 1 year, with night shifts n = 30,566, the number of measurements = 4,497,122, but borderline (high normal) blood pressure.
 Results. The lowest levels of systolic blood pressure (SBP) were found to be recorded in a cohort of subjects per day with a night shift, the highest – in the general group of workers and in a cohort of subjects per day with a day shift.
 The daily trend of SBP was characterized by a regular change of phases in all observation groups. In the general group, a subgroup of persons with normotonia, in a cohort of subjects, when working on a day shift, a DECLINE curve of the same type in configuration was formed.
 Limitations. The representativeness of the sample size was ensured by the participation in the study of employees of locomotive crews with a range of ages 
 of 19-62 years. The limitations of the study are related to the distribution of respondents by gender: there are no female respondents in the sample.
 Conclusions. Parameters of the daily rhythm of blood pressure sensitively react to changes in working hours. To the greatest extent, changes in the daily rhythm during the hours of night working wakefulness are typical for the indicators of the daily rhythm of diastolic blood pressure.

SAT155 Insulin Receptor Autoantibody Syndrome (Iras): A Rare Occurrence In Lymphoproliferative Disease

Abstract Disclosure: C. Villatoro Santos: None. E.A. Oral: None. Insulin receptor antibody syndrome (IRAS) may present as fasting hypoglycemia, high serum insulin, and serum autoantibodies to insulin receptor at low titers. We present a case of a patient with multiple myeloma (MM) who developed hypoglycemia suspected to be related to insulin receptor antibodies. The patient is a 60-year-old male with history of prediabetes, MM, anemia, and thrombocytopenia treated with carfilzomib, dexamethasone 20 mg weekly, and prior radiation to the right pelvis, who presented to the hospital for increased right hip pain and cough. Patient reported 4 days of markedly decreased appetite with poor intake. He noted increased chronic right hip and low back pain. On exam, he was cachectic, had hyperpigmentation under bilateral eyes, and muscle wasting. Hypoglycemia as low as 38 mg/dL (70-180 mg/dL) was noted. MM studies on hospital day 4 showed increased kappa-M protein and kappa-free light chains with worsening anemia and thrombocytopenia, concerning for progression of his disease. He later developed recurrent hypoglycemia; endocrinology was consulted on hospital day 6. He also had hyponatremia and borderline low blood pressure. Cortisol on hospital day 7 at 9:00 am was 15.4 μg/dL (5.3-22.5 μg/dL) in the setting of normoglycemia. On hospital day 9, hematology started dexamethasone 40 mg daily for 3 days for MM relapse, which resulted in marked improvement in his mental status, appetite, and resolution of hypoglycemia. On hospital day 11, he started weekly cyclophosphamide, bortezomib, plus dexamethasone for 3 weeks. Results for hypoglycemia workup returned on hospital day 12 from samples of Day 7: glucose 53 mg/dL (70-180 mg/dL), C-peptide 0.2 ng/mL (1-5.2 ng/mL), insulin 14.6 μU/mL (1-21 μU/mL), insulin antibodies undetectable, negative serum screen for oral hypoglycemic agents. His course was complicated by sepsis with gram-negative bacteremia treated with antibiotics and stress dose hydrocortisone. He was discharged to rehab on hospital day 34 on dexamethasone 4 mg daily. Glucose, c-peptide and insulin levels could be consistent with exogenous hyperinsulinemic hypoglycemia but may also represent delayed insulin clearance due to insulin receptor antibodies and autocrine suppression of pancreatic insulin production in a patient with no access to insulin. Therefore, the most likely diagnosis was IRAS. The insulin antibody radioactive essay was negative for native IgG and IgM antibodies; testing for insulin receptor antibodies is in progress as a clinical test is unavailable. Treatment is common with high doses of steroids. IRAs can be seen in patients with lymphoproliferative disorders and would respond to steroid treatment for hospital management. Definitive treatment should be tailored with oncology guidance. There is a need for an accessible clinical test for IRAS in the US. Presentation: Saturday, June 17, 2023

Unique Approach to Management of Hypertrophic Obstructive Cardiomyopathy within a Resource-Limited Hospital

