Objective: Healthy habits during childhood has been of prime importance. We aimed to gather basel... more Objective: Healthy habits during childhood has been of prime importance. We aimed to gather baseline information about health habits from children in kindergarten and first grade (typically ages 5-7). Our objectives were to validate the questionnaire in assessing health habits, as well as the electronic audience response system, iClicker (MPS, Gordonsville, VA), in this age group. Results: The questionnaire completed by 75 kindergarteners and 66 first graders. For the first graders, questions involving healthy choices were answered correctly 78% of the time (range 8-94%) and had 84% agreement on repeat testing (range 64-93%). Questions on diabetes were answered correctly 79% of the time (range 65-94%) and had 85% agreement on repeat testing. Crohnbach's alpha was calculated to determine the reliability of the questionnaire: on the revised kindergarten questionnaire, this ranged from 0.79 to 0.81 on Day 1 and 0.84-0.97 on Day 5; for the first graders, this ranged 0.79-0.81 on Day 1 and 0.84-0.97 on Day 5. Both kindergarteners and first graders answered the simplest of the basic knowledge questions correctly > 80% of the time, with acceptable test-retest agreement. Additionally, these children demonstrated acceptable understanding of the use of the iClicker classroom response system.
Body: Introduction: The majority of tobacco users begin before the age of 18. A preventative inte... more Body: Introduction: The majority of tobacco users begin before the age of 18. A preventative intervention targeted at elementary school children has been previously reported (Surani S. et al. Int J Pediatr. 2011; 584589), though the changes attributable to the intervention are not known. Objectives: The purpose of this study is to assess the effect of the intervention on the perception and knowledge of, and attitudes toward, tobacco use. Methods: After permission from the school districts, children from second and third grade underwent an educational program. The "AntE tobacco" program, a 13-minute educational cartoon video depicting the ill effects of smoking by a colony of ants, was presented to the students. A 17-point questionnaire assessing 4 categories related to tobacco use (perceptions of the smoking prototype, behavioral willingness to smoke, attitudes toward use, and knowledge about risks) was administered before and after the intervention. Results: Pre-and post-intervention questionnaires were completed by 447 students. Following the intervention, children who smoked were felt to be significantly less popular and cool, and more boring than before the intervention. However, children were more likely to agree that smoking makes them look cool, have more friends, and look more grown-up following the intervention. There was little to no change in responses in behavioral willingness to smoke or knowledge of tobacco use risks. Conclusions: The effects of the intervention were contradictory on the perception and attitudes toward tobacco use among elementary students. Other interventions may be needed to address willingness to use tobacco and knowledge of the risks.
The prevalence of childhood obesity is rapidly increasing, and has consequences for asthma, sleep... more The prevalence of childhood obesity is rapidly increasing, and has consequences for asthma, sleep apnea, and a number of other long-term health implications. We aimed to gather baseline information about health habits from children in kindergarten and first grade (typically age 5-7 years) using a simple questionnaire and the iClicker electronic response system. The electronic response system was favored in an attempt to reduce costs, and minimize the opportunities for assistance from teachers and other students; however, the iClicker tool had not been validated in this age group. METHODS: The entire kindergarten and first grade classes at a local elementary school completed a 32-item questionnaire, covering healthy food choices, exercise, and basic diabetes knowledge. The questionnaires were completed using the iClicker classroom response system (MPS, Gordonsville, VA). The first 5 items of the questionnaire were designed to test the baseline validity of the response system, and included questions about gender, grade level, type of school, location, and the year. The students then completed the questionnaire in an identical manner 5 days later without specific intervention/education. RESULTS: The questionnaire was at least partially completed by 75 kindergarteners and 66 first graders. Both kindergarteners and first graders answered the questions, "what city do you live in?" and "what grade level are you in?" correctly >80% in both instances, with >85% test-retest agreement; the question on gender generated 90% agreement when repeated. First graders answered the questions, "what year are we in?" and "what kind of school do you do to?" correctly $70% of the time, with 75% agreement when retested; kindergarteners did not perform as well on these questions. Overall, kindergarteners averaged 74% correct answers and 75% agreement; first graders averaged 81% correct and 80% agreement. CONCLUSIONS: The iClicker is a valid tool for obtaining questionnaire responses from early grade school children. CLINICAL IMPLICATIONS: This audience response technology can be used effectively to improve educational activities in promoting health.
