Heteroresistance to rifampicin & isoniazid in clinical samples of patients with presumptive drug-resistant tuberculosis in Central India

Background & objectives: A combination of resistant and susceptible Mycobacterium tuberculosis (MTB) isolated from clinical specimens is referred to as heteroresistance. Heteroresistance leads to difficulties in drug resistance testing and may adversely affect treatment outcomes. The present study estimated the proportion of heteroresistance among MTB in clinical samples of presumptive drug-resistant tuberculosis (TB) patients in Central India. Methods: A retrospective analysis of data generated from line probe assay (LPA) at a tertiary care hospital in Central India between January 2013 and December 2018 was carried out. A heteroresistant MTB in a sample was indicated by the presence of both wild-type and mutant-type patterns on an LPA strip. Results: Data analysis was carried out on interpretable 11,788 LPA results. Heteroresistance in MTB was detected in 637 (5.4%) samples. Of these, heteroresistance in MTB was detected in 413 (64.8%), 163 (25.5%) and 61 (9.5%) samples with respect to rpoB, katG and inhA genes, respectively. Interpretation & conclusions: Heteroresistance is considered a preliminary step in the development of drug resistance. Delayed or suboptimal anti-tubercular therapy in patients with heteroresistance of MTB may elicit full clinical resistance and negatively impact the National TB Elimination Programme. Further studies are, however, needed to determine the impact of heteroresistance on treatment outcomes in individual patients.

Experiences and challenges in telemedicine of physicians from the National Capital Region during the COVID-19 pandemic: A qualitative study / The Health Sciences Journal

Introduction@#The COVID-19 pandemic caused a shift to delivering health services through telemedicine. This study recognized the perceptions, experiences, and challenges of physicians who practice synchronous teleconsultation in the Philippines.@*Methods@#A qualitative descriptive research design using purposive sampling, eight physicians from NCR were interviewed. Data collected were subjected to thematic analysis for common themes and integrated into an analytic narrative.@*Results@#Eight physicians were included as participants. Different measures taken to remedy the gap included upskilling of physicians, adjustment of clerical work, ensuring data privacy, and creating a conducive workplace. Remote consultations posed limitations on physical examination and emphasized the reliance on diagnostics. Digital platforms used depended on the physician’s preference, type of practice, and patient’s accessibility. This led to an increased dependency on good internet and network service connections to ensure smooth teleconsultations. A lack of respect for the physician’s personal boundaries and work-life balance was cited as a major challenge. @*Conclusion@#Telemedicine proved to be an option to provide healthcare despite its limitations, but the shift to its practice exposed many challenges as it is not a replacement for physical consultations.

An Audit on Gastrointestinal Perforation in a Tertiary Care Teaching Hospital Based in Northern Part of India: A Study of 100 Cases