LVOT obstruction in HCM results from systolic anterior motion (SAM) of the anterior leaflet of the mitral valve and is often a dynamic process (increasing with volume depletion and decreases with volume repletion or afterload augmentation). Hence, understanding the underlying pathophysiological process is crucial in tailoring management decisions. We herein present a case of a 57-year-old female who presented to the emergency department with complaints of shortness of breath (SOB), cough and borderline blood pressure who further decompensated during hospital course, suffering from acute hypotension related to dynamic LVOT obstruction. The patient was managed with a pure α-agonist, phenylephrine. This case report highlights the importance of having a high index of suspicion to early recognize such dynamic LVOT obstruction and further highlights the uniqueness of managing symptomatic hypotension in HCM with LVOT obstruction in an under-resourced hospital.

A Study to Correlate Smart Phone Addiction and Adult Hypertension Among Students of KPGU University: A Pilot Study

Background: The prevalence of hypertension is rising globally due to unhealthy lifestyle. Smartphones are vitalinstrument as a result of the rising use of technology in education. Anxiety, sadness, and sleep difficulties are alllinked to smartphone addiction. These mental illnesses also have an impact on blood pressure. The purpose ofthis study was to investigate the prevalence of hypertension and its association with smartphone addiction amongadults.Methods: An university-based cross-sectional study was conducted on 74 young adults, aged 17-24 years(18.47±0.51for males and 19.27±0.97 for females) by random cluster sampling method after getting consent.Systolic and Diastolic blood pressure were measured according to normative data of ACSM guidelines. BMIwas calculated to identify the prevalence of obesity and its association with an increase in blood pressure. TheSmartphone Addiction Scale - a short version was used to assess level of smartphone addiction.Results: The prevalence of risk of developing hypertension in those who are having smartphone addiction was9.45% ((OR=0.53, 95% CI: 0.155-1.762). And the association between smartphone addiction and obesity was 6.75%.Conclusion: Among college-going students surveyed at KPGU University Vadodara, there is a risk of developinghypertension due to excessive smartphone addiction as it shows borderline or elevated blood pressure and obesity.This can affect their physical as well as mental health. Therefore it is essential to arrange educational seminars tomake students aware of reducing the use of social media by engaging them in various recreational activities.

PS-P03-5: QUALITATIVE INSIGHTS INTO THE BARRIERS TOWARDS BLOOD PRESSURE SCREENING, TREATMENT ADHERENCE AND LIFESTYLE MODIFICATIONS IN SINGAPORE

In Singapore, despite numerous blood pressure (BP) campaigns, hypertension prevalence amongst adults has increased to 35%, exceeding the global rate of 31.1%. In light of the worrying trend, this research aims to examine major barriers faced by Singapore residents in their management of BP health. Through a novel reverse socialisation program, the study reached out to at-risk family members through their children and employed an in-depth qualitative lens to gain meaningful insights into the barriers faced at various stages of BP management care. An intergenerational hypertension education program was launched among Singapore grade 5 students. Students were educated about hypertension and taught how to utilize a BP monitor. They then shared their knowledge and measured their family members BP at home. Family members found with borderline or high BP were invited for an interview and had their BP measurements validated by a medical professional. In-depth semi-structured interviews were conducted with 15 adults who were identified to have borderline hypertension or hypertension. Transcripts were analysed using the constant comparative approach, an analytic strategy based on grounded theory. The study identified varying personal, psychosocial, and/or external barriers faced at three different stages of BP management care - regular screening, medical adherence and lifestyle modifications (Table 1). Firstly, a major barrier towards regular BP screening was low perceived need to seek medical care due to a lack of physiological symptoms, suggesting that many respondents perceived themselves as being less susceptible to hypertension. Secondly, barriers towards medical adherence were especially a concern for diagnosed hypertensives. A dominant factor was a lack of self-efficacy in following-up with the required care, such as fear of failing doctors expectations in follow-up appointments, lack of time and inability to comply with prescribed sudden changes to dietary and exercise habits Thirdly, the inability to comply with recommended lifestyle modifications was nuanced by various factors related to ones identity such as age, job, familial obligations and culture. The in-depth qualitative perspectives revealed a complex web of barriers to BP screening, adherence and lifestyle modifications. These have important implications for future health intervention designs. Particularly, health education and communication to at-risk communities require tailored interventions to overcome the varied personal, psychosocial, and external gaps at different stages of hypertension management care. For instance, threat-framed messages could be more effective in tackling the barrier of low perceived susceptibility to hypertension, while coping-framed interventions may be better suited for improving self-efficacy for treatment adherence.