Mood disorders are common in obstructive sleep apnea (OSA), though the interactions are not wellu... more Mood disorders are common in obstructive sleep apnea (OSA), though the interactions are not wellunderstood. The objective of this study was to evaluate the relationship between anxiety and depression with OSA. Methods Patients who presented to the sleep center underwent polysomnography (PSG). Records were included if the sleep study showed OSA (Apnea-Hypopnea Index (AHI) ≥5 events/hour). All patients completed an Epworth Sleepiness Scale (ESS) and Hospital Anxiety and Depression Scale (HADS). A score of 8 or higher on the respective portion of the HADS was abnormal. Results A total of 45 records were included, with 28 scoring positive for anxiety and 29 positive for depression. Patients with anxiety had lower AHI (median (interquartile ratio)) than those without (21.4 (9.6-41.3) vs. 50.5 (25.1-94.3); p=0.0076). The peripheral oxygen saturation (SpO 2) nadir (80 (74-84)% vs. 65 (57-76)%; p=0.0007) and time with SpO 2 <90% (11 (6-12) minutes vs. 36 (13-68) minutes; p=0.0002) were less abnormal in patients with anxiety. The anxiety score on the HADS weakly correlated with AHI (r =-0.29). Patients with depression were not significantly different than those without depression in AHI, SpO 2 nadir, and time with SpO 2 <90%. Conclusions Symptoms of anxiety and depression are both prevalent in patients with OSA. There is an inverse relationship between OSA severity and the presence of anxiety, suggesting that comorbid anxiety may prompt sleep evaluation in less severe disease. Depression symptoms did not demonstrate a similar relationship with OSA severity.
Background and objectives: Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstruct... more Background and objectives: Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstructive pulmonary disease (COPD) are independently linked to an increase in cardiovascular disease (CVD). Only a few studies have been published linking the association between overlap syndrome and congestive heart failure (CHF). This review highlights the interplay between overlap syndrome (OSAHS-COPD) and CHF. Materials and methods: We thoroughly reviewed published literature from 2005 to 2022 in PubMed, Google Scholar, and Cochrane databases to explore the link between overlap syndrome and cardiovascular outcomes, specifically congestive heart failure. Results: Research indicates that individuals with overlap syndrome are more likely to develop congestive heart failure than those with COPD or OSA alone. Congestive heart failure is a common comorbidity of overlap syndrome, and it has a two-way connection with sleep-related breathing disorders, which tend to occur together more frequently t...
Atherosclerotic Cardiovascular Disease (ASCVD) is the leading cause of death worldwide. In Diabet... more Atherosclerotic Cardiovascular Disease (ASCVD) is the leading cause of death worldwide. In Diabetics, ASCVD is associated with poor prognosis and a higher case fatality rate compared with the general population. Sub-Saharan Africa is facing an epidemiological transition with ASCVD being prevalent among young adults. To date, over 20 million people have been living with DM in Africa, Tanzania being one of the five countries in the continent reported to have a higher prevalence. This study aimed to identify an individual's 10-year ASCVD absolute risk among a diabetic cohort in Tanzania and define contextual risk enhancing factors. Methods: A prospective observational study was conducted at the Aga Khan hospital, Mwanza, for a period of 8 months. The hospital is a 42-bed district-level hospital in Tanzania. Individuals 10-year risk was calculated based on the ASCVD 2013 risk calculator by ACC/AHA. Pearson's chi-square or Fischer's exact test was used to compare categorical and continuous variables. Multivariable analysis was applied to determine contextual factors for those who had a high 10-year risk of developing ASCVD. Results: The overall cohort included 573 patients. Majority of the individuals were found to be hypertensive (n = 371, 64.7%) and obese (n = 331, 58%) having a high 10-year absolute risk (n = 343, 60%) of suffering ASCVD. The study identified duration of Diabetes Mellitus (>10 years) (OR 8.15, 95% CI 5.25-14.42), concomitant hypertension (OR 1.82 95% CI 1.06-3.06), Diabetic Dyslipidemia (OR 1.44, 95% CI 1.08-1.92) and deranged serum creatinine (OR 1.03, 95% CI 1.02-1.03) to be the risk enhancing factors amongst our population. Conclusion: The study confirms the majority of diabetic individuals in the lake region of Tanzania to have a high 10-year ASCVD risk. The high prevalence of obesity, hypertension and dyslipidemia augments ASCVD risk but provides interventional targets for health-care workers to decrease these alarming projections.
Our objective was to implement a comprehensive quality improvement project to decrease the 30-day... more Our objective was to implement a comprehensive quality improvement project to decrease the 30-day readmission rate for all-cause acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at a rural Midwestern community hospital in the United States. Prospective data were collected from January 1 to December 31, 2017. A total of 77 patients met the study criteria and were included for analysis. Baseline data analysis involved data for 72 patients from September 1, 2015, to October 1, 2016, and showed a 30.6% all-cause 30-day AECOPD readmission rate. The Define, Measure, Analyze, Improve, and Control (DMAIC) model was used for this quality improvement project. All aspects of this project were successfully implemented, and the resulting 30-day all-cause AECOPD readmission rate decreased to 16.9% during the study time frame. Through this comprehensive quality improvement project, the 30-day all-cause AECOPD readmission rate was reduced by 23.7%.
Introduction Obstructive sleep apnea (OSA) is a heterogenous disease with both anatomic and nonan... more Introduction Obstructive sleep apnea (OSA) is a heterogenous disease with both anatomic and nonanatomic factors contributing to the pathophysiology. Recently low arousal threshold (ArTH) has been described in some patients with sleep apnea and there is early evidence emerging that it could be a clinical phenotype. The aim of this study was to characterize this phenotype in a large cohort of patients with sleep apnea confirmed by overnight polysomnography Methods The setting was a community sleep center. We performed a retrospective review of patient charts. We included patients who underwent full-night diagnostic PSG. OSA was defined as an apnea hypopnea index (AHI) of > 5. Epworth score, body mass index (BMI), neck circumference, and upper airway size using Modified Friedman (MF) were recorded. Low ArTH was calculated using AHI, fraction of hypopneas and O2 nadir.Abnormal airway narrowing was defined by MF >2. Large neck was defined by neck circumference ≥ 17 inches in males ...
