Medical Specialties Commons^™

Factors That Influence Advance Directives Completion Amongst Terminally Ill Patients At Akuhn, Stephen Omondi Otieno

Master of Medicine in Internal Medicine

Background: An advance directive is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves, and which is then used to guide decisions on life-sustaining treatment in the event that they become incapacitated. Advance directives can take one of four forms: a living will, a limitation of care document, a do-not-resuscitate order, and an appointment of a surrogate by durable power of attorney. The completion rate of advance directives varies from region to region, and it is influenced by different patient, caregiver, legal, institutional, cultural, and religious factors. …

Outcomes In Patients With Acute Coronary Syndromes At The Aga Khan University Hospital, Nairobi, Mohamed Hasham Varwani

Master of Medicine in Internal Medicine

Background: As the prevalence of cardiovascular diseases in Sub-Saharan Africa rises, coronary artery disease, with its acute presentations, is being increasingly recognized in Kenyans and treated at tertiary level hospitals. It is just over a decade since the introduction and wide availability of modern cardiology services, including interventional cardiology in Kenya. Following an acute coronary syndrome (ACS), patients remain at high risk of death and other adverse events such as heart failure, recurrent myocardial infarction, stroke, and bleeding. Local and regional data on long-term outcomes following ACS are lacking. These data are important to clinicians for prognostication and to health …

The Association Between Asymptomatic And Mild Neurocognitive Impairment And Adherence To Antiretroviral Therapy Amongst People Living With Hiv, Violet Maloba Awori

Master of Medicine in Internal Medicine

Background: HIV disease is associated with neurocognitive impairment which is one of the neurological complications of the viral infection. The spectrum of HIV Associated neurocognitive impairment has significantly changed since the advent of ART. The inclusion of the asymptomatic but cognitively impaired population of patients has changed the dynamics of this population, and requires further research to identify the impact it has on the progression of the disease as well as on any other aspects. Poor adherence to ART is one of the main causes of treatment failure and studies done previously point towards the milder forms of Neurocognitive Impairment …

Prevalence Of Bladder Dysfunction In Children With Primary Nocturnal Enuresis Presenting To The Hospital, Nikita Pravin Jethwa

Master of Medicine in Paediatrics and Child Health

Introduction: Bladder dysfunction is thought to be a common cause of nocturnal enuresis. It can either be overactive, underactive or dysfunctional. Currently, there is a paucity of data on what proportions of children with nocturnal enuresis have bladder dysfunction. Studies have shown the prevalence of bladder dysfunction to be as high as 77-94.5% (28), and children with bladder dysfunction have poor response to treatment. There are currently no protocols for investigating and managing children with nocturnal enuresis. The decision for bladder ultrasound is usually made by the primary physician, and at times after the child has been on treatment for …

Comparison Of Weight Adjusted Dose Versus Fixed Dose Ondansetron In Preventing Shivering Following Spinal Anesthesia For Cesarean Deliveries, Moses Kimuri Gicheru

Master of Medicine in Anaesthesiology

Background: Spinal anesthesia is an effective regional anesthesia technique, which is preferred in almost 86% of cesarean sections in the United States and United Kingdom. Eighty percent of cesarean sections done at the Aga Khan University hospital are under spinal anesthesia. Shivering is a common complication of spinal anesthesia, it occurs in 40%-64% of patients after neuraxial anesthesia. Shivering may cause maternal and fetal hypoxemia, maternal discomfort and a problem to the anesthesiologists when it comes to monitoring the patient during cesarean sections. Ondansetron a 5-HT3 receptor antagonist is effective in treatment and prevention of post spinal anesthesia shivering. In …

Effect Of Laryngeal Mask Airway Manometry On Post-Operative Sore Throat In Spontaneously Breathing Adult Patients Presenting For Surgery At Aga Khan University Hospital, Nairobi, David Njoroge Waruingi