ESTILO DE VIDA Y FACTORES DE RIESGO CARDIOVASCULAR EN ESTUDIANTES UNIVERSITARIOS

Introduction: The beginning of university studies is associated with changes in lifestyle that could create predisposition to the appearance of cardiovascular risk factors. Objective: The purpose of this study was to examine the association between two-year changes in the lifestyle and incident elevated Blood Pressure (BP) and central obesity in university students. Materials and Methods: First-year medical students were evaluated in 2017 and 2019. Waist circumference and BP were assessed. A Lifestyle Score (HOLS) was applied that included Body Mass Index, plus four behavioral factors: smoking, alcohol use, fruit/vegetable consumption, and physical activity. Multivariate logistic regression was used with BP and waist circumference in 2019 as dependent variable and HOLS change between 2017 and 2019 as the primary predictor. Results: The prevalence of borderline BP was higher in men than in women in 2017 and unchanged in 2019. The proportion of students with abdominal obesity did not change. In 2017, in both sexes, excess weight, low consumption of fruits and vegetables and little physical activity were highlighted. This determined a low HOLS score (6.2). After two years a decrease in the score was observed in both sexes. A two-year decrease in HOLS was associated with significantly greater odds of incident central obesity as compared to stable HOLS. No associations were observed between variations in HOLS and BP. Conclusion: The applied score is a tool to evaluate the lifestyle of the students. A decrease in HOLS was associated with an increased risk of central obesity. Key words: Lifestyle; blood pressure; central obesity; student.

ODP026 An Incidental Giant Normotensive Pheochromcytoma with Elevated Metanephrines demonstrated no evidence of hypertensive crisis during a major surgery

Abstract A 48-year-old Caucasian male with no known past medical history admitted to our hospital following MVA resulting in acute severely comminuted displaced fracture of the left femur and tibia. On admission, the patient was in severe pain. His vitals were significant for elevated blood pressure (BP) of 137/100 and pulse rate of 161 per minute, which resolved soon after pain medications and splint placement. On review of systems, he denied episodic spells of headaches, palpitations, pallor, tremors, anxiety, abdominal pain, or diaphoresis. He denied any family history of endocrine disorders. Physical exam was unremarkable, except for the left femur traction splint. He had multiple CT imaging performed for evaluation of his injuries. On CT scan of the abdomen, he was found to have a 7.2cm adrenal incidentaloma with imaging characteristics consistent with pheochromocytoma. He was admitted to the intensive care unit for one day for closer monitoring where he remained hemodynamically stable without any BP lowering medications. Laboratory work up for a pheochromocytoma was pending. However, due to concern of compartment syndrome of left lower extremity, patient underwent two emergent procedures of open reduction and internal fixation of left femur and tibial fracture repair. Robust monitoring of hemodynamics was performed during both surgeries but patient did not require any antihypertensive medications during the procedures. Eventually, serum total metanephrines drawn on admission day two, resulted as 7848 pg/ml (normal <205pg/ml), normetanephrines 3626 pg/ml (normal <148pg/ml), and metanephrines 4224 pg/ml (normal<57pg/ml). Serum cortisol, aldosterone, renin, dehydroepiandrosterone sulfate, and glucose were within normal limits. On day 3 of admission, repeated serum metanephrines were persistently elevated in 4000s. 24-hour (hr) urine studies showed total metanephrines 7353 mg/24hr (normal <832 mg/24hr), metanephrines 4934 mg/24hr (normal <315 mg/24hr), normetanephrines 2419 mg/24hr (normal <676 mg/24hr) and creatinine2.3g/24 hr (normal <2. 0g/24hr) . MRI abdomen confirmed pheochromocytoma abutting the pancreas and left upper pole of kidney. Interestingly, patient remained hemodynamically stable with highest BP measurement of 120/90 throughout the hospital course. He was eventually discharged on Prazosin 1 mg twice daily which was gradually increased to 5 mg daily in divided doses; increase fluid intake and high salt diet. Beta-blocker was not added due to borderline blood pressure. The patient underwent robotic left radical adrenalectomy without any intraoperative hemodynamic instability. Pathology was consistent with pheochromocytoma, confined to the adrenal gland without no capsular invasion. The patient refused genetic testing. Presentation: No date and time listed

