The Prevalence of Elevated Blood Pressure and Its Association With Obesity in Children Aged 6-13 Years in Rural India: A Cross-Sectional Study

Introduction Globally, hypertension is one of the major risk factors for cardiovascular disease. Childhood hypertension is one of the emerging conditions due to the increase in the prevalence of obesity in children in developing countries. An increase in blood pressure (BP) can be classified as secondary hypertension if it is caused by an underlying disease process or as primary hypertension if there is no identifiable cause. Primary hypertension during childhood often tracks into adulthood. The prevalence of primary hypertension, mostly in older school-aged children and adolescents, has increased in parallel with an obesity epidemic. Materials and methods This cross-sectional descriptive study was taken in different schools in the rural areas of Trichy District, Tamil Nadu, for a period of six months from July 2022 to December 2022; the study was done in children between six and 13 years. Anthropometry was taken, and blood pressure was measured using an appropriate-size BP cuff and standardized sphygmomanometer. Three values were taken at an interval for a minimum of five minutes, and the mean of the three values was calculated. Blood pressure percentiles were adopted from the American Academy of Pediatrics (AAP) 2017 guidelines for childhood hypertension. Results Out of 878 students, 49 (5.58%) students had abnormal BP, of which 28 (3.19%) students were categorized into elevated BP and 21 (2.39%) students had hypertension both in stages 1 and 2. Abnormal blood pressure was equally distributed in both males and females. More students were from the age group between 12 and 13 years (chi-square value: 58.469, P=0.001), which shows that as age increases, the prevalence of hypertension increases. The mean weight was around 31.97 kg, and the mean height was 135.34 cm. In this study, we found that 223 (25%) students were overweight and 53 (6.03%) students were obese. The prevalence of hypertension was 15.09% in the obese category and 1.35% in the overweight category (chi-square value: 83.712, P=0.000). Conclusion Due to limited data available on childhood hypertension based on the American Academy of Pediatrics (AAP) 2017 guidelines, this study highlights the AAP 2017 guidelines for early diagnosis of elevated BP and various stages of hypertension in children, and also, the need for early detection of obesity is essential for the implementation of a healthy lifestyle. This study helps create awareness among parents regarding the rise of obesity and hypertension in children in rural populations of India.

A comprehensive set of coded chief complaints for the emergency department

OBJECTIVE

To develop a generally applicable set of coded chief complaints for the computerized patient records of emergency departments (EDs).

METHODS

At an urban teaching ED the chief complaints of more than 50,000 patients were analyzed retrospectively during a 29-month period (June 1995-October 1997). Applying continuous quality improvement methods, a multidisciplinary team examined the current process documenting the patient's chief complaint. During two prospective periods (November 1997-December 1998; January 1999-June 1999), more than 34,000 chief complaints were analyzed. To reduce free-text charting practices, a variety of interventions on individual and team level were applied. Quantitative analysis was performed with statistical process control charts, and a qualitative evaluation was performed with a questionnaire.

RESULTS

The charting of chief complaint in free-text format decreased from 23% to 1%. The range among individual ED staff members narrowed from 45% to 9%. During the refinement of the set of coded chief complaints, six infrequently charted items were removed. Five new chief complaints identified by analysis of free-text entries during the second study period were added. The current set of chief complaints consists of 54 codable and the three original free-text items. The ED staff members perceived all the interventions beneficial. A poster displaying all available terms as a visual aid, however, had the largest impact on charting the patient's chief complaint in coded format.

CONCLUSIONS

Applying continuous quality improvement methods, the authors created a clinically developed and applicable set of codable chief complaints that can be easily integrated into a computerized patient record of an ED.

The challenge of variation in medical practice

Medicine has been identified as a profession for almost 3000 years based on a core premise that physicians have the right to evaluate their own quality. Because medicine is a profession and because of the special privileges granted to physicians by society, quality-based principles that evolved in the manufacturing business have been difficult to adapt to medical practice. Physicians learn from other physicians and medical literature. This leads to wide variation in what is considered best practice. Variation has complex association, including the variation in expert opinion, the complexity of medical knowledge, the variation in physician decision-making potential, and human error. Guidelines or algorithms are a strategy that are finding favor as a solution. The control of variation through guideline development, iterative refinement of guidelines, and feedback to physicians will improve medical practice. By removing variation, physicians can honor the fiduciary trust that they have made to patients, make reasoned decisions, improve outcomes, and focus attention on making medical improvements.