Introduction Sleep disturbances are common in COPD. Hospitalization due to COPD exacerbations lik... more Introduction Sleep disturbances are common in COPD. Hospitalization due to COPD exacerbations likely have a negative impact on sleep in these patients and may contribute to their recovery. The aim of this study was to measure the prevalence of sleep disturbances in hospitalized patients with COPD and characterize their impact by use of the Functional outcomes of Sleep questionnaire (FOSQ). Methods The study was done at a community hospital. We included all patients who were admitted with a diagnosis of acute COPD exacerbation. Patients were administered the FOSQ on the day of discharge. Standard statistical methods were used to analyze the data Results A total of 54 patients - 28 males and 26 females filled out the questionnaire completely and were included in the analysis. The mean age was 66 +/- 14 years. The average FOSQ was 15 +/- 7. 60% of the patients had a FOSQ of <17.9 showing a high prevalence of sleep morbidity. Individual domains of the FOSQ -( mean +/- SD) showed the ...
Background: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and i... more Background: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and increased morbidity and mortality. Patients requiring PMV are referred mostly to Long-Term Acute Care (LTAC) facilities. Objective: To determine if protocol-driven weaning from mechanical ventilator by Respiratory Therapist (RT) would result in quicker weaning from mechanical ventilation, cost-effectiveness, and decreased mortality. Methods: A retrospective case-control study was conducted that utilized protocol-driven ventilator weaning by respiratory therapist (RT) as a part of the Respiratory Disease Certification Program (RDCP). Results: 51 patients on mechanical ventilation before initiation of protocol-based ventilator weaning formed the control group. 111 patients on mechanical ventilation after implementation of the protocol formed the study group. Time to wean from the mechanical ventilation before the implementation of protocol-driven weaning by RT was 16.76 +/- 18.91 days, whil...
Heart failure (HF) is a major public health problem in the United States as well as worldwide. Ch... more Heart failure (HF) is a major public health problem in the United States as well as worldwide. Chronic heart failure is a syndrome of reduced cardiac output resulting from impaired ventricular function, impaired filling, or a combination of both. Associated symptoms include dyspnea, fatigue, and decreased exercise tolerance. HF has a marked effect on morbidity and mortality, given limited therapeutic choices. The first line of therapeutic agents indicated in heart failure are beta-blockers. Other drugs and therapeutic modalities employed in HF treatment include angiotensin-receptor blockers (ARBs), sacubitril (neprilysin inhibitor) combination with the ARB, valsartan, small doses of aldosterone receptor antagonists (ARAs) in the setting of angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers. Additionally, the sodiumglucose transporter-2 inhibitor, dapagliflozin in the setting of ACE inhibitors, ARBs, or sacubitril-valsartan plus beta-blocker have been employed. Other therapeutic modalities have included loop diuretics, digoxin, the hydralazine-isosorbide dinitrate combination, ivabradine, the inotropes, dobutamine, milrinone, and dopamine. Decreased cardiac contractility is central to the systolic HF. Therapeutic agents employed to increase cardiac contractility in HF are limited because of their mechanistic-related adverse effect profiles. Omecamtiv mecarbil (OM) is a first of its class cardiac myosin activator that increases the cardiac contractility by specifically binding to the catalytic S1 domain of cardiac myosin, to be employed in heart failure treatment. This agent has demonstrated benefit in reducing heart rate, peripheral vascular resistance, mean left arterial pressure, and left ventricular end-diastolic pressure in the animal models. Additionally, OM is known to improve systolic wall thickening, stroke volume (SV), and cardiac output (CO). OM increases systolic ejection time (SET), cardiac myocyte fractional shortening without significant increase of LV dP/dtmax, myocardial oxygen consumption, and myocyte intracellular calcium. The benefits of OM have been demonstrated through key trials, as (i) The Acute Treatment with Omecamtiv mecarbil to Increase Contractility in Acute Heart Failure (ATOMIC-AHF), and (ii) The Chronic Oral Study of Myosin Activation to Increase Contractility in Heart Failure (COSMIC-HF). The Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial is ongoing and can help provide further clinical data. OM provides a novel mechanism and therapeutic approach to managing patients with HF. Preclinical and clinical data suggest that OM capability can improve cardiac function, decrease ventricular wall stress, reverse ventricular remodeling, and promote sympathetic withdrawal.
Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutroph... more Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consoli...