Hypertensive patients' knowledge and practices on lifestyle modification in Extension 6, Middelburg.

BackgroundHypertension (HTN) is one of the most common chronic diseases affecting the majority of patients worldwide, including in South Africa. The control of HTN and prevention of complications are major challenges for patients and healthcare workers. The proper control of the disease requires a multifactorial approach consisting of medical treatment, as well as lifestyle modification, with the assistance of healthcare workers. Addressing patients’ beliefs, the practice of lifestyle and acceptance of change are some of the ways of aiding control.MethodsThe researchers used a cross-sectional and descriptive survey to establish the knowledge and practices of lifestyle modifications in patients with hypertension. A validated questionnaire was adopted. A total of 250 participants from the Extension 6 Clinic in Middelburg, Mpumalanga, constituted the study population.ResultsMost of the participants had borderline high blood pressure (37.2%) or uncontrolled high blood pressure (46%). The participants’ knowledge of HTN and its complications was not adequate. The study established that increased age and long duration of HTN were associated with high numbers of uncontrolled HTN. Most of the participants (88.8%) had difficulty exercising. Also, most of the participants (90.8%) did not have a place or facility for exercises. Fifty per cent of the participants were unable to maintain a balanced healthy diet which included fruits and vegetables.ConclusionThe study explored the participants’ knowledge and practice of lifestyle modification. The participants lacked knowledge regarding the definition of HTN and the meaning of controlled HTN. To assist the patients and improve on the identified pitfalls, each consultation session should include some methods of education, and motivation for healthy behaviours and lifestyle modification. This should be extended to all the people visiting the health facilities for them to adopt a healthier diet, greater intake of vegetables and availability of fitness facilities for the community.

A Pharmacist-Driven Education and Intervention Program that Improves Outcomes for Hypertensive Patients.

Purpose: Uncontrolled hypertension is serious and may lead to severe cardiovascular events and death. To better educate and empower patients to meet their blood pressure (BP) management goals, a large, integrated academic healthcare system implemented the Blood Pressure Goals Achievement Program (BPGAP), a longitudinal intervention embedding community pharmacists within healthcare teams. This study evaluated BPGAP on its ability to promote patient BP management goals. Methods: A pre-/post-intervention analysis was conducted whereby BP measurements were evaluated longitudinally within acuity groups determined by k-means clustering. Generalized linear mixed models evaluated trends in BP by time period, and proportions of patients meeting BP management goals (<140/90 mmHg) were assessed in relation to BPGAP enrollment date. Results: There were 5,125 patients who were clustered into Uncontrolled, Borderline, and Controlled blood pressure groups; 2,108 patients had BP measurements across 4 time periods before and after BPGAP enrollment. Groups differed by patient age, sex, and other demographics (p<0.0001). Patients in the Uncontrolled and Borderline BP clusters demonstrated significant BP decreases after BPGAP enrollment, continuing at least to 1-year post-intervention; Controlled cluster patients maintained BPs throughout the study period. The proportion of patients with controlled BPs increased from 56% immediately pre-BPGAP to 74% in the 3- to 6-months following enrollment. Conclusion: BPGAP is effective at helping patients achieve their BP management goals. Pharmacists may play a key role in hypertension control through measuring BPs and including updates and recommendations in the electronic health record, educating patients, and engaging in communication with healthcare teams.

Management of acute sickle cell priapism in an African (Togo) pediatric department includes conservative measures and intracavernous epinephrine which is safe and efficacious.