The impact of a multidisciplinary approach on caring for ventilator-dependent patients

OBJECTIVE

To determine the clinical and financial outcomes of a highly structured multidisciplinary care model for patients in an intensive care unit (ICU) who require prolonged mechanical ventilation. The structured model outcomes (protocol group) are compared with the preprotocol outcomes.

DESIGN

Descriptive study with financial analysis.

SETTING

A twelve-bed medical-surgical ICU in a non-teaching tertiary referral center in Ogden, Utah.

STUDY PARTICIPANTS

During a 54 month period, 469 consecutive intensive care patients requiring mechanical ventilation for longer than 72 hours who did not meet exclusion criteria were studied.

INTERVENTIONS

A multidisciplinary team was formed to coordinate the care of ventilator-dependent patients. Care was integrated by daily collaborative bedside rounds, monthly meetings, and implementation of numerous guidelines and protocols. Patients were followed from the time of ICU admission until the day of hospital discharge.

MAIN OUTCOME MEASURES

Patients were assigned APACHE II scores on admission to the ICU, and were divided into eight diagnostic categories. ICU length of stay, hospital length of stay, costs, charges, reimbursement, and in-hospital mortality were measured.

RESULTS

Mortality in the preprotocol and protocol group, after adjustment for APACHE II scores, remained statistically unchanged (21-23%). After we implemented the new care model, we demonstrated significant decreases in the mean survivor's ICU length of stay (19.8 days to 14.7 days, P= 0.001), hospital length of stay (34.6 days to 25.9 days, P=0.001), charges (US$102500 to US$78500, P=0.001), and costs (US$71900 to US$58000, P=0.001).

CONCLUSIONS

Implementation of a structured multidisciplinary care model to care for a heterogeneous population of ventilator-dependent ICU patients was associated with significant reductions in ICU and hospital lengths of stay, charges, and costs. Mortality rates were unaffected.

Lipoprotein(a) interactions with lipid and nonlipid risk factors in early familial coronary artery disease

An interaction between high plasma lipoprotein(a) [Lp(a)], unfavorable plasma lipids, and other risk factors may lead to very high risk for premature CAD. Plasma Lp(a), lipids, and other coronary risk factors were examined in 170 cases with early familial CAD and 165 control subjects to test this hypothesis. In univariate analysis, relative odds for CAD were 2.95 (P < .001) for plasma Lp(a) above 40 mg/dL. Nearly all the risk associated with elevated Lp(a) was found to be restricted to persons with historically elevated plasma total cholesterol (6.72 mmol/L [260 mg/dL] or higher) or with a total/HDL cholesterol ratio > 5.8. Nonlipid risk factors were also found to at least multiply the risk associated with Lp(a). When Lp(a) was over 40 mg/dL and plasma total/HDL cholesterol > 5.8, relative odds for CAD were 25 (P = .0001) in multiple logistic regression. If two or more nonlipid risk factors were also present (including hypertension, diabetes, cigarette smoking, high total homocysteine, or low serum bilirubin), relative odds were 122 (P < 1 x 10(-12)). The ability of nonlipid risk factors to increase risk associated with Lp(a) was dependent on at least a mildly elevated total/HDL cholesterol ratio. In conclusion, high Lp(a) was found to greatly increase risk only if the total/HDL cholesterol ratio was at least mildly elevated, an effect exaggerated by other risk factors. Aggressive lipid lowering in those with elevated Lp(a) therefore appears indicated.

Cellular proliferative fraction of metastatic lymph nodes predicts survival in stage D1 (TxN+M0) prostate cancer

PURPOSE

We assessed the ability of tumor cellular proliferative fraction to predict long-term survival among patients with lymphatic metastases from prostate cancer.

MATERIALS AND METHODS

We studied 50 patients with stage D1 (TxN+M0) prostate cancer who underwent pelvic lymphadenectomy and 125iodine seed implantation between 1970 and 1978. We used the MIB-1 monoclonal antibody to Ki67 to stain sections of the lymphatic metastases in these patients. The Ki67 proliferative fraction was defined as the fraction of positively stained malignant nuclei. We also used flow cytometry to determine the deoxyribonucleic acid content of the lymphatic metastases.

