Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Association of low-dose triple combination therapy vs usual care with time at target blood pressure: A secondary analysis of the TRIUMPH Randomized Clinical Trial(American Medical Association, 2022) Gnanenthiran, S.R.; Wang, N.; Luca Di Tanna, G.; Salam, A.; Webster, R.; de Silva, H.A.; Guggilla, R.; Jan, S.; Maulik, P.K.; Naik, N.; Selak, V.; Thom, S.; Prabhakaran, D.; Schutte, A.E.; Patel, A.; Rodgers, A.; TRIUMPH Study GroupImportance: Cumulative exposure to high blood pressure (BP) is an adverse prognostic marker. Assessments of BP control over time, such as time at target, have been developed but assessments of the effects of BP-lowering interventions on such measures are lacking. Objective: To evaluate whether low-dose triple combination antihypertensive therapy was associated with greater rates of time at target compared with usual care. Design, setting, and participants: The Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) trial was a open-label randomized clinical trial of low-dose triple BP therapy vs usual care conducted in urban hospital clinics in Sri Lanka from February 2016 to May 2017. Adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg or in patients with diabetes or chronic kidney disease, systolic BP >130 mm Hg and/or diastolic BP >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy were included. Patients were excluded if they were currently taking 2 or more blood pressure-lowering drugs or had severe or uncontrolled blood pressure, accelerated hypertension or physician-determined need for slower titration of treatment, a contraindication to the triple combination pill therapy, an unstable medical condition, or clinically significant laboratory values deemed by researchers to be unsuitable for the study. All 700 individuals in the original trial were included in the secondary analysis. This post hoc analysis was conducted from December 2020 to December 2021. Intervention: Once-daily fixed-dose triple combination pill (telmisartan 20 mg, amlodipine 2.5 mg, and chlorthalidone 12.5 mg) therapy vs usual care. Main outcomes and measures: Between-group differences in time at target were compared over 24 weeks of follow-up, with time at target defined as percentage of time at target BP. Results: There were a total of 700 randomized patients (mean [SD] age, 56 [11] years; 403 [57.6%] women). Patients allocated to the triple pill group (n = 349) had higher time at target compared with those in the usual care group (n = 351) over 24 weeks' follow-up (64% vs 43%; risk difference, 21%; 95% CI, 16-26; P < .001). Almost twice as many patients receiving triple pill therapy achieved more than 50% time at target during follow-up (64% vs 37%; P < .001). The association of the triple pill with an increase in time at target was seen early, with most patients achieving more than 50% time at target by 12 weeks. Those receiving the triple pill achieved a consistently higher time at target at all follow-up periods compared with those receiving usual care (mean [SD]: 0-6 weeks, 36.3% [30.9%] vs 21.7% [28.9%]; P < .001; 6-12 weeks, 5.2% [31.9%] vs 33.7% [33.0%]; P < .001; 12-24 weeks, 66.0% [31.1%] vs 43.5% [34.3%]; P < .001). Conclusions and relevance: To our knowledge, this analysis provides the first estimate of time at target as an outcome assessing longitudinal BP control in a randomized clinical trial. Among patients with mild to moderate hypertension, treatment with a low-dose triple combination pill was associated with substantially higher time at target compared with usual care.Item Combatting the Global Crisis of Cardiovascular Disease.(Carlton, Vic., Australia : Blackwell Science Asia, 2019) Palagyi, A.; de Silva, H.A.; Praveen, D.; Patel, A.No abstract availableItem Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study.