Medical Specialties Commons^™

How Do Red Blood Cells Die?, Perumal Thiagarajan, Charles J Parker, Josef T Prchal

Faculty, Staff and Students Publications

Normal human red blood cells have an average life span of about 120 days in the circulation after which they are engulfed by macrophages. This is an extremely efficient process as macrophages phagocytose about 5 million erythrocytes every second without any significant release of hemoglobin in the circulation. Despite large number of investigations, the precise molecular mechanism by which macrophages recognize senescent red blood cells for clearance remains elusive. Red cells undergo several physicochemical changes as they age in the circulation. Several of these changes have been proposed as a recognition tag for macrophages. Most prevalent hypotheses for red cell …

Conduction Disorders In The Setting Of Acute Stemi, Kjell Nikus, Yochai Birnbaum, Miquel Fiol-Sala, Jani Rankinen, Antoni Bayés De Luna

Faculty, Staff and Students Publications

ST-elevation myocardial (STEMI) is frequently associated with conduction disorders. Regional myocardial ischemia or injury may affect the cardiac conduction system at various locations, and neural reflexes or changes in the balance of the autonomous nervous system may be involved. Sinoatrial and atrioventricular blocks are more frequent in inferior than anterior STEMI, while new left anterior fascicular block and right bundle branch block indicate proximal occlusion of the left anterior descending coronary artery. New left bundle branch block is associated with multi-vessel disease. Most conduction disorders associated with STEMI are reversible with reperfusion therapy, but they may still impair prognosis because …

Effects Of Intensive Blood Pressure Treatment On Orthostatic Hypotension : A Systematic Review And Individual Participant-Based Meta-Analysis, Stephen P Juraschek, Jiun-Ruey Hu, Jennifer L Cluett, Anthony Ishak, Carol Mita, Lewis A Lipsitz, Lawrence J Appel, Nigel S Beckett, Ruth L Coleman, William C Cushman, Barry R Davis, Greg Grandits, Rury R Holman, Edgar R Miller, Ruth Peters, Jan A Staessen, Addison A Taylor, Lutgarde Thijs, Jackson T Wright, Kenneth J Mukamal

Faculty, Staff and Students Publications

BACKGROUND: Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH).

PURPOSE: To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults.

DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions.

STUDY SELECTION: Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, …

Pericardial Fluid Proteomic Label-Free Quantification Of Differentially Expressed Proteins In Ischemic Heart Disease Patients With Systolic Dysfunction By Nano-Lc-Esi-Ms/Ms Analysis, Junaid Ullah, Satwat Hashmi, Arslan Ali, Faisal Khan, Shahid Ahmed Sami, Nageeb Basir, Syedah Saira Bokhari, Hasanat Sharif, Hesham R. El-Seedi, Syed Ghulam Musharraf

Department of Biological & Biomedical Sciences

Left ventricular systolic dysfunction (LVSD) is common in patients with pre-existing ischemic heart disease (IHD) and myocardial infarction. An untargeted proteomic approach is used to improve the understanding of the molecular mechanisms associated with LVSD and to find out potential proteomic signatures in pericardial fluid. The pericardial fluid of IHD (n = 45) patients was grouped into two categories according to the left ventricular ejection fraction, LVEF ≥45 (n = 33) and LVEF <45 (n = 12), and analyzed by using nano-liquid chromatography–mass spectrometry (nano-LC-MS/MS) technique. The nano-LC-MS/MS analysis resulted in the identification of 709 pericardial fluid (PF) proteins …

Routine Outpatient Electrocardiogram: What Is The Diagnosis?, Muzamil Khawaja, Vincent R J Siebert, John Allison, Yochai Birnbaum

The Texas Heart Institute Journal

No abstract provided.

Improper Use Of Temporary Epicardial Pacing Wires, Emre Kubat, Isil Tasoz, Kubilay Karabacak, Suat Doganci

The Texas Heart Institute Journal

No abstract provided.