Priapism is a well‐known urologic complication of sickle cell anemia. This study describes the results of a protocol for the treatment of acute priapism by intracavernous injection of epinephrine due to unavailability of etilefrine. A descriptive cross‐sectional study of 18 cases of acute priapism in sickle cell patients treated in the pediatric department of the Sylvanus Olympio CHU from January 1 to December 31, 2020. The average age was 21.7 ± 7.7 years, the youngest patient was 8 and the oldest was 32 years old. Students represented 61.1% of the patients. The hemoglobin profiles were homozygous SS (n = 14) and double heterozygous SC (n = 4). Most of the crisis (83.3%) occurred at night. Most of the patients (66.7%) came to the hospital before the sixth hour of crisis, one patient came by the 48th hour. Walking was the most self‐relief method tried by patients (67%). It was followed by a cold penile bath, attempted urination, body bath, and lastly lukewarm bath. Fourteen patients had a history of chronic intermittent priapism. The average pain intensity was 9.5 ± 0.9 with restlessness (33.3%) and crying (33.3%). Fifteen patients were treated upon admission with an intracavernosal injection of epinephrine, and three patients were first drained. Thirteen patients achieved remission immediately, while five patients required a second injection and only one had to be drained before remission. Tolerance was good. One patient had a borderline systolic blood pressure. One erectile weakness case was noticed and no cases of sexual impotence. Epinephrine by intracavernosal injection is an efficient treatment for acute priapism in sickle cell patients. Epinephrine, which has a good tolerance in pediatric and young adult patients, should be used in lieu of etilefrine due to its unavailability in areas where it is unavailable.

Peritoneal Dialysis for Refractory Heart Failure from a Congenitally Corrected Transposition of the Great Arteries who has not Undergone Definitive Surgery: A Case Report

Heart failure (HF) is a major cause of significant morbidity, mortality, and hospitalization worldwide including the Philippines. Congenitally corrected transposition of the great arteries (C-TGA) occurs when the right atrium enters the morphological left ventricle which gives rise to the pulmonary artery and the left atrium communicates with the right ventricle which gives rise to the aorta. Heart failure can occur in C-TGA especially if associated with other heart defects. Ideal management is anatomic correction via surgery to prevent or address heart failure. Peritoneal dialysis has been used as a therapeutic intervention for patients with refractory heart failure and kidney injury with or without kidney failure due to its gentler fluid removal compared to conventional ultrafiltration resulting in less myocardial stunning and neurohormonal activation. We present the case of a patient with heart failure who started on peritoneal dialysis (PD) as an adjunct therapy for fluid management after failing to satisfactorily achieve volume control with diuretics. The patient is a 56-year-old man with C-TGA admitted for decompensated heart failure. He was initially treated with intravenous diuretics on the first admission but was readmitted after 3 months for decompensation this time with borderline low blood pressure making diuresis difficult. The patient was given loop diuretics, tolvaptan, and angiotensin receptor neprilysin inhibitor (ARNI) but still with decreasing trends in urine output and inadequate symptom control. PD was initiated before discharge with subsequent improvement in heart failure symptoms. The patient was on regular follow-up for PD maintenance and titration of heart failure medication. In this case report, we have shown how PD can be an effective adjunct to guideline-directed medical therapy in patients with severely symptomatic heart failure who have an unstable hemodynamic status and for which volume management cannot be satisfactorily achieved with diuretics.

Different hypertension thresholds and cognitive decline: a pooled analysis of three ageing cohorts