(Scientific & Medical, Macmillan Press, 2019) Minhas, J. S.; Wang, X.; Lavados, P.M.; Moullaali, T.J.; Arima, H.; Billot, L.; Hackett, M.L.; Olavarria, V.V.; Middleton, S.; Pontes-Neto, O.; de Silva, H.A.; Lee, T. H.; Pandian, J. D.; Mead, G. E.; Watkins, C.; Chalmers, J.; Anderson, C.S.; Robinson, T.G.; HeadPoST InvestigatorsThe Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0°) or sitting-up (head elevated ≥30°) position. This post hoc analysis aimed to determine the association between blood pressure variability (BPV) and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to the standard criteria, with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 h. Outcome was ordinal 90-day Modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying flat vs. sitting up), and fixed period, random cluster, and random cluster-period, effects. Nine thousand one hundred and fifty six (8324 acute ischemic stroke and 817 intracerebral hemorrhage; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio 1.06, 95% confidence interval 1.02–1.11; P = 0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03–1.12; P = 0.001) over 24 h post stroke was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06–1.19) compared with lying-flat position (1.03, 0.98–1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, and the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability.Item A large-scale multi-ancestry genome-wide study accounting for smoking behavior identifies multiple significant loci for blood pressure(University of Chicago Press, 2018) Sung, Y.J.; Winkler, T.W.; de Las Fuentes, L.; Bentley, A.R.; Brown, M.R.; Kraja, A.T.; Schwander, K.; Ntalla, I.; Guo, X.; Franceschini, N.; Lu, Y.; Cheng, C.Y.; Sim, X.; Vojinovic, D.; Marten, J.; Musani, S.K.; Li, C.; Feitosa, M.F.; Kilpelainen, T.O.; Richard, M.A.; Noordam, R.; Aslibekyan, S.; Aschard, H.; Bartz, T.M.; Dorajoo, R.; Liu, Y.; Manning, A.K.; Rankinen, T.; Smith, A.V.; Tajuddin, S.M.; Tayo, B.O.; Warren, H.R.; Zhao, W.; Zhou, Y.; Matoba, N.; Sofer, T.; Alver, M.; Amini, M.; Boissel, M.; Chai, J.F.; Chen, X.; Divers, J.; Gandin, I.; Gao, C.; Giulianini, F.; Goel, A.; Harris, S.E.; Hatwig, F.P.; Horimoto, A.R.V.R.; Hsu, F.C.; Jackson, A.U.; Kahonen, M.; Kasturiratne, A.; Kuhnel, B.; Leander, K.; Lee, W.J.; Lin, K.H.; an Luan, J.; McKenzie, C.A.; Meian, H.; Nelson, C.P.; Rauramaa, R.; Schupf, N.; Scott, R.A.; Sheu, W.H.H.; Stancakova, A.; Takeuchi, F.; van der Most, P.J.; Varga, T.V.; Wang, H.; Wang, Y.; Ware, E.B.; Weiss, S.; Wen, W.; Yanek, L.R.; Zhang, W.; Zhao, J.H.; Afag, S.; Alfred, T.; Amin, N.; Arking, D.; Aung, T.; Barr, R.G.; Bielak, L.F.; Boerwincle, E.; Bottinger, E.P.; Braund, P.S.; Brody, J.A.; Broeckel, U.; Cabrera, C.P.; Cade, B.; Caizheng, Y.; Campbell, A.; Canouil, M.; Chakravarti, A.; CHARGE Neurology Working Group; Chauhan, G.; Christensen, K.; Cocca, M.; COGENT-Kidney Consortium; Collins, F.S.; Connel, J.M.; de Mutsert, R.; de Silva, H.J.; Debette, S.; Dorr, M.; Duan, Q.; Eaton, C.B.; Ehret, G.; Evangelou, E.; FAul, J.D.; Fisher, V.A.; Forouhi, N.G.; Franco, O.H.; Friedlander, Y.; Gao, H.; GIANT Consortium; Gigante, B.; Graff, M.; Gu, C.C.; Gu, D.; Gupta, P.; Hagenaars, S.P.; Harris, T.B.; He, J.; Heikkinen, S.; Heng, C.K.; Hirata, M.; Hofman., A.; Howard, B.V.; Hunt, S.; Irvin, M.R.; Jia, Y.; Joehanes, R.; Justice, A.E.; Katsuya, T.; Kaufman, J,; Kerrison, N.D.; Khor, C.C.; Koh, W.P.; Koistinen, H.A.; Komulainen, P.; Kooperberg, C.; Krieger, J.E.; Kubo, M.; Kuusisto, J.; Lanefeld, C.D.; Langenberg, C.; Launer, L.J.; Lehne, B.; Lewis, C.E.; Li, Y.; Lifelines Cohort Study; Lim, S.H.; Lin, S.; Liu, C.T.; Liu, J.; Liu, J.; Liu, K.; Liu, Y.; Loh, M.; Lohmann, K.K.; Long, J.; Louie, T.; Magi, R.; Mahajan, A.; Meitinger, T.; Metspalu, A.; Milani, L.; Momozawa, Y.; Morris, A.P.; Mosley, T.H.Jr.; Munson, P.; Murray, A.D.; Nalls, M.A.; Nasri, U.; Norris, J.M.; North, K.; Ogunniyi, A.; Padmanabhan, S.; Palmas, W.R.; Palmer, N.D.; Pankow, J.S.; Pedersen, N.L.; Peters, A.; Peyser, P.A.; Polasek, O.; Raitakari, O.T.; Renstrom, F.; Rice, T.K.; Ridker, P.M.; Robino, A.; Robinson, J.G.; Rose, L.M.; Rudan, I.; Salako, B.L.; Sandow, K.; Schmidt, C.O.; Schreiner, P.J.; Scott, W.R.; Seshadri, S.; Sever, P.; Sitlani, C.M.; Smith, J.A.; Snieder, H.; Starr, J.M.; Strauch, K.; Tang, H.; Taylor, K.D.; Teo, Y.Y.; Tham, Y.C.; Uitterlineden, A.G.; Waldenberger, M.; Wang, L.; Wang, Y.X.; Wei, W.B.; Williams, C.; Wilson, G.; Wojczynski, M.K.; Yao, J.; Yuan, J.M.; Zonderman, A.B.; Becker, D.M.; Boehnke, M.; Bowden, D.W.; Chambers, J.C.; Chen, Y.I.; de Faire, U.; Deary, I.J.; Esco, T.; Farrall, M.; Forrester, T.; Franks, P.W.; Freedman, B.I.; Froguel, P.; Gasparini, P.; Gieger, C.; Horta, B.L.; Hung, Y.J.; Jonas, J.B.; Kato, N.; Kooner, J.S.; Laakso, M.; Lehtimaki, T.; Liang, K.W.; Magnusson, P.K.E.; Newman, A.B.; Oldehinkel, A.J.; Pereira, A.C.; Redline, S.; Rettig, R.; Samani, N.J.; Scott, J.; Shu, X.O.; van