RESULTS

Median followup was 6.1 years. Patients whose metastases had a Ki67 proliferative fraction of less than 0.1 had significantly longer survival compared to those with a proliferative fraction of greater than 0.1 (8.7 years versus 4.4 years, respectively, p = 0.005, log rank test). The Ki67 proliferative fraction and ploidy were not independent variables. Patients whose metastases were diploid had a significantly longer survival than those with aneuploid metastases (8.8 years versus 4.4 years, respectively, p = 0.01, log rank test). Multivariate analysis showed that ploidy had a slightly stronger effect on survival than did the Ki67 proliferative fraction.

CONCLUSIONS

Cellular proliferative fraction of lymphatic metastases is useful to predict survival in patients with stage D1 prostatic carcinoma. Proliferative fraction may be useful as a marker of progression among patients with other stages of disease.

The fall in incidence of prostate carcinoma. On the down side of a prostate specific antigen induced peak in incidence--data from the Utah Cancer Registry

BACKGROUND

In the 1980s, prostate specific antigen (PSA) came into wide use as a prostate carcinoma screening and detection method in the United States. Following the introduction of PSA, the age-adjusted incidence of prostate carcinoma reported by the Surveillance, Epidemiology, and End Results (SEER) program in the United States rose rapidly (from 84.4/100,000 in 1984 to 163/100,000 in 1991). When an increase in incidence is observed following the introduction of a screening method, a subsequent decrease in incidence may be expected as prevalent cases are removed from the population (a cull effect). Incidence rates may also fall due to factors such as decreased intensity of screening. The Utah Cancer Registry data were examined for a decrease in prostate cancer incidence.

METHODS

We tracked age-adjusted prostate carcinoma incidence trends from the population-based Utah Cancer Registry and compared them with rates from the SEER national registry.

RESULTS

A rapid and highly correlated rise in prostate carcinoma incidence has been observed in both SEER and Utah incidence rates between 1988 and 1991, the last year for which SEER data are available. In 1992, Utah incidence rates peaked at 236.2 per 100,000. In 1993 and 1994, Utah incidence rates fell to 195.0, and an estimated 164.0 per 100,000, respectively.

CONCLUSIONS

Population-based data from the Utah Cancer Registry indicates that the incidence of prostate carcinoma is decreasing rapidly after a similarly rapid increase.

Higher serum bilirubin is associated with decreased risk for early familial coronary artery disease

Mildly increased serum bilirubin has recently been suggested as a protective factor, possibly reducing the risk of coronary artery disease (CAD) by acting as an antioxidant. We tested this hypothesis by examining serum bilirubin concentrations and other coronary risk factors in 120 men and 41 women with early familial CAD and 155 control subjects. At screening, both cases and control subjects were 38 to 68 years old. Early familial CAD patients had experienced myocardial infarction, coronary artery bypass grafting, or coronary angioplasty by age 55 years for men and 65 for women and had another sibling similarly affected. The average total serum bilirubin concentration was 8.9 +/- 6.1 mumol/L in cases and 12.4 +/- 8.1 mumol/L in control subjects (P = .0001 for difference). In univariate analysis stratified by sex, serum bilirubin was strongly and inversely related to CAD risk, with relative odds of 0.4 to 0.1 (relative to the lowest quintile, P = .04 to .00001) in both men and women as bilirubin increased into the upper two quintiles. Multiple logistic regression analysis was performed including age, sex, smoking, body mass index, diabetes, hypertension, plasma measured LDL cholesterol, HDL cholesterol, triglycerides, and serum bilirubin as potential risk factors. Bilirubin entered as an independent protective factor with an odds ratio of 0.25 (P = .0015) for an increase of 17 mumol/L (1 mg/dL). The standardized logistic regression coefficient for bilirubin was -.33 compared with -.34 for HDL, suggesting that the protective effect of bilirubin on CAD risk in the population is comparable to that of HDL cholesterol. A history of cigarette smoking was associated with significantly lower serum bilirubin concentration and appeared to attenuate the protective effect of bilirubin.

