The Clinical and Endoscopic Profiles of Patients With Upper Gastrointestinal Bleeding (UGIB) and the Role of the Rockall Scoring System in Predicting Adverse Outcomes.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is one of the common emergencies seen by physicians. Upper gastrointestinal (UGI) endoscopy remains a crucial tool in the identification of UGIB. OBJECTIVE: The aim of the present study was to determine the clinical and endoscopic profiles of UGIB in an adult population. METHODS: This prospective, cross-sectional study was conducted in Dayanand Medical College and Hospital (DMCH), Ludhiana, where 75 patients aged 18 years and above admitted to the hospital with a history of UGIB from July 1 to December 31, 2018, were enrolled in the study. After obtaining the demographic data, all patients underwent clinical examination, laboratory investigations, and video endoscopy. The Rockall scoring system was used to assess their prognosis. RESULTS: The mean age of the study population was 52.19±6.65 years. The majority (33%) were in the age group of 51-60 years. Of the study population, 82.7% were male and 17.3% were female. Chronic alcohol intake was found to be the most common risk factor, followed by drug intake. On upper gastrointestinal endoscopy, esophageal varices (65.3%) were the most common finding, followed by peptic ulcer disease (25.2%), gastric erosions (2.6%), gastroduodenitis (1.3%), Mallory-Weiss tear (1.3%), carcinoma stomach (1.3%), Camron's lesion (1.3%), and Dieulafoy's lesion (1.3%). Mortality attributed to UGIB was found to be 8%. CONCLUSION: The present study reported portal hypertension as the most common cause of UGIB, while the most common endoscopic lesions reported were esophageal varices. The factors associated with poor prognosis were age >60 years, shock, respiratory failure, low hemoglobin, low platelet count, deranged international normalized ratio (INR), variceal bleed, renal failure, rebleed, Rockall score ≥ 8, and late endoscopy (>24 hours of admission). Urgent appropriate hospital management definitely helps to reduce morbidity and mortality in patients with UGIB.

White Coat Effect: Is It Because of the Hospital Setting, or Is It Physician-Induced?

INTRODUCTION: White coat hypertension (WCH) patients are those individuals who have high blood pressure (BP) in the medical environment but are normal during their daily activities. White coat hypertensive patients with normal daytime ambulatory blood pressure monitoring (ABPM) rapidly progress to sustained hypertension. WCH is mainly treated with non-pharmacological methods. Alpha-1 agonists and beta blockers are logical treatment choices for patients with fixed hypertension with the White Coat Effect (WCE). Masked hypertension patients are those individuals who have normal values at the doctor's office but elevated BP at home or during 24-hour ABPM (24-hour or daytime). ABPM is a more practical and reliable method for detecting patients with WCH. MATERIAL AND METHODS: This observational study was conducted at Dayanand Medical College & Hospital, Ludhiana, over the course of one year (December 2015 to November 2016). The primary objective of the study was to determine whether there was a difference in blood pressure readings between the home setting and the hospital setting. The secondary objective was to determine whether the difference, if present, between the hospital and home readings was due to the hospital setting, physician presence, or a combination of both. Patients with stage 1 hypertension were included in the study, irrespective of antihypertensive treatment. Patients with ischemic heart disease, chronic liver failure, and chronic kidney disease who could not follow protocol instructions were excluded. RESULTS: In our study, the mean age of patients was 53.91±12.86 years. The patient's mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings at the hospital were higher than their home readings (p-0.012; p-0.001, respectively). Mean hospital SBP and DBP readings recorded by the physician were higher than readings recorded by patients alone at home (p-0.002; p-0.014, respectively) and alone at the hospital (p-0.004; p-0.001, respectively). BP readings taken by the physician with a manual sphygmomanometer were significantly lower than those taken with a digital sphygmomanometer by patients and physicians in all settings (p<0.05). The mean rise in BP was significant in both the physician's presence and the hospital environment (p<0.05 for both), and this rise was more significantly associated with the hospital effect than the physician effect (p<0.05). CONCLUSION: Misdiagnosis of hypertension results in inappropriate prescription and overuse of antihypertensive medications for individuals who are not persistently hypertensive. So it is very important to rule out WCH in both the hospital setting and the physician's presence, more precisely by ABPM. WCH can be diagnosed with regular BP monitoring by a digital sphygmomanometer at home.

Risk Factors and Outcome Analysis of Gram-Positive Bacteremia in Critically Ill Patients.

Introduction Bloodstream infection (BSI) is a common problem for patients in the intensive care unit (ICU). Nearly 60% of primary bloodstream infections are caused by Gram-positive cocci. Gram-positive bacteria gain access to the bloodstream through invasive procedures and various patient care equipment like catheters, intravenous lines, and mechanical ventilators. S. aureus is considered to be the major cause of septicemia. Knowledge of healthcare-associated infections and the antimicrobial susceptibility patterns of the isolates are crucial in guiding empirical treatment. Methods This prospective observational study was conducted in Medical ICU, Dayanand Medical College & Hospital, Ludhiana over a period of one year (December 2015 to November 2016). Patients whose blood cultures tested positive for Gram-positive bacteria were included in the study. This study was carried out to assess the implications and risk factors for nosocomial BSI and several factors, including the age of the patient, the severity of illness, the presence of catheters, and the microorganisms causing the BSI to independently predict mortality. Chief complaints and risk factors were evaluated. APACHE-II scores were calculated for all patients and outcomes were analyzed. Results In our study, the mean age of patients was 50.93±14.09 years. Central line insertion was found as the most common risk factor (58.7%). A statistically significant correlation was obtained between APACHE-II scores and the presence of risk factors i.e. central line insertion (p-value=0.010) and diabetes mellitus (p-value=0.003). The most common Gram-positive pathogen isolated by blood culture was methicillin-sensitive S. aureus (44.2%). For management, the majority of the patients were prescribed teicoplanin (58.7%). The 28-day overall mortality rate in our study was 52.9%. Conclusion We conclude that independent risk factors like diabetes mellitus, central line insertion, and acute pancreatitis in adult patients with Gram-positive bacteremia were associated with higher mortality. We have also concluded that the administration of early appropriate antibiotics improves patient outcomes.