BackgroundThe 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for high blood pressure (BP) in adults came up with a new definition of hypertension with a threshold BP level of 130/80 mmHg. But the 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines adhered to a conventional hypertension definition as BP ≥ 140/90 mmHg. We aimed to compare the trajectories of cognitive decline between participants with BP < 130/80 mmHg in all BP measurement waves and others with all BP < 140/90 mmHg.MethodsThis pooled analysis involved middle-aged and older participants from three nationally representative ageing cohorts, including the Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA), and the China Health Retirement Longitudinal Study (CHARLS). Participants were divided into the Normal (BP < 130/80 mmHg on all occasions throughout the study), the Borderline (BP < 140/90 mmHg on all occasions throughout the study but not in the Normal group), and the High (the rest of participants) BP groups. Global cognitive Z score was calculated from tests on memory, executive function, and orientation.ResultsA total of 17,590 participants (HRS 6964, median follow-ups 12 years; ELSA 5334, median follow-ups 16 years; CHARLS 5292, median follow-ups 7 years) were included. No significant difference in global cognitive decline rate was detected between the Normal and the borderline groups (men, pooled β = − 0.006 standard deviation [SD]/year; 95% confidence interval [CI], − 0.020 to 0.008; P = 0.377; women, pooled β = 0.006 SD/year; 95% CI − 0.005 to 0.018; P = 0.269). Participants in the High group had a significantly faster cognitive decline (men, pooled β = − 0.011 SD/year; 95% CI − 0.020 to − 0.002; P = 0.013; women, pooled β = − 0.017 SD/year; 95% CI − 0.026 to − 0.008; P < 0.001) than that in the Borderline group.ConclusionsIndividuals in the Borderline group did not experience significantly faster cognitive decline compared with those in the Normal group. It might not be necessary for individuals with borderline BP (between 130/80 and 140/90 mmHg) to initiate antihypertension therapy in consideration of cognitive decline.

Safety and feasibility of a nurse-led ambulatory abdominal paracentesis service.

63 Background: Ascites is a common complication of cancer. Symptomatic ascites contributes to cancer-related morbidity and is distressing for patients (pts). Therapeutic abdominal paracentesis (TAP) provides symptom relief but requires specialized procedural knowledge and is usually performed in the inpatient setting with several days of hospitalization. Additionally, high hospital bed occupancy during the COVID-19 pandemic prevented timely admission for TAP. An Advanced Practice Nurse (APN)-led ambulatory TAP service was introduced at our center, with the aim of improving access to TAP and reducing hospital bed occupancy. Methods: A multidisciplinary team developed workflows and safety guidelines for TAP to enable right-siting of pts in a cancer day care unit. Pts were scheduled for radiologically guided insertion of abdominal drains in the morning before 10am to allow adequate time for drainage. Pre-procedure clinical examination and safety checks were performed by APNs in the day unit. Following the procedure, abdominal fluid was drained with concurrent administration of 20% IV albumin. Drains were removed by the APN and pts were examined before discharge on the same day. Data for all cancer pts requiring TAP in the day unit and hospital from 1 Jan to 30 Nov 2020 were extracted from the electronic medical record system. The primary outcome was length-of-stay (LOS). The primary safety outcome was adverse events in the day unit. Continuous data were compared using the t-test. Data analysis was done in SPSS version 22. Results: The number of TAPs performed in the day unit and general ward requiring hospitalization were 102 and 133, respectively. There was a significant reduction in average LOS with TAPs performed in the day unit vs. hospitalization (1.48 vs. 5.82 days, p&lt;0.001) (Table). The mean difference was 4.34 (95% confidence interval 3.33 - 5.34) days saved per pt, or a saving of 443 inpatient bed days. The TAP day unit service encountered 10 adverse events (AEs) requiring admission to the ward for continued drainage. AEs were borderline baseline blood pressure, pt frailty and inability to care for an indwelling catheter. There were no infective or bleeding complications. The majority of TAPs (86.8%) were performed in one day, with the remainder over 2-days with the abdominal drain left in-situ and reattendance at the day unit the next day for further drainage. Differences in average length-of-stay with TAP in the hospital vs. day unit. Conclusions: An APN-led ambulatory abdominal paracentesis service is a safe alternative to inpatient paracentesis. Optimal utilization of a day unit enabled reduced LOS for pts with advanced cancer. This reduction in LOS was critical during a pandemic where bed demand was high. This was possible from advanced scheduling and control over the day unit capacity.[Table: see text]