Background: A prospective study was conducted on 100 patients of perforation peritonitis: To find out the incidence of gastro intestinal perforation in various age groups, sex, riral or urban, socio economic status, To find out the various causes and sites of gastra intestinal perforartions, To determine various types of procedures being done to treat gastro intestinal perforations.Methods:The study population consisted of 100 patients of perforation peritonitis admitted at surgical wards of Rajindra Hospital, Patiala. Patients underwent necessary investigations such as Blood counts, biochemical analysis and urine analysis. X-ray Abdomen and chest / USG Abdomen/Pelvis CT-Abdomen (as and when required). All diagnosed patients were subjected to surgery. In all cases, operative findings and postoperative course were followed up for three months. Final outcome was evaluated on the basis of clinical, operative and radiological findings. In pre-pyloric and duodenal perforation, GRAHAM扴 PATCH REPAIR carried out. In Ileal and Jejunal perforations, primary closure or exteriorization done depending upon the condition of the gut and duration of the symptoms. The patient outcome was assessed by duration of hospital stay, wound infection, wound dehiscence, leakage/entero-cutaneous fistula, intra-abdominal collection/abscess, ileostomy related complications and reoperation. Wound infection was graded as per SSI grading.Results:Most common age group for perforation was 21-40 years (50%) followed by 41-60 (33%) years in present study. Mean age of the patients is 37.91 + 13.15 years with male predominance (78%) in our study. 4% of the patients were of upper socio-economic status while 32% of the patients were of middle and 64% of the patients were of lower socio-economic status.Abdominal pain was seen in 100% of the patients while abdominal distension was present in 69% of the patients. Nausea/Vomiting was seen in 61% of the patients while Fever and Constipation was seen in 53% and 86% of the patients respectively. Diarrhoea was seen in 3% of the patients. Tenderness, guarding & rigidity, distension, obliteration of liver dullness and evidence of free fluid were present in 100% of the patients. Bowel sounds were not detected in all the patients. Most common perforations were Duodena(37%), Ileal (25%), Gastric (25%) followed by Appendicular (9%), Jejunal (4%) and Colonic perforation (2%). The most common etiology of gastrointestinal perforations was Peptic ulcer followed by Typhoid, Appendicitis, Tuberculosis, Trauma, Malignancy and non-specific infection.In Gastric perforations, Peptic ulcer was the most common cause of perforation followed by Trauma. In Ileal perforations, Typhoid was the most common cause of perforation followed by Tuberculosis and non-specific infection. In Appendicular perforations, most common cause was Appendicitis. In Jejunal perforations, most common cause was Trauma. In Colonic perforations, most common cause was Malignancy.Conclusions:The incidence of gastrointestinal perforations was common in 21-40 years age group followed by 41-60 years age group with male preponderance in our study. The most common site of perforations was Gastro-duodenal followed by Ileal perforations and the most common cause for these perforations was peptic ulcer followed by typhoid. The most common procedure done to treat gastrointestinal perforations was primary closure, resection and anastomosis, appendectomy and stoma formation. However, small sample size and short follow up period were the limitations of the present study.

The Challenges of Medical Technologists during COVID-19 Specimen Collection

Background@#The coronavirus disease, also known as COVID-19, is a highly contagious disease caused by a new strain of the coronavirus SARS-CoV-2. Medical technologists, along with doctors and nurses, are also heroes in the fight against the virus as they risk their own health in order to collect and analyze specimens for the diagnosis of the disease. However, they face numerous challenges along the way. @*Objectives@#This study aimed to better understand the difficulties of medical technologists assigned to collect COVID-19 specimen in tertiary hospitals or laboratories in Metro Manila, Philippines. @*Methodology@#Utilizing the qualitative case study design, the researchers interviewed 14 medical technologists and examined the data according to Colaizzi's method which consisted of grouping and categorizing relevant remarks before formulating themes. @*Findings@#The researchers were able to formulate the following themes: (1) patient-related challenges, namely, attitude, age, health status, and communication; (2) physical challenges, namely, fatigue, work hours, number of patients, and the use of personal protective equipment; (3) environmental challenges, namely, collection setting, temperature, and exposure to the virus; (4) resource challenges, namely, supplies and human resources; and (5) psychological challenges, namely, fear, anxiety, and emotional fatigue. @*Conclusion@#The study was able to analyze the obstacles faced by COVID-19 specimen collectors in order to give a means of hearing from and comprehending their viewpoints. This shows the importance of performing regular reviews of healthcare workers to ensure their safety. Medical technologists and their supervisors should be able to communicate effectively in order to improve current standards and procedures.

Neuro-imaging in severe hypertensive disorders of pregnancy: a study from North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy comprising of pre-eclampsia and eclampsia are a major cause of adverse pregnancy outcomes. Neurological manifestations of pregnancy induced hypertension are the most common cause of maternal and foetal morbidity and mortality. Cranial neuro-imaging reveals focal regions of symmetric hemispheric oedema; with parietal and occipital regions getting most commonly affected.Methods: The study was conducted among 65 antenatal women diagnosed with pre-eclampsia and eclampsia at gestational age >20 weeks in the department of obstetrics and gynecology, Kamla Nehru State Hospital for Mother and Child IGMC Shimla. Clinical signs and symptoms, neuroimaging findings were recorded for study purpose.Results: About 17.6% of severe pre-eclampsia and 100% of eclampsia had findings observed on cranial MRI. Headache and visual complaints were most frequently recorded. PRES was the predominant neuroradiographic finding in present study and occipital lobe was commonly affected region. No significant difference was observed regarding blood pressure parameters between MRI positive and negative subjects.Conclusions: Neuroimaging in antenatal with severe hypertensive disorders might aid in better understanding of the poorly explained phenomenon. In addition, this would be helpful in better management of the disorders along with their much-dreaded complications. Patients with hypertensive disorders of pregnancy should be subjected routinely to cranial imaging for the better perinatal outcomes.