Master of Medicine in Anaesthesiology

Background: Laryngeal mask airways (LMAs) are widely used in anaesthesia and are considered to be generally safe. Postoperative sore throat (POST) is a frequent complication following LMA use and can be very distressing to patients. The use of an LMA cuff pressure of between 30 and 32cm of H20 in alleviating postoperative sore throat has not been investigated. Primary objective: To compare the occurrence of POST between the intervention group in which LMA cuff pressures will be adjusted to 30-32cm of H20 and the control group in which only monitoring of LMA cuff pressures will be done. Secondary Objectives: To …

Effect Of Low-Dose Ketamine Versus Fentanyl On Attenuating The Haemodynamic Response To Laryngoscopy And Endotracheal Intubation In Patients Undergoing General Anaesthesia At The Aga Khan University Hospital, Nairobi, Angela Ongewe

Master of Medicine in Anaesthesiology

Background: The use of drugs to attenuate the haemodynamic response to laryngoscopy and endotracheal intubation is the standard of care during elective surgery. Current evidence is conflicting concerning the best agent and optimal dose for this purpose. In the majority of cases, Fentanyl is widely utilized to attenuate haemodynamic responses. Ketamine, an established available drug, has been scarcely studied in this regard at low doses and against varying doses of other common agents. Objective: The primary objective was to compare the overall occurrence of hypertension and tachycardia immediately pre-intubation (post-induction) until 10 minutes post intubation between the study group receiving …

Risk Factors, Clinico-Pathologic Characteristics And Outcomes In Young Kenyan Female Patients With Breast Cancer In Akuh-N, Gilford Mutwiri Mwikamba

Master of Medicine in Internal Medicine

Background: Breast cancer in the young refers to a diagnosis of breast cancer in a female under the age of forty years. This is considered a distinct disease with different risk factors, biology, and prognosis. Young age at breast cancer diagnosis is reportedly more common among African-Americans. The highest proportion of breast cancer in the young has been reported in Africa. Early detection of breast cancer in Africa is hampered by lack of access to health care services, appropriate screening tools, and high cost of magnetic resonance imaging for the high risk groups. Despite a worse prognosis, management of breast …

Maternal Inflammatory Markers In The Diagnosis Of Chorioamnionitis And Prediction Of Neonatal Sepsis In Preterm Pre-Labour Rupture Of Membranes: A Systematic Review, Angela Koech Etyang

Master of Medicine in Obstetrics and Gynecology

Background: There is no consensus on the potential role of inflammatory markers in identifying chorioamnionitis in women with Preterm Pre-labour Rupture of Membranes (PPROM) or in predicting Early Onset Neonatal Sepsis (EONS) in their neonates. Objectives: To perform a quantitative review on the accuracy of maternal C reactive protein (CRP), Procalcitonin (PCT) and Interleukin 6 (IL6) in the diagnosis of Histological Chorioamnionitis and/or Funisitis (HCA/Funisitis) and their role in the prediction of EONS in PPROM. Methods: MEDLINE, EMBASE and The Cochrane Library databases were searched from inception to October 2015, for studies where these markers were assessed against a reference …

Cerebral Aspergillosis And Pulmonary Tuberculosis In A Child With Chronic Granulomatous Disease, Muhammad Waqas, Sidra Zafar, Tooba Rehman, Muhammed Riyaz, Muhammad Ehsan Bari, Romana Idress

Section of Neurosurgery

Background: Chronic granulomatous disease (CGD) is an immune disorder that affects phagocytes. It is characterized by recurrent or persistent bacterial and fungal infections. Reports of tuberculosis (TB) in patients with CGD are rare. In developing countries, where TB is endemic, possibility of other chronic infections is often overlooked by physicians.
Case description: We report the case of a 4-year-old boy who had recurrent respiratory infections and episodes of headache. He was put on antituberculosis (ATT) drugs without microbiological or pathological evidence 2 months prior to presentation. The child did not improve and was brought to our hospital where a computed …