Prevalence of Prehypertension in Nigeria: a Systemic Review and Meta-analysis

Prehypertension is a borderline blood pressure status associated with both higher incidence of cardiovascular disease as well as higher risk of progression to hypertension. The rising burden of hypertension and prehyperension globally is a serious concern to all and sundry. This study aims to estimate the burden of prehypertension in Nigeria. Online searches of Google Scholar, PubMed and African Index Medicus were conducted and studies selected based on predefined criteria. 21 studies consisting of 25839 individuals conducted between 2011 and 2021 were included in the meta-analysis. The pooled prevalence of prehypertension in Nigeria was found to be 34%(95% CI: 30%-40%) translating to 41.4 million adult Nigerians. Males have higher prehypertension prevalence of 39.1% (95% CI: 30.9%-47.6%) than females with prevalence of 28.5% (95% CI: 21.2%-36.4%). Differences between sexes are not statistically significant. The region with the lowest prehypertension prevalence is North-East at 18%. The region with the highest prevalence of prehypertension is North-West at 43%. Differences between the regions are statistically significant. The pooled prevalence in rural settlements is 32% whereas the pooled prevalence for urban settlements is 37%. Differences rural and urban settlements were not statistically significant. In conclusion, the burden of prehypertension in Nigeria is high and represents a future burden of hypertension and other cardiovascular diseases

Cardiogenic shock without hypotension in acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiogenic Shock(CS)complicates 10%of Acute Myocardial Infarction(AMI), being the main cause for intra-hospital death in these patients.Although early revascularization has contributed to increase survival,mortality still presents high, being 40-50%.CS usually presents with inadequate cardiac output and persistent hypotension.However,after large AMI,peripheral hypoperfusion can occur with sustained or borderline systolic blood pressure(SBP). Purpose Characterize patients(pts)with CS after AMI in the absence of hypotension(defined as SBP &amp;lt; 90mmHg),and assess impact in mortality. Methods We evaluated 528pts presenting with CS in context of AMI.We considered 2groups:Group 1-Pts who had SBP ≥90mmHg,without any inotropic drug or assist device and 2-Pts with SBP &amp;lt; 90mmHg.We registered age,gender,co-morbidities,presentation,coronary anatomy and treatment strategies.We evaluated in-hospital mortality and complications:re-infarction,mechanical complications,high-grade atrioventricular block(AVB),sustained ventricular tachycardia,atrial fibrillation,resuscitated cardiac arrest and stroke. Results AMI presenting as Cardiogenic Shock without hypotension(CSWH)was found in 51%of pts(n = 272),of whom 69%were male.They were younger(between age of 45-64years old in 34%of cases vs 25%,p = 0.040)and had higher body mass index (27.3 ± 4.5vs 26 ± 4.1,p = 0.001).Hypertension was a similarly distributed comorbidity.In group 1,pts were previously more frequently under beta blocker medication (25.2%vs 17.7%,p = 0.047).In this group,mean left ventricular (LV)ejection fraction was 39 ± 13%,a quarter having severely depressed LV function(&amp;lt;30%).Although STEMI was the most common presentation in both sets(73.5% vs 87.1%,p &amp;lt; 0.001),NSTEMI was more prevalent in CSWH(23.9%vs12.1%,p &amp;lt; 0.001).Those pts presented more,at admission,with dyspnea(14.9%vs5.5%,p &amp;lt; 0.001)and in sinus rhythm(81.9%vs69%,p &amp;lt; 0.001).In this group,ICU admission was less frequent(19.4%vs27.2%,p = 0.036),and only about half of pts were medicated with inotropic drugs(vs 78.1%,p &amp;lt; 0.001).However,difference in intra-aortic balloon use wasn’t found.CSWH presented with multivessel disease in 63.8%of pts,being LAD more frequently the culprit vessel(42.4% vs 30.7%,p = 0.030),but fewer left main artery(LM)(4.2%vs14.0%,p = 0.003).Group 1 had fewer prevalence of vessel occlusion,which was particularly true for LM(3.8%vs11.5%,p = 0.015) and circumflex(12.4%vs20.7%,p = 0.047),and were less often submitted to revascularization.Group 1 had fewer AVB(9.8%vs22.4%,p &amp;lt; 0.001).Rates of other complications were similar.In-hospital mortality was higher in classic CS(33.1% vs 43.8%, p= 0.012). Conclusion Cardiogenic Shock without hypotension was found in about half of pts with CS due to AMI.A majority of these were younger and globally had a less severe event and complications.Even though CSWH was associated with one third of in-hospital mortality,it was lower than in pts with hypotension.