Single-Dose Del Nido Cardioplegia Compared With Standard Cardioplegia During Coronary Artery Bypass Grafting At A Veterans Affairs Hospital, Michael R Reidy, Ernesto Jimenez, Shuab Omer, Lorraine D Cornwell, Sabrina X Runbeck, Ourania Preventza, Gabriel Loor, Todd K Rosengart, Joseph S Coselli

The Texas Heart Institute Journal

Del Nido cardioplegic solution (DNC), used chiefly in pediatric patients, rapidly induces prolonged cardiac arrest during cardiac surgery. To determine whether surgical outcomes after coronary artery bypass grafting in a United States military veteran population differed when DNC was used instead of our standard Plegisol cardioplegia, we retrospectively reviewed 155 consecutive operations performed from July 2016 through June 2017. Del Nido cardioplegia was used to induce cardiac arrest in 70 patients, and Plegisol in 85. Compared with the Plegisol group, the DNC group had a shorter mean cardiopulmonary bypass time (96.8 vs 117 min; P48 hours, atrial fibrillation, tracheostomy, reintubation, …

Benign Metastasizing Leiomyoma In The Heart Of A 45-Year-Old Woman, Mohamad Karnib, Isaac Rhea, Robin Elliott, Saneka Chakravarty, Sadeer G Al-Kindi

The Texas Heart Institute Journal

We report a rare case of benign metastasizing leiomyoma in the heart of a 45-year-old woman 2 years after a uterine leiomyoma had been discovered during hysterectomy. Computed tomograms at presentation showed a large mixed cystic mass in the pelvis and bilateral lung nodules suggestive of metastatic disease. A large cardiac mass, attached to the chordae of the tricuspid valve and later shown to be histopathologically consistent with uterine leiomyoma, was successfully resected through a right atriotomy. This case suggests that benign metastasizing leiomyoma should be considered in the differential diagnosis of right-sided cardiac tumors.

Impact Of 17-Beta Estradiol And Moderate-Intensity Exercise On Mesenteric Arterial Function Of Uc Davis Type-2 Diabetes Mellitus Rats, Md Rahatullah Razan

University of the Pacific Theses and Dissertations

The studies in this dissertation were designed to investigate the impacts of estrogen (17-β estradiol/E2) and moderate-intensity exercise (MIE) on the mesenteric arterial (MA) function of the University of California Davis type-2 diabetes mellitus (UCD-T2DM) Rat model. Our recent report suggests that diabetes impairs MA vasorelaxation in both sexes of the UCD-T2DM model. Particularly, we reported that MA from prediabetic male rats showed a greater impairment compared to that in prediabetic females. However, when females become diabetic, they exhibit a greater vascular dysfunction than males. Therefore, the aim of the first study was to investigate whether female sex hormone, specifically …

Mitral Valve Repair Complicated By Left Circumflex Coronary Artery Occlusion: The Vital Role Of The Anesthesiologist, Andres Bacigalupo Landa, Jason Hoyos, Jayanand D'Mello

Faculty, Staff and Students Publications

The anatomical relationship between the mitral valve and the left circumflex coronary artery places this vessel at risk for occlusion during mitral valve repair or replacement. In view of the potential high morbidity and mortality of this complication, the anesthesiologist has a vital role in its prompt diagnosis. We present the case of a 47-year-old man who underwent a minimally invasive mitral valve repair, which was complicated by left circumflex coronary artery occlusion.

A New Aortic Arch Dissection Classification: The Fuwai Classification, Juntao Qiu, Xinjin Luo, Jinlin Wu, Wei Pan, Qian Chang, Xiangyang Qian, Xiaogang Sun, Bo Wei, Liang Zhang, Shen Liu, Wenxiang Jiang, Cuntao Yu

Faculty, Staff and Students Publications

Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications.

Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are …

Can Erythropoietin Reduce Hypoxemic Neurological Damages In Neonates With Congenital Heart Defects?, Sara Ottolenghi, Giuseppina Milano, Michele Dei Cas, Tina O Findley, Rita Paroni, Antonio F Corno

Faculty, Staff and Student Publications

Congenital heart defects (CHD), the most common cause of birth defects with increasing birth prevalence, affect nearly 1% of live births worldwide. Cyanotic CHD are characterized by hypoxemia, with subsequent reduced oxygen delivery to the brain, especially critical during brain development, beginning in the fetus and continuing through the neonatal period. Therefore, neonates with CHD carry a high risk for neurological comorbidities, even more frequently when there are associated underlying genetic disorders. We review the currently available knowledge on potential prevention strategies to reduce brain damage induced by hypoxemia during fetal development and immediately after birth, and the role of …

Trace Element Concentrations In Blood And Scute Tissues From Wild And Captive Hawaiian Green Sea Turtles (Chelonia Mydas), Katherine R Shaw, Jennifer M Lynch, George H Balazs, T Todd Jones, Jeff Pawloski, Marc R Rice, Amanda D French, Jing Liu, George P Cobb, David M Klein