Predicting pregnancy outcomes from homocysteine level: an evidence from a North Indian study

Background: Hypertensive disorders of pregnancy are a major cause of adverse pregnancy outcomes. Though the etiology of spectrum of vascular disorders of pregnancy is still not understood completely, yet abnormally elevated homocysteine level has been implicated in the causal pathway and pathogenesis. Hyperhomocysteinemia has been significantly associated with increased risk of poor maternal and foetal outcomes in terms of PIH, abruption, IUGR, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present prospective study was conducted among 180 pregnant women (57 exposed and 123 non exposed) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of determining association of abnormally elevated homocysteine level in pregnancy and adverse pregnancy outcomes. Socio-demographic, clinical, biochemical including homocysteine level, laboratory, ultrasonographic parameters and foeto-maternal outcomes of pregnancy of all the participants were documented.Results: The mean homocysteine level of exposed group (23.26±10.77 µmol/L) was significantly higher than the unexposed group (8.99±2.47 µmol/L). Among hyperhomocysteinemic subjects, 10.5% had abruption, 15.8% had PRES and 8.7% PPH which was significantly higher than normal subjects. Similarly, patients with homocysteinemia had significantly higher proportion (21.3%) of poor Apgar score, more (41.9%) NICU admissions and higher frequency (4.7%) of meconium aspiration syndrome.Conclusions: The present study generates necessary evidence for associating abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and adverse pregnancy outcomes. It further demands the need of robustly designed studies and trials to further explore the phenomenon. Moreover, it emphasizes on a simple and timely intervention like estimating the much-neglected homocysteine levels during pregnancy which can definitely contribute in predicting and preventing adverse perinatal outcomes.

The World- After COVID-19 Apocalypse

Corona virus disease which originated from Wuhan in China has engulfed the whole globe. Covid-19 is leading the list of diseasespeople are extremely concerned about, followed by cancer and HIV/AIDS, according to the study by market research and analysiscompany Velocity MR. This disease has brought around many changes in the lives of people. The medical officials and scientistsare working all day long to find a cure for this disease or to create a vaccine. But the question that rises is will there ever be acure?. Will the world be normal again? For how long will this disease cause a havoc in the life of the people? And many suchquestions which still remain unanswered. But in this article we have discussed about how will the world change after COVID-19pandemic.

Creation of a Smoke-free Environment for Children: An Assessment of Compliance to COTPA 2003 Legislation in an Urban Area

Objective: To ascertain the compliance to Cigarette and Other Tobacco Products Act(COTPA) 2003 which ensures the protection of children from the adverse health effects ofsecond hand smoke. Methods: This cross-sectional study assessed the compliance of 32educational institutions and 157 points of sale of Shimla city. Results: About 88% of theeducational institutions and mere 7.6% points of sale were found having good compliance tothe key indicators. No point of sale was found within the premises of educational institutions;however, 26% were found selling tobacco products within 100 metres radius of aneducational institution. 7.6% points of sale were found selling a tobacco product to children.Conclusion: Despite having the status of a smoke-free city, lapses were observed incompliance to the Act. Strict adherence to the provisions of the Act would ultimately lead to asmoke-free environment for our children