Residents’ Perception On The Need For Clinical Leadership Training At The Aga Khan University, Nairobi, Lance Mayabi

Master of Medicine in General Surgery

Background:The healthcare environment is becoming increasingly complex with physicians undertaking more leadership roles. The majority of physicians are not prepared to take up these roles, despite evolving evidence that good clinical leadership yields better clinical outcomes for both patients and healthcare organizations. Further, few residency programs explicitly embed leadership training for their students despite their positions at the forefront of healthcare delivery. This deficit ultimately leaves a multilevel healthcare “leadership” gap in a sector that depends heavily on the education process to improve clinical outcomes. A pre-study survey of residency graduates at the Aga Khan University, Nairobi (AKU,N) undertaken by …

Effect Of Additional Lumbosacral Corset On The Outcome Of Patients With Non-Specific Acute Low Back Pain At The Aga Khan University Hospital, Nairobi, Stanley Aruyaru Mwenda

Master of Medicine in General Surgery

Introduction: Low back pain (LBP) is a common problem world over affecting 60-90% of the population in their lifetime. It is a leading reason for hospital admission, healthcare spending, workplace absenteeism and years lived with disability. Up to 90% of patients suffering from low back pain do not have a serious pathology warranting imaging or further intervention besides symptom relief. These are categorized as having non- specific low back pain. This has a good prognosis running a short course of 3 to 6 weeks. The management of non-specific acute LBP entails analgesia and non-pharmacologic interventions (back school and physical therapy). …

Prevalence Of Hepatic Steatosis As Diagnosed On Unenhanced Abdominal Ct, Naushad H. Karim Sokwalla

Master of Medicine in Imaging and Diagnostic Radiology

Background: Hepatic steatosis is the accumulation of triglycerides within hepatocytes. It may be broadly classified into alcoholic and non-alcoholic fatty liver disease, whereby non-alcoholic fatty liver disease is steatosis secondary to causes such as steatogenic medication. Liver biopsy remains the gold standard for diagnosis of hepatic steatosis. However, it is invasive and may potentially suffer from sampling errors. Hepatic steatosis may be diagnosed on unenhanced CT if the hepatic attenuation is less than 40 HU, or if the attenuation of the liver is at least 10 HU less than the spleen. Over the past three decades, non-alcoholic fatty liver disease …

A Survey And Analysis Of The American Public's Perceptions And Knowledge About Antibiotic Resistance, Rebecca R. Carter, Jiayang Sun, Robin L.P. Jump

Faculty Scholarship

Background. Little is known about the American public's perceptions or knowledge about antibiotic-resistant bacteria or antibiotic misuse. We hypothesized that although many people recognize antibiotic resistance as a problem, they may not understand the relationship between antibiotic consumption and selection of resistant bacteria. Methods. We developed and tested a survey asking respondents about their perceptions and knowledge regarding appropriate antibiotic use. Respondents were recruited with the Amazon Mechanical Turk crowdsourcing platform. The survey, carefully designed to assess a crowd-sourced population, asked respondents to explain "antibiotic resistance" in their own words. Subsequent questions were multiple choice. Results. Of 215 respondents, the …

Mitochondria Mediates Caspase-Dependent And Independent Retinal Cell Death In Staphylococcus Aureus Endophthalmitis, Pawan K. Singh, Ashok Kumar

Ophthalmology Faculty Research Publications

Bacterial endophthalmitis, a vision-threatening complication of ocular surgery or trauma, is characterized by increased intraocular inflammation and retinal tissue damage. Although significant vision loss in endophthalmitis has been linked to retinal cell death, the underlying mechanisms of cell death remain elusive. In this study, using a mouse model of Staphylococcus aureus endophthalmitis and cultured human retinal Müller glia (MIO-M1 cell line), we demonstrate that S. aureus caused significant apoptotic cell death in the mouse retina and Müller glia, as evidenced by increased number of terminal dUTP nick end labeling and Annexin V and propidium iodide-positive cells. Immunohistochemistry and western blot …