Background: The emergence of the novel coronavirus disease 2019 (COVID-19) has caused millions of... more Background: The emergence of the novel coronavirus disease 2019 (COVID-19) has caused millions of deaths worldwide. There has been paucity of data for hospitalized African patients suffering from COVID-19. This study aimed to identify factors associated with in-hospital mortality in patients suffering from COVID-19 in Tanzania. Methods: This was a single center, retrospective, observational cohort study in adult patients hospitalized with confirmed COVID-19 infection. Demographics, clinical pattern, laboratory and radiological investigations associated with increased odds of mortality were analyzed. Results: Of the 157 patients, 107 (68.1%) patients survived and 50 (31.8%) died. Mortality was highest in patients suffering with severe (26%) and critical (68%) forms of the disease. The median age of the cohort was 52 years (IQR 42-61), majority of patients were male (86%) and of African origin (46%), who presented with fever (69%), cough (62%) and difficulty in breathing (43%). Factors that were associated with mortality among our cohort were advanced age (OR 1.07, 95% CI 1.03-1.11), being overweight and obese (OR 9.44, 95% CI 2.71-41.0), suffering with severe form of the disease (OR 4.77, 95% CI 1.18-25.0) and being admitted to the HDU and ICU (OR 6.68, 95% CI 2.06-24.6). Conclusion: The overall in-hospital mortality was 31.8%. Older age, obesity, the severe form of the disease and admission to the ICU and HDU were major risk factors associated with in-hospital mortality.
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory s... more Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified on 8thDecember 2019 in Wuhan, Hubei, China, and has since spread globally to become an emergency of international concern. Patients infected with SARS-CoV-2 may be asymptomatic or present with symptoms ranging from mild clinical manifestations: such as fever, cough, and sore throat to moderate and severe form of the disease such as pneumonia and acute respiratory distress syndrome (ARDS). In some patients, SARS-CoV-2 can affect the heart and cause myocardial injury which is evidenced either by electrocardiographic (ECG) changes or by a rise in serum troponin level. Patients with myocardial involvement are generally at risk of developing severe illness and tend to have a poor outcome. We hereby present a case of a hypertensive male patient with undiagnosed, asymptomatic COVID-19, who underwent an emergency urologic procedure for ...
Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality r... more Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality rate. Pirfenidone is one of two oral antifibrotic therapies approved to treat idiopathic pulmonary fibrosis (IPF). Pirfenidone helps decrease disease progression in patients with IPF and reduces vital capacity. This has led to widespread use of this medication in recent years. In this case report, we present a 60-year-old male who started treatment with pirfenidone for IPF and had severe skin reactions after initiation of therapy.
Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus.... more Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus. Endobronchial aspergilloma is a very rare type of aspergillosis which is not yet included in the classification of aspergillosis. Due to its rare nature and a limited number of cases, there are no current treatment guidelines. Here we present the case of a 57-year-old female with an endobronchial aspergilloma. The patient was started on intravenous voriconazole and subsequently discharged on oral voriconazole.
Journal of Community Hospital Internal Medicine Perspectives, 2021
Background: Many countries are experiencing outbreaks of the second wave of COVID-19 infection. W... more Background: Many countries are experiencing outbreaks of the second wave of COVID-19 infection. With these outbreaks, the severity of the disease is still ambiguously projected. Certain inflammatory markers are known to be associated with the severity of the disease and regular monitoring of these biomarkers in intensive care unit admissions is paramount to improve clinical outcomes. Objectives: This study was aimed to compare the severity markers of the patients infected during the first wave versus the second wave in an intensive care unit. Methods: We conducted a retrospective study obtaining patient's data from hospital records, admitted during the first wave in March-May 2020, and compared the data with those COVID-19 patients admitted during the second wave from October-November 2020. A descriptive comparison was done among the patients admitted to intensive care unit (ICU) during both waves of the pandemic. Results: 92 patients from first wave and 68 patients from second wave were included in the analysis, all admitted to ICU with equal gender distribution. Increased age and length of ICU stay was observed during the first wave. BMI, in-hospital mortality and invasive ventilation were statistically indifferent between both the waves. There was significantly higher APACHE-II during first wave (p = 0.007), but SOFA at day 1 (p = 0.213) and day 7 of ICU stay remain indifferent (p = 0.119). Inflammatory markers were less severe during second wave while only neutrophils and lymphocytes were found to peak higher. Conclusion: Most of the severity markers were less intense during the early analysis of second wave.
The cost of health care has been rising in the United States and globally and will continue to in... more The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.
Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent co... more Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent collapse of the upper airway while sleeping and is estimated to plague 936 million adults globally. Although the initial clinical presentation of OSA appears harmless, it increases the risk of cardiovascular diseases such as heart failure, stroke, and hypertension; metabolic disorders; and an overall decrease in quality of life, in addition to increasing mortality. Current treatment of OSA includes lifestyle changes, behavioral modification, mandibular advancement devices, surgical treatment, and continuous positive airway pressure, which remains the gold standard. It is crucial to identify OSA early on and initiate treatment to mitigate the adverse health risks it imposes. This review will discuss the pathophysiology, epidemiology, management strategies, and medical treatment of OSA.
Part of the Critical Care Commons Right click to open a feedback form in a new tab to let us know... more Part of the Critical Care Commons Right click to open a feedback form in a new tab to let us know how this document benefits you. Right click to open a feedback form in a new tab to let us know how this document benefits you.