Can serum homocysteine predict hypertensive disorders of pregnancy?: an evidence from a case control study in a North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy are a major cause of both maternal and foetal morbidity and mortality. Although pregnancy induced hypertension (PIH) is still regarded as a disease of theories and unknown etiology, elevated homocysteine level has been hypothesized as a key risk factor. Abnormally raised homocysteine has been significantly associated with increased risk of PIH, abruption, intrauterine growth restriction, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present case control study was conducted among 180 pregnant women (90 cases and 90 controls) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of ascertaining the role of homocysteine in pregnancy related hypertensive disorders. Socio-demographic, clinical, biochemical including homocysteine level, laboratory and ultrasonographic parameters of all the participants were documented.Results: The mean homocysteine level of cases (18.30±10.81) was significantly higher than the controls (8.70±2.64).  About 62.2% cases had abnormally raised homocysteine level (>15 µmol/L), while only 1.1% controls had such level. The odds of a case having abnormally elevated homocysteine level were 146.6 (CI: 19.52-1101) times to that of controls. Eclamptics had the highest homocysteine level followed by preeclamptics and controls.Conclusions: The present study significantly associates the abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and demands much needed robustly designed studies to further explore the phenomenon. A simple intervention like estimating the much neglected homocysteine levels prior to pregnancy can definitely aid in predicting and preventing perinatal outcomes.

Epidemiological profile of animal bite patients attending emergency department at a tertiary care health facility in a northern hilly Indian city

Background: Rabies is a highly infectious zoonotic disease with a high case fatality rate. In India, approximately 20,000 deaths among 17.4 million exposed people occur every year. The data on animal bites is scarce and unreliable due to poor surveillance and hence, the projected figures are far less from the actual numbers. The present study was conducted to describe epidemiological characteristics of animal bite patients attending casualty department at a tertiary care Government health facility in Shimla, Himachal Pradesh.Methods: It was a retrospective study based on secondary data received from animal bite register for year 2017 at casualty department of the Indira Gandhi Medical College and Hospital, Shimla, Data of 1512 patients attending the casualty department with history of animal bite was included for the study purpose.Results: About 58% of victims were males and the maximum (22.6%) animal bites were seen in 21-30 years age group. Majority (51.6%) of patients were exposed to dog bites, followed by monkey bites (42.85%) and cat bite 49 (3.2%). About 69.9% of animal bites were in the lower limbs, followed by upper limbs (22.1%), abdomen (4.4%) and head and neck region (3.6%). Maximum bites were category III bites (74.6%) followed by of category II bites (12.9%).Conclusions: Study highlights the neglected but significant picture of animal bite in the Shimla city. Timely and correct post exposure prophylaxis for the animal bite victims is necessary to prevent rabies. This should be supplemented with a robust surveillance and reporting system. With the global aim of zero rabies deaths by 2030; it is time to strengthen the anti-rabies activities at every level.

A descriptive study to quantify severity in patients with severe scrub typhus in hilly city of Northern India

Background: Himachal Pradesh is an endemic area for scrub typhus. If not treated early, it can lead to life threatening complications. Therefore, more emphasis needs to be laid on the diagnosis and prompt treatment, so that mortality due to severe scrub typhus can be prevented. So, this study was done with an objective to study the clinical profile of patients diagnosed with severe scrub typhus and assess their severity using APACHE II score in IGMC, Shimla.Methods: Authors conducted a descriptive cross-sectional study in Indira Gandhi Medical College, Shimla over one year (June 2016-May 2017). Out of 538 confirmed scrub typhus cases, 58 severe cases were reported, and their severity was assessed with predefined criteria of sepsis and APACHE II score.Results: Mean age of males (50.18±18.6 yrs) was found to be more than that of females (45.52±14.5 yrs), the difference being statistically insignificant t(56)= -1.01, (P=0.32). Fever (100%), headache (84.5%), vomiting (79.3%) were the major presenting symptoms and tachycardia (96.5%), hypotension (87.9%), tachypnoea (94.8%) were the main clinical signs. The mean APACHE II score on admission was 16.25±5.0 with a predicted mortality of 23.5%, that was found to be less than actual reported hospital mortality (25.8%).Conclusions: APACHE II score was found reliable tool for risk stratification. Case fatality in diagnosed cases of severe scrub typhus was found high. Early diagnosis and prompt treatment according to guidelines would help in decreasing the mortality, financial burden on patient, society and health system.