Severity And Clustering Of Menopausal Symptoms Among Obese And Nonobese Postmenopausal Women In India, E. S. Sharanya Shre, Kate Trout, Sonia Pant Singh, Awnish Kumar Singh, Surapaneni Krishna Mohan, Ashish Joshi

Publications and Research

Background: The symptoms of menopause have a negative impact on quality of life, especially in women transitioning to menopause and earlier transitions. This study was conducted with the objective of assessing the effect of obesity on the severity of menopausal symptoms and the clustering of symptoms in postmenopausal women in India.

Methodology: The Menopausal Rating Scale (MRS) was used to assess the severity of menopausal symptoms of postmenopausal women of Chennai, visiting Saveetha Medical College, Chennai, India. This cross‑sectional study was conducted from August to November 2013 in Chennai, India. Sociodemographic characteristics, anthropometric measurements, blood pressure level, menopausal history, personal …

The Frequency Of Influenza And Bacterial Co-Infection: A Systematic Review And Meta-Analysis., Eili Y. Klein, Bradley Monteforte, Alisha Gupta, Wendi Jiang, Larissa May, Yu-Hsiang Hsieh, Andrea Freyer Dugas

Emergency Medicine Faculty Publications

AIM: Co-infecting bacterial pathogens are a major cause of morbidity and mortality in influenza. However, there remains a paucity of literature on the magnitude of co-infection in influenza patients.

METHOD: A systematic search of MeSH, Cochrane Library, Web of Science, SCOPUS, EMBASE, and PubMed was performed. Studies of humans in which all individuals had laboratory confirmed influenza, and all individuals were tested for an array of common bacterial species, met inclusion criteria.

RESULTS: Twenty-seven studies including 3,215 participants met all inclusion criteria. Common etiologies were defined from a subset of eight articles. There was high heterogeneity in the results (I(2) …

Surgical Apgar Score (Sas) Predicts Perioperative Morbidity And Length Of Stay In Patients Undergoing Esophagectomy At A High-Volume Center, Danica Giugliano, Md, Andrew Morgan, Francesco Palazzo, Md, Nathaniel R. Evans Iii, M.D., Ernest L Rosato, Md, Adam C. Berger, Md, Benjamin E Leiby, Phd

Department of Surgery Posters

Background:

Esophagectomy is a procedure that carries considerable morbidity. Many studies have evaluated factors to predict patients at risk and improve clinical outcomes. The aim of this study was to determine whether the SAS predicts complications, length of stay, and anastomotic leak for patients undergoing esophagectomy at a high-volume institution.

Use Of Antenatal Corticosteroids At Health Facilities And Communities In Low-And-Middle Income Countries., Mabel Berrueta, Jennifer Hemingway-Foday, Vanessa R. Thorsten, Robert L. Goldenberg, Waldemar A. Carlo, Ana Garces, Archana Patel, Sarah Saleem, Omrana Pasha, Elwyn Chomba, Patricia L. Hibberd, Nancy F. Krebs, Shivaprasad Goudar, Richard J. Derman, Fabian Esamai, Edward A. Liechty, Janet L. Moore, Elizabeth M. Mcclure, Marion Koso-Thomas, Pierre M. Buekens, José M. Belizán, Fernando Althabe

Community Health Sciences

BACKGROUND:

Antenatal corticosteroids (ACS) for women at high risk of preterm birth is an effective intervention to reduce neonatal mortality among preterm babies delivered in hospital settings, but has not been widely used in low-middle resource settings. We sought to assess the rates of ACS use at all levels of health care in low and middle income countries (LMIC).