Faculty, Staff and Students Publications

Sea turtles are exposed to trace elements through water, sediment, and food. Exposure to these elements has been shown to decrease immune function, impair growth, and decrease reproductive output in wildlife. This study compares trace element concentrations in green turtles in captivity at Sea Life Park Hawaii (n = 6) to wild green turtles in Kapoho Bay, HI (n = 5 to 7). Blood and scute samples were collected and analyzed for eleven elements via inductively coupled plasma-mass spectrometry (ICP-MS). Selenium was significantly greater (p < 0.05) in the blood of captive turtles compared to wild turtles, while V, Ni, and Pb were significantly greater in the blood of wild turtles. In scute, V, Cu, Se, and Cr were significantly greater in captive turtles, while As was significantly greater in wild turtles. Pelleted food fed to the captive turtles and representative samples of the wild turtle diet were analyzed via ICP-MS to calculate trophic transfer factors and daily intake values. Wild turtles had greater estimated daily intake than captive turtles for all elements except Cu and Se. Because captive turtles are fed a diet very different from their wild counterparts, captive turtles do not represent control or reference samples for chemical exposure studies in wild turtles. No toxic thresholds are known for sea turtles, but rehabilitation and managed care facilities should monitor sea turtle elemental concentrations to ensure the animals’ health.

Cardio-Pulmonary Sequelae In Recovered Covid-19 Patients: Considerations For Primary Care, Zouina Sarfraz, Azza Sarfraz, Alanna Barrios, Radhika Garimella, Asimina Dominari, Manish Kc, Krunal Pandav, Juan C. Pantoja, Varadha Retnakumar, Ivan Cherrez-Ojeda

Department of Paediatrics and Child Health

Background: Current literature lacks characterization of the post-recovery sequelae among COVID-19 patients. This review characterizes the course of clinical, laboratory, radiological findings during the primary infection period, and the complications post-recovery. Primary care findings are presented for long-COVID care.
Methods: Adhering to PRISMA guidelines, 4 databases were searched (PubMed, Embase, CINAHL Plus, Scopus) through December 5, 2020, using the keywords "COVID-19 and/or recovered and/or cardiovascular and/or long-term and/or sequelae and/or sub-acute and/or complication." We included published peer-reviewed case reports, case series, and cross-sectional studies providing the clinical course of COVID-19 infection, and cardiopulmonary complications of patients who recovered from COVID-19, …

Transfer Of Patients With St Elevation Myocardial Infarction For Primary Percutaneous Coronary Intervention During Ordinary & Pandemic Times Position Statement Of The Saudi Arabian Cardiac Intervention Society, Shukri M. Al Saif, Owayed Al Shammeri, Abdullah Alkhushail, Ramzi Almohammadi, Mohamed Kurdi

Journal of the Saudi Heart Association

Primary percutaneous coronary intervention is the most effective therapy in the management of acute ST Elevation Myocardial Infarction. Evidence recommends keeping the period from symptom onset to reperfusion to a minimum in order to preserve left ventricular function, improve outcome, and reduce mortality. The position statement describes the recommendations of the the Saudi Arabian Cardiac Intervention Society for optimal conditions and timing for the acute management of patients presenting with ST Elevation Myocardial Infarction during ordinary and pandemic times.

Pulling Heart Strings: Quality Improvement Algorithm For Temporary Epicardial Pacing Wire Removal Post Cardiac Surgery, Jessica Norman

Doctors of Nursing Practice (DNP) Final Projects, 2020-current

The placement of temporary epicardial pacing wires (TEPW) is considered standard practice post cardiac surgery and is dependent on the patient’s cardiac function intra-operatively and their electrophysiologic profile after weaning from cardiopulmonary bypass (Reade, 2007; Elmistekawy et al, 2016). Complications associated with TEPW removal include myocardial damage, infection, perforation, tamponade, disruption of anastomoses, ventricular arrythmias, and death (Bojar, 2009; Carroll et al, 1998;Timothy & Rodeman, 2004). Currently there is no standard practice on the removal of TEPW and there is wide variation in removal practices involving patients who are routinely on medications such as dual antiplatelet therapies and systemic anticoagulation. …

A Steroid Receptor Coactivator Stimulator (Mcb-613) Attenuates Adverse Remodeling After Myocardial Infarction, Lisa K Mullany, Aarti D Rohira, John P Leach, Jong H Kim, Tanner O Monroe, Andrea R Ortiz, Brittany Stork, M Waleed Gaber, Poonam Sarkar, Andrew G Sikora, Todd K Rosengart, Brian York, Yongcheng Song, Clifford C Dacso, David M Lonard, James F Martin, Bert W O'Malley