der Harst, P.; Wagenknecht, L.E.; Wareham, N.J.; Watkins, H.; Weir, D.R.; Wickremasinghe, A.R.; Wu, T.; Zheng, W.; Kamatani, Y.; Laurie, C.C.; Bouchard, C.; Cooper, R.S.; Evans, M.K.; Gudnason, V.; Kardia, S.L.R.; Kritchevsky, S.B.; Levy, D.; O'Connell, J.R.; Psaty, B.M.; van Dam, R.M.; Sims, M.; Arnett, D.K.; Mook-Kanamori, D.O.; Kelly, T.N.; Fox, E.R.; Hayward, C.; Fornage, M.; Rotimi, C.N.; Province, M.A.; van Dujin, C.M.; Tai, E.S.; Wong, T.Y.; Loos, R.J.F.; Reiner, A.P.; Rotter, J.I.; Zhu, X.; Bierut, L.J.; Gauderman, W.J.; Caulfield, M.J.; Elliott, P.; Rice, K.; Munroe, P.B.; Morrison, A.C.; Cupples, L.A.; Rao., D.C.; Chasman, D.I.Genome-wide association analysis advanced understanding of blood pressure (BP), a major risk factor for vascular conditions such as coronary heart disease and stroke. Accounting for smoking behavior may help identify BP loci and extend our knowledge of its genetic architecture. We performed genome-wide association meta-analyses of systolic and diastolic BP incorporating gene-smoking interactions in 610,091 individuals. Stage 1 analysis examined ∼18.8 million SNPs and small insertion/deletion variants in 129,913 individuals from four ancestries (European, African, Asian, and Hispanic) with follow-up analysis of promising variants in 480,178 additional individuals from five ancestries. We identified 15 loci that were genome-wide significant (p < 5 × 10-8) in stage 1 and formally replicated in stage 2. A combined stage 1 and 2 meta-analysis identified 66 additional genome-wide significant loci (13, 35, and 18 loci in European, African, and trans-ancestry, respectively). A total of 56 known BP loci were also identified by our results (p < 5 × 10-8). Of the newly identified loci, ten showed significant interaction with smoking status, but none of them were replicated in stage 2. Several loci were identified in African ancestry, highlighting the importance of genetic studies in diverse populations. The identified loci show strong evidence for regulatory features and support shared pathophysiology with cardiometabolic and addiction traits. They also highlight a role in BP regulation for biological candidates such as modulators of vascular structure and function (CDKN1B, BCAR1-CFDP1, PXDN, EEA1), ciliopathies (SDCCAG8, RPGRIP1L), telomere maintenance (TNKS, PINX1, AKTIP), and central dopaminergic signaling (MSRA, EBF2).Item Blood pressure drop in dengue without fluid leakage(Sri Lanka Medical Association, 2013) Miththinda, J.K.N.D.; Premaratna, R.; Ragupathy, R.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: Plasma leakage is considered the most important reason for reduction in blood pressures (BP) in Dengue shock syndrome (DSS). However other causes such as dehydration, vascular dilatation due metabolic causes such as lactic acidosls or reduced cardiac output due to myocarditis or cardiomyopathy may lead to reduction in BP. We document observations in 7 patients with dengue who had reduced BP with no evidence of fluid leakage. METHODS: We monitored 106 patients with confirmed dengue for fluid leakage with ultrasonography and other clinical, haematological and biochemical parameters. These parameters of the 7 patients (Group A) were compared with an age and sex matched group of patients from the same cohort who did not develop any complications (Group B) in order to investigate the reasons for the BP drop. RESULTS: Comparison between Group A vs Group B; systolic blood pressure drop 21.7mmHg (7.9) vs 5.7mmHg (7.9) p =0.025; diastoiic blood pressure drop 17.1mmHg (7.6) vs 7.1mmHg (7.7) p =0.03; percentage rise in Hb 2.8% (3.9) vs 5.3% (4.4) p =0.3; percentage rise of PCV 3.5% (1.5) vs 6.2% (5) ^=0.06. Five out of 7 in Group A and none in Group B had T wave inversions in the ECG in more than 3 consecutive leads. ECHO and cardiac enzymes were not done. CONCLUSIONS: Except for blood pressure drop and ECG changes, there were no significant differences in clinical, haematological or biochemical parameters between the two groups. Our findings suggest an alternative cause for the drop in blood pressure in dengue patients with no evidence of fluid leakage.