COTPA 2003 compliance assessment of tobacco vendors and products: current status of an earliest smoke free Indian city

Background: Tobacco smoking is a global phenomenon, associated not only with health but also with other issues like employment, trade and revenue. However, the ill aspects of tobacco outweigh any productivity related to it. Various regulatory measures have been devised to control this menace at national as well as international level. In India, COTPA-2003 legislation intends to control and regulate tobacco consumption, advertisement and trade. Methods: The present study assessed the compliance of 157 points of sale and 59 tobacco products to the Sections 5,7,8,9 and 10 of the smoke free legislation using a structured observational checklist. Results: In total (41%) POS were advertising tobacco in one or other form with product showcasing (64%) being the most common modality of advertisement. Actual advertisement boards were seen at only 14.6% of POS. About 87% of the advertisement boards carried a health warning. Loose cigarettes were being sold at about 77% of the POS. All tobacco products available in the city were observed to display good compliance; however none of the smoke product displayed nicotine and tar content on the pack. Conclusions: Negligible number of PoS was seen to display an actual advertisement. Almost all tobacco products displayed good compliance to the Act. The striking shortcoming was the absence of nicotine and tar content on the package of the product even after 16 years of enactment. Discrepancies need to be addressed appropriately supplemented with aggressive monitoring of adherence to the Act in order to sustain the smoke free status of the city.

Assessment of compliance to the COTPA 2003 legislation in tertiary healthcare institutes of Shimla: a smoke free city in India

Background: Tobacco smoking is a pandemic affecting populations and contributing to global morbidity and mortality. It is well known that the second hand smoke is equally hazardous like first hand smoke. Cigarette and other tobacco products act 2003 is an effort put forth by Government of India in order to curb this menace and protect people from ill effects of second hand smoke.Methods: The present study was conducted to assess the compliance to smoke free act in tertiary healthcare institutes in Shimla city, Himachal Pradesh. A total of 57 public places and 8 shops in five Tertiary healthcare institutes were evaluated for various provisions of the act. Compliance to different sections of the act was assessed using a structured observational checklist.Results: Signage indicating ban on smoking was seen at 71.9% places. Active smoking was absent at 77.2% places. About 25% shops around the institutes were found selling tobacco products. Signage displaying ban on sale within 100 m of educational institution and sale to minors was not observed at any shop. Tobacco product vendor was seen around 80% of educational buildings. Tobacco free institution signage was seen at 60% of educational premises.Conclusions: The study highlights that the level of compliance did not meet the standards laid down for a smoke free city. Timely and periodic assessment of the compliance must be conducted by the administrative authorities of the institutes for ensuring the adherence and strict implementation of the provisions of the act.

HPV infection: in need of timely intervention

Persistent infection with human papilloma virus (HPV) has been proved beyond doubt to be associated with the development of cervical cancer. One woman dies of cervical cancer every 8 minutes in India. As per estimations for the year 2018, about 96922 new cervical cancer cases are diagnosed annually in India and it ranks as the second most common female cancer in all age groups. But being an infectious cause it is possible to contain its development and transmission. Coupled with this, we have a potent vaccine to fight this infection. A well documented account of positive impact of HPV vaccination has been published in numerous studies around the globe. By 2013, its vaccination had been introduced in about fifty countries around the globe. In India also, recently, two HPV vaccination projects for operational feasibility were launched in Andhra Pradesh and Gujarat. In November 2016, Punjab becamethe first state in the country to include the vaccine in its universal immunization program. This era belongs to women empowerment and we cannot deny them the opportunity of good health. Hence it’s high time India introduces an effective HPV vaccination program.

Optimization of the isolation and purification method of pharmaceutical grade pectin from pomelo fruit peels (Citrus maxima Merr. Family Rutaceae)