Objective: Healthy habits during childhood has been of prime importance. We aimed to gather basel... more Objective: Healthy habits during childhood has been of prime importance. We aimed to gather baseline information about health habits from children in kindergarten and first grade (typically ages 5-7). Our objectives were to validate the questionnaire in assessing health habits, as well as the electronic audience response system, iClicker (MPS, Gordonsville, VA), in this age group. Results: The questionnaire completed by 75 kindergarteners and 66 first graders. For the first graders, questions involving healthy choices were answered correctly 78% of the time (range 8-94%) and had 84% agreement on repeat testing (range 64-93%). Questions on diabetes were answered correctly 79% of the time (range 65-94%) and had 85% agreement on repeat testing. Crohnbach's alpha was calculated to determine the reliability of the questionnaire: on the revised kindergarten questionnaire, this ranged from 0.79 to 0.81 on Day 1 and 0.84-0.97 on Day 5; for the first graders, this ranged 0.79-0.81 on Day 1 and 0.84-0.97 on Day 5. Both kindergarteners and first graders answered the simplest of the basic knowledge questions correctly > 80% of the time, with acceptable test-retest agreement. Additionally, these children demonstrated acceptable understanding of the use of the iClicker classroom response system.
Body: Introduction: The majority of tobacco users begin before the age of 18. A preventative inte... more Body: Introduction: The majority of tobacco users begin before the age of 18. A preventative intervention targeted at elementary school children has been previously reported (Surani S. et al. Int J Pediatr. 2011; 584589), though the changes attributable to the intervention are not known. Objectives: The purpose of this study is to assess the effect of the intervention on the perception and knowledge of, and attitudes toward, tobacco use. Methods: After permission from the school districts, children from second and third grade underwent an educational program. The "AntE tobacco" program, a 13-minute educational cartoon video depicting the ill effects of smoking by a colony of ants, was presented to the students. A 17-point questionnaire assessing 4 categories related to tobacco use (perceptions of the smoking prototype, behavioral willingness to smoke, attitudes toward use, and knowledge about risks) was administered before and after the intervention. Results: Pre-and post-intervention questionnaires were completed by 447 students. Following the intervention, children who smoked were felt to be significantly less popular and cool, and more boring than before the intervention. However, children were more likely to agree that smoking makes them look cool, have more friends, and look more grown-up following the intervention. There was little to no change in responses in behavioral willingness to smoke or knowledge of tobacco use risks. Conclusions: The effects of the intervention were contradictory on the perception and attitudes toward tobacco use among elementary students. Other interventions may be needed to address willingness to use tobacco and knowledge of the risks.
The prevalence of childhood obesity is rapidly increasing, and has consequences for asthma, sleep... more The prevalence of childhood obesity is rapidly increasing, and has consequences for asthma, sleep apnea, and a number of other long-term health implications. We aimed to gather baseline information about health habits from children in kindergarten and first grade (typically age 5-7 years) using a simple questionnaire and the iClicker electronic response system. The electronic response system was favored in an attempt to reduce costs, and minimize the opportunities for assistance from teachers and other students; however, the iClicker tool had not been validated in this age group. METHODS: The entire kindergarten and first grade classes at a local elementary school completed a 32-item questionnaire, covering healthy food choices, exercise, and basic diabetes knowledge. The questionnaires were completed using the iClicker classroom response system (MPS, Gordonsville, VA). The first 5 items of the questionnaire were designed to test the baseline validity of the response system, and included questions about gender, grade level, type of school, location, and the year. The students then completed the questionnaire in an identical manner 5 days later without specific intervention/education. RESULTS: The questionnaire was at least partially completed by 75 kindergarteners and 66 first graders. Both kindergarteners and first graders answered the questions, "what city do you live in?" and "what grade level are you in?" correctly >80% in both instances, with >85% test-retest agreement; the question on gender generated 90% agreement when repeated. First graders answered the questions, "what year are we in?" and "what kind of school do you do to?" correctly $70% of the time, with 75% agreement when retested; kindergarteners did not perform as well on these questions. Overall, kindergarteners averaged 74% correct answers and 75% agreement; first graders averaged 81% correct and 80% agreement. CONCLUSIONS: The iClicker is a valid tool for obtaining questionnaire responses from early grade school children. CLINICAL IMPLICATIONS: This audience response technology can be used effectively to improve educational activities in promoting health.