Faculty, Staff and Students Publications

Progressive remodeling of the heart, resulting in cardiomyocyte (CM) loss and increased inflammation, fibrosis, and a progressive decrease in cardiac function, are hallmarks of myocardial infarction (MI)-induced heart failure. We show that MCB-613, a potent small molecule stimulator of steroid receptor coactivators (SRCs) attenuates pathological remodeling post-MI. MCB-613 decreases infarct size, apoptosis, hypertrophy, and fibrosis while maintaining significant cardiac function. MCB-613, when given within hours post MI, induces lasting protection from adverse remodeling concomitant with: 1) inhibition of macrophage inflammatory signaling and interleukin 1 (IL-1) signaling, which attenuates the acute inflammatory response, 2) attenuation of fibroblast differentiation, and 3) promotion …

The Link Between Heart Disease In Low Socioeconomic Communities In America, Khristopher Chea

Nursing | Senior Theses

As a future medical professional in the healthcare field, we continue to see patients admitted for cardiovascular issues. Cardiovascular diseases (CVDs) remain the leading cause of mortality among adults living in the U.S. despite advances in treatment throughout the past century. A number of risk factors such as hypertension, obesity, smoking, and physical inactivity contribute to the significant rise of cardiovascular disease. Research data suggests that there is correlation between cardiovascular disease, low socioeconomic status, and diet. According to the American Phycological Association socioeconomic status is measured by income, educational status, and occupation, and has been shown to be closely …

Inferior St-Elevation Myocardial Infarction Presenting When Urgent Primary Percutaneous Coronary Intervention Is Unavailable: Should We Adhere To Current Guidelines?, Yochai Birnbaum, Glenn N Levine, John French, Juan Carlos Kaski, Dan Atar, Mahboob Alam, David Hasdai, Hani Jneid, Barry F Uretsky

Faculty, Staff and Students Publications

The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital …

Inferior St-Elevation Myocardial Infarction Presenting When Urgent Primary Percutaneous Coronary Intervention Is Unavailable: Should We Adhere To Current Guidelines?, Yochai Birnbaum, Glenn N Levine, John French, Juan Carlos Kaski, Dan Atar, Mahboob Alam, David Hasdai, Hani Jneid, Barry F Uretsky

Faculty, Staff and Students Publications

The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital …

The Cancer Patient And Cardiology, José Luis Zamorano, Christer Gottfridsson, Riccardo Asteggiano, Dan Atar, Lina Badimon, Jeroen J Bax, Daniela Cardinale, Antonella Cardone, Elizabeth A M Feijen, Péter Ferdinandy, Teresa López-Fernández, Chris P Gale, John H Maduro, Javid Moslehi, Torbjørn Omland, Juan Carlos Plana Gomez, Jessica Scott, Thomas M Suter, Giorgio Minotti

Faculty, Staff and Students Publications

Advances in cancer treatments have improved clinical outcomes, leading to an increasing population of cancer survivors. However, this success is associated with high rates of short- and long-term cardiovascular (CV) toxicities. The number and variety of cancer drugs and CV toxicity types make long-term care a complex undertaking. This requires a multidisciplinary approach that includes expertise in oncology, cardiology and other related specialties, and has led to the development of the cardio-oncology subspecialty. This paper aims to provide an overview of the main adverse events, risk assessment and risk mitigation strategies, early diagnosis, medical and complementary strategies for prevention and …

Multivessel Traumatic Coronary Artery Dissection After A Motor Vehicle Accident With Successful Percutaneous Coronary Intervention, Yagya Pandey, Brittany Owen, Gilad Birnbaum, Rashed Tabbaa, Ihab Hamzeh, Nasser Lakkis, Waleed Kayani

Faculty, Staff and Students Publications

Coronary artery dissection is a rare complication of blunt chest wall trauma. We report a case of acute left anterior descending and right coronary artery dissections after a motor vehicle accident. The musculoskeletal injuries obscured the cardiac symptoms. Electrocardiogram and bedside echocardiogram revealed cardiac pathology, which prompted urgent coronary angiography and intervention. (Level of Difficulty: Advanced.)

Nurse-Initiated Protocols For Chest Pain In The Emergency Department, Matthew Hodges

Student Scholarly Projects

Practice Problem: Emergency department crowding inhibits the ability to provide safe patient care to chest pain patients and negatively impact patient outcomes. A Veteran Affairs emergency department has identified a similar concern and implemented a nurse-initiated protocol to decrease the length of stay and improve patient outcomes.