Higher plasma homocyst(e)ine and increased susceptibility to adverse effects of low folate in early familial coronary artery disease

To examine the graded risks for coronary artery disease (CAD) associated with plasma homocyst(e)ine [H(e)] and to evaluate the extent to which this risk is mediated by altered vitamin status, we measured plasma concentrations of H(e), vitamins B6 and B12, and folate as well as other coronary risk factors in subjects with early familial CAD and in control subjects. We studied 120 male and 42 female patients with early CAD who were unrelated to each other but were from families in which at least one other sibling had early CAD. Control subjects were 85 men and 70 women with the same age range (38 to 68) as the subjects with CAD at screening. Increasing H(e) was associated with graded increased risks of CAD that appeared consistent with a multiplicative model. Relative odds for CAD were approximately 12.8 in women when those with H(e) levels of 9 mumol/L and above were compared with those with H(e) levels of 9 mumol/L or less (P = .007). For men, the same comparison yielded relative odds of 13.8 (P = .0002). Plasma H(e) remained a strong, independent risk factor after adjustment for standard risk factors and plasma vitamin levels in multiple logistic regression (relative odds, 8.1 for a 10-mumol/L increase in H(e); 95% confidence interval, 3.2 to 20.4; P < .0001). In multivariate ANCOVA the slope of H(e) versus folate was much steeper in subjects with CAD than in control subjects (P = .0035). These data suggest that high plasma H(e) is an important, independent contributor to risk for early familial CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

International comparison of waiting times for selected cardiovascular procedures

OBJECTIVES

This study was designed to compare waiting times for cardiovascular procedures in five different health care delivery/financing systems.

BACKGROUND

A recurrent criticism of national health care systems is long waiting times, or "queues," for high technology procedures. However, no objective data exist comparing waiting times in the United States with those in other systems.

METHODS

Directors of cardiac catheterization laboratories, directors of cardiac surgery in the United States, U.S. Department of Veterans Affairs (VA) system, Canada and the United Kingdom and directors of cardiology clinics in Sweden were asked to respond to a mailed questionnaire as to how long it would take to obtain coronary angiography or coronary artery bypass surgery, or both, for specified case scenarios at their institutions.

RESULTS

Significant differences in waiting times (p < 0.00001) were found among the systems for all four scenarios (elective and urgent angiography, elective and urgent bypass surgery). Compared with non-VA hospitals in the United States, waiting times were significantly longer in all systems, with the exception of waiting times for urgent surgery in the U.S. VA hospitals (p = 0.9). The longest waiting times for all four procedures were reported in the United Kingdom, Sweden and Canada, with some waiting times for elective procedures > 9 months.

CONCLUSIONS

Physicians report that patients treated in health care systems structured differently from the non-VA hospital system in the United States wait significantly longer for cardiac catheterization and coronary artery bypass surgery.

Plasma homocyst(e)ine as a risk factor for early familial coronary artery disease

We measured plasma homocyst(e)ine [H(e)] and other coronary risk factors in 266 patients with early coronary artery disease from 170 families in which two or more siblings were affected and in 168 unmatched controls. The mean H(e) concentration adjusted for significant correlates (serum creatinine, uric acid, and low-density lipoprotein cholesterol) was 12.0 mumol/L in proband cases compared with 10.1 mumol/L in controls (P = 0.0001). Many (17.6%) of the proband cases had H(e) concentrations exceeding the 95th percentile for the controls (relative odds = 4.9, P &lt; 0.001). H(e) among cases was bimodally distributed even after adjustment for concentrations of plasma vitamins. Concordant high H(e) was seen in at least 10 (12%) of 85 families with two or more affected siblings. We conclude that a substantial proportion of early familial coronary artery disease is probably related to production of high concentrations of H(e) by one or more major genes.

Plasma homocyst(e)ine as a risk factor for early familial coronary artery disease

We measured plasma homocyst(e)ine [H(e)] and other coronary risk factors in 266 patients with early coronary artery disease from 170 families in which two or more siblings were affected and in 168 unmatched controls. The mean H(e) concentration adjusted for significant correlates (serum creatinine, uric acid, and low-density lipoprotein cholesterol) was 12.0 mumol/L in proband cases compared with 10.1 mumol/L in controls (P = 0.0001). Many (17.6%) of the proband cases had H(e) concentrations exceeding the 95th percentile for the controls (relative odds = 4.9, P < 0.001). H(e) among cases was bimodally distributed even after adjustment for concentrations of plasma vitamins. Concordant high H(e) was seen in at least 10 (12%) of 85 families with two or more affected siblings. We conclude that a substantial proportion of early familial coronary artery disease is probably related to production of high concentrations of H(e) by one or more major genes.