Mood disorders are common in obstructive sleep apnea (OSA), though the interactions are not wellu... more Mood disorders are common in obstructive sleep apnea (OSA), though the interactions are not wellunderstood. The objective of this study was to evaluate the relationship between anxiety and depression with OSA. Methods Patients who presented to the sleep center underwent polysomnography (PSG). Records were included if the sleep study showed OSA (Apnea-Hypopnea Index (AHI) ≥5 events/hour). All patients completed an Epworth Sleepiness Scale (ESS) and Hospital Anxiety and Depression Scale (HADS). A score of 8 or higher on the respective portion of the HADS was abnormal. Results A total of 45 records were included, with 28 scoring positive for anxiety and 29 positive for depression. Patients with anxiety had lower AHI (median (interquartile ratio)) than those without (21.4 (9.6-41.3) vs. 50.5 (25.1-94.3); p=0.0076). The peripheral oxygen saturation (SpO 2) nadir (80 (74-84)% vs. 65 (57-76)%; p=0.0007) and time with SpO 2 <90% (11 (6-12) minutes vs. 36 (13-68) minutes; p=0.0002) were less abnormal in patients with anxiety. The anxiety score on the HADS weakly correlated with AHI (r =-0.29). Patients with depression were not significantly different than those without depression in AHI, SpO 2 nadir, and time with SpO 2 <90%. Conclusions Symptoms of anxiety and depression are both prevalent in patients with OSA. There is an inverse relationship between OSA severity and the presence of anxiety, suggesting that comorbid anxiety may prompt sleep evaluation in less severe disease. Depression symptoms did not demonstrate a similar relationship with OSA severity.
Background and objectives: Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstruct... more Background and objectives: Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstructive pulmonary disease (COPD) are independently linked to an increase in cardiovascular disease (CVD). Only a few studies have been published linking the association between overlap syndrome and congestive heart failure (CHF). This review highlights the interplay between overlap syndrome (OSAHS-COPD) and CHF. Materials and methods: We thoroughly reviewed published literature from 2005 to 2022 in PubMed, Google Scholar, and Cochrane databases to explore the link between overlap syndrome and cardiovascular outcomes, specifically congestive heart failure. Results: Research indicates that individuals with overlap syndrome are more likely to develop congestive heart failure than those with COPD or OSA alone. Congestive heart failure is a common comorbidity of overlap syndrome, and it has a two-way connection with sleep-related breathing disorders, which tend to occur together more frequently t...
Atherosclerotic Cardiovascular Disease (ASCVD) is the leading cause of death worldwide. In Diabet... more Atherosclerotic Cardiovascular Disease (ASCVD) is the leading cause of death worldwide. In Diabetics, ASCVD is associated with poor prognosis and a higher case fatality rate compared with the general population. Sub-Saharan Africa is facing an epidemiological transition with ASCVD being prevalent among young adults. To date, over 20 million people have been living with DM in Africa, Tanzania being one of the five countries in the continent reported to have a higher prevalence. This study aimed to identify an individual's 10-year ASCVD absolute risk among a diabetic cohort in Tanzania and define contextual risk enhancing factors. Methods: A prospective observational study was conducted at the Aga Khan hospital, Mwanza, for a period of 8 months. The hospital is a 42-bed district-level hospital in Tanzania. Individuals 10-year risk was calculated based on the ASCVD 2013 risk calculator by ACC/AHA. Pearson's chi-square or Fischer's exact test was used to compare categorical and continuous variables. Multivariable analysis was applied to determine contextual factors for those who had a high 10-year risk of developing ASCVD. Results: The overall cohort included 573 patients. Majority of the individuals were found to be hypertensive (n = 371, 64.7%) and obese (n = 331, 58%) having a high 10-year absolute risk (n = 343, 60%) of suffering ASCVD. The study identified duration of Diabetes Mellitus (>10 years) (OR 8.15, 95% CI 5.25-14.42), concomitant hypertension (OR 1.82 95% CI 1.06-3.06), Diabetic Dyslipidemia (OR 1.44, 95% CI 1.08-1.92) and deranged serum creatinine (OR 1.03, 95% CI 1.02-1.03) to be the risk enhancing factors amongst our population. Conclusion: The study confirms the majority of diabetic individuals in the lake region of Tanzania to have a high 10-year ASCVD risk. The high prevalence of obesity, hypertension and dyslipidemia augments ASCVD risk but provides interventional targets for health-care workers to decrease these alarming projections.
Our objective was to implement a comprehensive quality improvement project to decrease the 30-day... more Our objective was to implement a comprehensive quality improvement project to decrease the 30-day readmission rate for all-cause acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at a rural Midwestern community hospital in the United States. Prospective data were collected from January 1 to December 31, 2017. A total of 77 patients met the study criteria and were included for analysis. Baseline data analysis involved data for 72 patients from September 1, 2015, to October 1, 2016, and showed a 30.6% all-cause 30-day AECOPD readmission rate. The Define, Measure, Analyze, Improve, and Control (DMAIC) model was used for this quality improvement project. All aspects of this project were successfully implemented, and the resulting 30-day all-cause AECOPD readmission rate decreased to 16.9% during the study time frame. Through this comprehensive quality improvement project, the 30-day all-cause AECOPD readmission rate was reduced by 23.7%.
Introduction Obstructive sleep apnea (OSA) is a heterogenous disease with both anatomic and nonan... more Introduction Obstructive sleep apnea (OSA) is a heterogenous disease with both anatomic and nonanatomic factors contributing to the pathophysiology. Recently low arousal threshold (ArTH) has been described in some patients with sleep apnea and there is early evidence emerging that it could be a clinical phenotype. The aim of this study was to characterize this phenotype in a large cohort of patients with sleep apnea confirmed by overnight polysomnography Methods The setting was a community sleep center. We performed a retrospective review of patient charts. We included patients who underwent full-night diagnostic PSG. OSA was defined as an apnea hypopnea index (AHI) of > 5. Epworth score, body mass index (BMI), neck circumference, and upper airway size using Modified Friedman (MF) were recorded. Low ArTH was calculated using AHI, fraction of hypopneas and O2 nadir.Abnormal airway narrowing was defined by MF >2. Large neck was defined by neck circumference ≥ 17 inches in males ...