PICOT: This evidence-based practice (EBP) project was guided by the following PICOT question: In the emergency department (ED), how does a nurse-initiated protocol (NIP) for chest pain (CP) patients compared to no protocol use influence length of stay (LOS) in the ED over 8 weeks?

Evidence: The reviewed literature supported the evidence of …

Long-Term Clinical Outcomes Of Percutaneous Coronary Intervention In Saphenous Vein Grafts In A Low To Middle-Income Country, Ghurfan Adnan, Intisar Ahmed, Javed Tai, Maria Ali Khan, Hammad Hasan

Section of Cardiology

Background: Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization.
Purpose: We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country.
Methods: In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events.
Results: The mean age was 71 ±9, and 81% were male. The most common reason …

Managing May-Thurner Syndrome And Associated Complications Throughout Pregnancy And Postpartum, Jessica A. Young, Stephen Zweibach, Nicole L. Plenty, Tiffany Tonismae

OB-GYN

No abstract provided.

Implementing Trauma-Informed Care Early In The Lives Of Children And Adults, Carley Clymer

Scholars Week

Throughout the health care industry, providers are failing to recognize the implications that adverse childhood experiences (ACEs) have upon adult health. As a result, these patients not only have to endure these traumas, but they’re also faced with crippling health conditions that accompany them including depression, heart disease and obesity. The prevalence of common high-risk behaviors such as smoking, drinking and illicit drug use can also co-exist with adversity, which leads to an exacerbation of already poor health. This presentation aims to relay the significance of adopting a trauma informed care (TIC) approach early in the lives of clients to …

Telomere Length In Young Patients With Acute Myocardial Infarction Without Conventional Risk Factors: A Pilot Study From A South Asian Population, Mohit D. Gupta, Manjula Miglani, Ankit Bansal, Vardhmaan Jain, Sameer Arora, Sameer Kumar, Salim S. Virani, Ankur Kalra, Rakesh Yadav, Q Pasha

Office of the Provost

Background: There is need to identify novel markers that lead to an early occurrence of myocardial infarction (MI) in young South Asian population. This population has different risk profile as compared with others. Telomere length is known to be a marker of aging, and shorter telomeres have been reported in cardiovascular diseases (CVDs). We aimed to identify the association of telomere length in young nonsmokers and non-diabetic MI patients.
Methods: In a case-control study of 154 subjects (n = 77 cases (ages 18-45 years, non-diabetic, non-smoker patients with MI) and n = 77, age and sex matched healthy controls), DNA …

Comparison Of Figure Of Eight And Traditional Simple Wire Closure Method To Prevent Dehiscence After Sternal Closure, Aleezay Asghar, Khawaja Muhammad Talha, Muneer Amanullah, Syed Shahabuddin

Medical College Documents

Objective: To investigate significant differences, if any, between figure of-eight method and simple wire closure technique in reducing the incidence of infectious and non-infectious sternal dehiscence in patients undergoing sternal closure.
Methods: The systematic review was conducted in the Cardiothoracic Surgery Department at Aga Khan University from 1st December 2015 to 13th December 2017. The review was registered with PROSPERO, the International Prospective Register of Systematic Reviews. Pubmed, Cochrane Library (Wiley) and Scopus databases were searched for articles published up to December 13, 2017. The search was limited to randomised control trials, clinical trials, retrospective cohort studies, journal analyses, systematic …

Availability And Affordability Of Medicines And Cardiovascular Outcomes In 21 High-Income, Middle-Income And Low-Income Countries, Clara Kayei Chow, Tu Ngoc Nguyen, Simone Marschner, Rafael Diaz, Omar Rahman, Alvaro Avezum, Scott A. Lear, Koon Teo, Karen E. Yeates, Khawar Kazmi

Section of Cardiology

Objectives: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study.
Methods: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types …

Stroke Preventive In African American Women Ages 20-40 That Are Using Or Have Used Oral Contraceptives, Ashanti L. N. Coleman

Electronic Theses and Dissertations

This Doctor of Nursing Practice project will inform the audience of stroke awareness as it pertains to oral contraceptives. The study’s focus was to enhance the knowledge of African American women ages 20–40 that have used or are currently using an oral contraceptive. It has been identified that this patient population lacked the knowledge regarding stroke and oral contraceptives, and African American women continue to have the highest incidence of stroke. African American women also make up more than half of the consumers utilizing oral contraceptives. An oral contraceptive knowledge questionnaire was utilized from previous research to determine if any …