Implementing practice guidelines through clinical quality improvement

The American health care delivery environment is changing. As provider-at-risk payment strategies become increasingly dominant, they will force health care providers to replace old strategies that measured and managed revenues with new strategies that measure and manage costs. Quality improvement (QI) theory provides a set of tools to do exactly that--to understand, measure, and manage health care delivery processes and their associated costs. As a methodology for process management, QI theory merges case management, practice guidelines, and outcomes research into a single coordinated effort. It appropriately redirects management focus to care delivery processes, rather than to physicians. It also defines and illustrates a set of principles by which health care administrators can constructively team with physicians to find and document the best patient care outcomes at the lowest necessary cost, using QI-based practice guidelines as a decision support and measurement tool.

Ratio of polyclonal-monoclonal prostate-specific antigen levels. Discrimination of nodal status in prostate tumors that produce low marker levels

The preliminary data we present in this report suggest that the ratio of polyclonal-monoclonal serum prostate-specific antigen levels may add clinically useful information to that obtained using serum prostate-specific antigen levels alone. We hypothesize that the diversity of prostate-specific antigen ratios observed in our data reflects a diversity in the antigenic and structural attributes of prostate-specific antigen molecules found in the sera of patients with prostate cancer. Further, this heterogeneity of molecules is a reflection of the diverse and altered metabolic state of human prostate cancer and appears to be related to biologic behavior in individual patients.

Plasma immunoreactive-trypsin(ogen) levels during development

We previously showed that the uptake of intact trypsin from the intestine of suckling animals was greater than that of weaned animals. To extend these studies, we measured plasma cationic immunoreactive-trypsin(ogen) in human subjects aged 3 days to 43 years. In agreement with the observation of other investigators, we found that the concentration of cationic immunoreactive-trypsin(ogen) was significantly increased in 3-day-old infants compared with other age groups. None of the cationic immunoreactive-trypsin in adult samples was bound to alpha 1-antitrypsin, whereas 28% of cationic immunoreactive-trypsin in infant samples was bound to alpha 1-anti-trypsin.

Flow cytometry of prostate cancer: relationship of DNA content to survival

Between March 1970 and December 1978 there were 366 patients with prostatic cancer treated by 125I seed implants and pelvic lymph node dissection. All had a minimum of 5 years follow-up. One hundred thirty-three patients had metastatic prostatic cancer in lymph nodes (Stage D1) at the time of lymph node dissection and seed implantation. Ninety-one of the 133 patients were judged to have sufficient metastatic prostatic cancer in their nodal tissue (greater than 50% replacement with tumor) to justify flow cytometric cellular DNA measurements on the involved paraffin-embedded nodal tissue. Nine patients were excluded due to uninterpretable DNA histograms leaving 82 patients for analysis. Forty-nine patients had aneuploid and 33 had diploid tumors. There was no statistical bias between the aneuploid and diploid groups due to age (P = 0.970, chi 2 test), time between diagnosis and implantation (P = 0.217, chi 2 test), number of positive nodes (P = 0.669, two-sample t test of means), or tumor grade (P = 0.332, chi 2 test). Median survival time of the aneuploid and diploid groups was 5.0 and 8.8 years, respectively (P = 0.0109, log rank test). Cox regression analysis confirmed the effect of aneuploidy versus diploidy on survival by controlling for other potentially confounding variables (age, time from diagnosis to implantation, number of positive nodes, and grade). Grade as a predictor of survival did not approach statistical significance in this series of relatively small size (P = 0.116). Thirty-eight of the 82 patients had moderately differentiated neoplasms. Nineteen of these were aneuploid and 19 diploid. The median survival was 5.8 and 9.1 years, respectively, for these grade-matched aneuploid and diploid groups (P = 0.039, log rank test). We conclude that flow cytometric DNA measurements on archived paraffin-embedded tumor in nodal metastases appear to be a strong predictor of survival for Stage DI prostatic cancer.