Introduction Sleep disturbances are common in COPD. Hospitalization due to COPD exacerbations lik... more Introduction Sleep disturbances are common in COPD. Hospitalization due to COPD exacerbations likely have a negative impact on sleep in these patients and may contribute to their recovery. The aim of this study was to measure the prevalence of sleep disturbances in hospitalized patients with COPD and characterize their impact by use of the Functional outcomes of Sleep questionnaire (FOSQ). Methods The study was done at a community hospital. We included all patients who were admitted with a diagnosis of acute COPD exacerbation. Patients were administered the FOSQ on the day of discharge. Standard statistical methods were used to analyze the data Results A total of 54 patients - 28 males and 26 females filled out the questionnaire completely and were included in the analysis. The mean age was 66 +/- 14 years. The average FOSQ was 15 +/- 7. 60% of the patients had a FOSQ of <17.9 showing a high prevalence of sleep morbidity. Individual domains of the FOSQ -( mean +/- SD) showed the ...
Background: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and i... more Background: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and increased morbidity and mortality. Patients requiring PMV are referred mostly to Long-Term Acute Care (LTAC) facilities. Objective: To determine if protocol-driven weaning from mechanical ventilator by Respiratory Therapist (RT) would result in quicker weaning from mechanical ventilation, cost-effectiveness, and decreased mortality. Methods: A retrospective case-control study was conducted that utilized protocol-driven ventilator weaning by respiratory therapist (RT) as a part of the Respiratory Disease Certification Program (RDCP). Results: 51 patients on mechanical ventilation before initiation of protocol-based ventilator weaning formed the control group. 111 patients on mechanical ventilation after implementation of the protocol formed the study group. Time to wean from the mechanical ventilation before the implementation of protocol-driven weaning by RT was 16.76 +/- 18.91 days, whil...
Heart failure (HF) is a major public health problem in the United States as well as worldwide. Ch... more Heart failure (HF) is a major public health problem in the United States as well as worldwide. Chronic heart failure is a syndrome of reduced cardiac output resulting from impaired ventricular function, impaired filling, or a combination of both. Associated symptoms include dyspnea, fatigue, and decreased exercise tolerance. HF has a marked effect on morbidity and mortality, given limited therapeutic choices. The first line of therapeutic agents indicated in heart failure are beta-blockers. Other drugs and therapeutic modalities employed in HF treatment include angiotensin-receptor blockers (ARBs), sacubitril (neprilysin inhibitor) combination with the ARB, valsartan, small doses of aldosterone receptor antagonists (ARAs) in the setting of angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers. Additionally, the sodiumglucose transporter-2 inhibitor, dapagliflozin in the setting of ACE inhibitors, ARBs, or sacubitril-valsartan plus beta-blocker have been employed. Other therapeutic modalities have included loop diuretics, digoxin, the hydralazine-isosorbide dinitrate combination, ivabradine, the inotropes, dobutamine, milrinone, and dopamine. Decreased cardiac contractility is central to the systolic HF. Therapeutic agents employed to increase cardiac contractility in HF are limited because of their mechanistic-related adverse effect profiles. Omecamtiv mecarbil (OM) is a first of its class cardiac myosin activator that increases the cardiac contractility by specifically binding to the catalytic S1 domain of cardiac myosin, to be employed in heart failure treatment. This agent has demonstrated benefit in reducing heart rate, peripheral vascular resistance, mean left arterial pressure, and left ventricular end-diastolic pressure in the animal models. Additionally, OM is known to improve systolic wall thickening, stroke volume (SV), and cardiac output (CO). OM increases systolic ejection time (SET), cardiac myocyte fractional shortening without significant increase of LV dP/dtmax, myocardial oxygen consumption, and myocyte intracellular calcium. The benefits of OM have been demonstrated through key trials, as (i) The Acute Treatment with Omecamtiv mecarbil to Increase Contractility in Acute Heart Failure (ATOMIC-AHF), and (ii) The Chronic Oral Study of Myosin Activation to Increase Contractility in Heart Failure (COSMIC-HF). The Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial is ongoing and can help provide further clinical data. OM provides a novel mechanism and therapeutic approach to managing patients with HF. Preclinical and clinical data suggest that OM capability can improve cardiac function, decrease ventricular wall stress, reverse ventricular remodeling, and promote sympathetic withdrawal.
Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutroph... more Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consoli...