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Pectin is a heteropolysaccharide used in pharmaceutical formulations as a binding agent. Importation of pectin costs billions of Philippine pesos, but the local laboratory-scale production of this excipient from fruit peel wastes is estimated to be cheaper by 80%.</p><p style="text-align: justify;"><strong>OBJECTIVE:</strong> To address economic and environment concerns associated with pectin production, this study aimed to optimize the isolation and purification of pharmaceutical grade pectin from pomelo (Citrus maxima Merr.) fruit peel as basis for commercial-scale production.</p><p style="text-align: justify;"><strong>METHODS:</strong> Pectin was extracted from pomelo using different solvents: 6.2% w/w citric acid, 1N acetic acid, 3N hydrochloric acid, 3N nitric acid, and 3N sulfuric acid. Temperatures for extracting pectin were explored at 40°C, 60°C, and 90°C. Obtained pectin samples were characterized based on the following parameters: equivalent weight (EW), methoxyl content (MC), ash content (AC), anhydrouronic acid content (AUA), and degree of esterification (DE).</p><p style="text-align: justify;"><strong>RESULTS:</strong> Highest pectin yield (9.25%) was obtained using 3N nitric acid and 3N sulfuric acid at 90°C.Based from the pharmacopeial standards (MC ? 6.7, AUA ? 74.0), all the samples did not pass the parameters, except the pectin extracted using 3N sulfuric acid at 90°C (MC = 6.76, AUA = 74.61).</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> Among the different solvents used for extraction, 3N sulfuric acid produced the highest percent yield of pharmaceutical grade pectin from pomelo fruit peel. Its optimum temperature for extraction was at 90°C. The sample passed the USP standards of MC values not less than 6.76 and AUA values not less than 74. Under the following conditions, pomelo fruit peel have the potential for commercial-scale production of pharmaceutical grade pectin.</p>

Medications for hypertension of hemodialysis patients in Cáceres - Mato Grosso, Brazil / Medicamentos para hipertensão de pacientes em hemodiálise em Cáceres - Mato Grosso, Brasil

Blood pressure in hemodialysis patients is difficult to control. The adequate use of antihypertensive drugs, associated with a good control of blood volume, are the most appropriate measures for the control of blood pressure in these patients. to objective describe the main drug classes used to control hypertension and to describe the epidemiological profile of chronic kidney disease patients on hemodialysis in the city of Cáceres-MT in the year 2014. Descriptive, cross-sectional epidemiological study with patients underwent hemodialysis in 2014 in the city of Cáceres, by means of patient medical records of a total of 17,134 hemodialysis sessions with 133 patients. The majority were male, black, married, with a mean age of 55 years, with hypertensive nephrosclerosis as the underlying disease. The main comorbidity was diabetes mellitus; 80% are diagnosed of end-stage chronic kidney disease; the mean time on hemodialysis (survival) was 4.8 years and 78.6% were hypertensive. Among hypertensive patients, 41.8% used a combination of two antihypertensive drugs and 32.6% used monotherapy; the adrenergic inhibitors class used was 27.1%, and 12.5% received diuretics. There was a mean survival of 5.2 years for hypertensive patients. The drug therapy used to control blood pressure complies with international recommendations in 81.6% of cases. The characteristics of patients being treated are similar to the other cities in the country. The mean survival of the hypertensive group of patients was higher than that of the non-hypertensive group

A pressão arterial em hemodialisados é de difícil controle. O uso adequado de anti-hipertensivos, associado a um bom controle da volemia, constituem-se nas medidas mais apropriadas para o controle da pressão arterial nestes pacientes. O objetivo é descrever as principais classes medicamentosas utilizadas para o controle da hipertensão e descrever o perfil epidemiológico dos pacientes renais crônicos em hemodiálise no município de Cáceres-MT no ano de 2014. Estudo epidemiológico descritivo, transversal, com pacientes em hemodiálise que dialisaram no ano de 2014 no município de Cáceres, por meio dos registros em prontuários de um total de 17.134 sessões de hemodiálise de 133 pacientes. A maioria é do sexo masculino, da raça negra, casados, com média de idade de 55 anos, com nefroesclerose hipertensiva como doença de base. A principal comorbidade é a diabetes mellitus; 80% tem diagnóstico de doença renal crônica em estágio final; a média de tempo em hemodiálise (sobrevida) foi de 4,8 anos e 78,6% são hipertensos. Entre os hipertensos 41,8% utilizam combinação de dois anti-hipertensivos e 32,6% utilizam monoterapia; a classe dos inibidores adrenérgicos foi utilizada em 27,1% e 12,5% receberam diuréticos. Verificou-se média de sobrevida de 5,2 anos para os hipertensos. A terapêutica medicamentosa utilizada para controle da pressão arterial atende as recomendações internacionais em 81,6% dos casos. As características dos pacientes em tratamento são comuns a outras localidades do país. A média de sobrevida do grupo de pacientes hipertensos foi maior que do grupo de não hipertensos.