Background: The emergence of the novel coronavirus disease 2019 (COVID-19) has caused millions of... more Background: The emergence of the novel coronavirus disease 2019 (COVID-19) has caused millions of deaths worldwide. There has been paucity of data for hospitalized African patients suffering from COVID-19. This study aimed to identify factors associated with in-hospital mortality in patients suffering from COVID-19 in Tanzania. Methods: This was a single center, retrospective, observational cohort study in adult patients hospitalized with confirmed COVID-19 infection. Demographics, clinical pattern, laboratory and radiological investigations associated with increased odds of mortality were analyzed. Results: Of the 157 patients, 107 (68.1%) patients survived and 50 (31.8%) died. Mortality was highest in patients suffering with severe (26%) and critical (68%) forms of the disease. The median age of the cohort was 52 years (IQR 42-61), majority of patients were male (86%) and of African origin (46%), who presented with fever (69%), cough (62%) and difficulty in breathing (43%). Factors that were associated with mortality among our cohort were advanced age (OR 1.07, 95% CI 1.03-1.11), being overweight and obese (OR 9.44, 95% CI 2.71-41.0), suffering with severe form of the disease (OR 4.77, 95% CI 1.18-25.0) and being admitted to the HDU and ICU (OR 6.68, 95% CI 2.06-24.6). Conclusion: The overall in-hospital mortality was 31.8%. Older age, obesity, the severe form of the disease and admission to the ICU and HDU were major risk factors associated with in-hospital mortality.
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory s... more Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified on 8thDecember 2019 in Wuhan, Hubei, China, and has since spread globally to become an emergency of international concern. Patients infected with SARS-CoV-2 may be asymptomatic or present with symptoms ranging from mild clinical manifestations: such as fever, cough, and sore throat to moderate and severe form of the disease such as pneumonia and acute respiratory distress syndrome (ARDS). In some patients, SARS-CoV-2 can affect the heart and cause myocardial injury which is evidenced either by electrocardiographic (ECG) changes or by a rise in serum troponin level. Patients with myocardial involvement are generally at risk of developing severe illness and tend to have a poor outcome. We hereby present a case of a hypertensive male patient with undiagnosed, asymptomatic COVID-19, who underwent an emergency urologic procedure for ...
Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality r... more Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality rate. Pirfenidone is one of two oral antifibrotic therapies approved to treat idiopathic pulmonary fibrosis (IPF). Pirfenidone helps decrease disease progression in patients with IPF and reduces vital capacity. This has led to widespread use of this medication in recent years. In this case report, we present a 60-year-old male who started treatment with pirfenidone for IPF and had severe skin reactions after initiation of therapy.
Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus.... more Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus. Endobronchial aspergilloma is a very rare type of aspergillosis which is not yet included in the classification of aspergillosis. Due to its rare nature and a limited number of cases, there are no current treatment guidelines. Here we present the case of a 57-year-old female with an endobronchial aspergilloma. The patient was started on intravenous voriconazole and subsequently discharged on oral voriconazole.
Journal of Community Hospital Internal Medicine Perspectives, 2021
Background: Many countries are experiencing outbreaks of the second wave of COVID-19 infection. W... more Background: Many countries are experiencing outbreaks of the second wave of COVID-19 infection. With these outbreaks, the severity of the disease is still ambiguously projected. Certain inflammatory markers are known to be associated with the severity of the disease and regular monitoring of these biomarkers in intensive care unit admissions is paramount to improve clinical outcomes. Objectives: This study was aimed to compare the severity markers of the patients infected during the first wave versus the second wave in an intensive care unit. Methods: We conducted a retrospective study obtaining patient's data from hospital records, admitted during the first wave in March-May 2020, and compared the data with those COVID-19 patients admitted during the second wave from October-November 2020. A descriptive comparison was done among the patients admitted to intensive care unit (ICU) during both waves of the pandemic. Results: 92 patients from first wave and 68 patients from second wave were included in the analysis, all admitted to ICU with equal gender distribution. Increased age and length of ICU stay was observed during the first wave. BMI, in-hospital mortality and invasive ventilation were statistically indifferent between both the waves. There was significantly higher APACHE-II during first wave (p = 0.007), but SOFA at day 1 (p = 0.213) and day 7 of ICU stay remain indifferent (p = 0.119). Inflammatory markers were less severe during second wave while only neutrophils and lymphocytes were found to peak higher. Conclusion: Most of the severity markers were less intense during the early analysis of second wave.
The cost of health care has been rising in the United States and globally and will continue to in... more The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.
Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent co... more Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent collapse of the upper airway while sleeping and is estimated to plague 936 million adults globally. Although the initial clinical presentation of OSA appears harmless, it increases the risk of cardiovascular diseases such as heart failure, stroke, and hypertension; metabolic disorders; and an overall decrease in quality of life, in addition to increasing mortality. Current treatment of OSA includes lifestyle changes, behavioral modification, mandibular advancement devices, surgical treatment, and continuous positive airway pressure, which remains the gold standard. It is crucial to identify OSA early on and initiate treatment to mitigate the adverse health risks it imposes. This review will discuss the pathophysiology, epidemiology, management strategies, and medical treatment of OSA.
Part of the Critical Care Commons Right click to open a feedback form in a new tab to let us know... more Part of the Critical Care Commons Right click to open a feedback form in a new tab to let us know how this document benefits you. Right click to open a feedback form in a new tab to let us know how this document benefits you.
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