METHODS:

We assessed rates of ACS in 7 sites in 6 LMIC participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Global Network for Women and Children's Health Research Antenatal Corticosteroids Trial (ACT), a cluster-randomized trial …

Induction Process Of Trainees In Pathology Residency, Imran Siddiqui, Natasha Bahadur Ali

Department of Pathology and Laboratory Medicine

This article describes the evolution of the induction process of pathology residency at The Aga Khan University hospital. The Department of Postgraduate Medical Education was established in 1985. The induction process is an exhaustive exercise that includes an admission test held simultaneously in Karachi, Hyderabad, Lahore, and Rawalpindi, followed by an interview of the shortlisted candidates. The pathology residency program was started 25 years ago and since then the induction process has undergone major changes with the course of time.

Rare Case Of Metastatic Pituitary Disease, Anitha Somasundaram, Md, Kevin D. Judy, Md, Kevin Furlong, Do

Department of Neurosurgery Posters

Background:

Metastatic involvement of the pituitary gland is extremely rare. We present a case of metastatic pituitary disease with panhypopituitarism and diabetes insipidus.

Association Of 24-32wk Maternal Triglyceride Levels And Neonatal Birth Weight At The Aga Khan University Hospital, Demetrius Mududa Omondi

Master of Medicine in Obstetrics and Gynecology

Introduction: The association of neonatal birth weight and mid-term maternal lipid levels has been demonstrated in several studies with elevated serum triglyceride levels shown to be a strong predictor of the large for gestational age baby/ fetal macrosomia. Maternal diabetes remains the strongest risk factor for developing a LGA/macrosomic baby explained by the Pederson hypothesis. However non-diabetic macrosomia is still an obstetric dilemma with the attendant fetal and maternal complications. This phenomenon could be explained by altered maternal lipid metabolism as lipids have been shown to be important for normal fetal growth and development. Objective: Our primary objective was to …

Elevated Mtss1 Expression Associated With Metastasis And Poor Prognosis Of Residual Hepatitis B-Related Hepatocellular Carcinoma, Xiu-Yan Huang, Zi-Li Huang, Bin Xu, Zi Chen

Dartmouth Scholarship

Background: Hepatectomy generally offers the best chance of long-term survival for patients with hepatocellular carcinoma (HCC). Many studies have shown that hepatectomy accelerates tumor metastasis, but the mechanism remains unclear.

Methods: An orthotopic nude mice model with palliative HCC hepatectomy was performed in this study. Metastasis-related genes in tumor following resection were screened; HCC invasion, metastasis, and some molecular alterations were examined in vivo and in vitro. Clinical significance of key gene mRNA expression was also analyzed.

Management Considerations Of Massive Hemoptysis While On Extracorporeal Membrane Oxygenation., Harrsion T. Pitcher, Meredith A. Harrison, Colette Shaw, Scott W. Cowan, Hitoshi Hirose, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously.

METHODS: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, …

Myocardial Infarction In Neonatal Mice, A Model Of Cardiac Regeneration, Jessica N. Blom, Xiangru Lu, Paul Arnold, Qingping Feng

Paediatrics Publications

Myocardial infarction induced by coronary artery ligation has been used in many animal models as a tool to study the mechanisms of cardiac repair and regeneration, and to define new targets for therapeutics. For decades, models of complete heart regeneration existed in amphibians and fish, but a mammalian counterpart was not available. The recent discovery of a postnatal window during which mice possess regenerative capabilities has led to the establishment of a mammalian model of cardiac regeneration. A surgical model of mammalian cardiac regeneration in the neonatal mouse is presented herein. Briefly, postnatal day 1 (P1) mice are anesthetized by …

Dual Kidney Allocation Score: A Novel Algorithm Utilizing Expanded Donor Criteria For The Allocation Of Dual Kidneys In Adults, Jill N. D'Souza, Md, Katherine Mckee-Cole, Md, Abigail Strang, Md, Patrick Barth, Md, Aaron Chidekel, Md, Udayan Shah, Md

Department of Otolaryngology - Head and Neck Surgery Posters

Abstract:

Objective The recognition of wound-related complications following pediatric tracheotomy is on the rise. These complications can have a significant impact on clinical course as well as on hospital healthcare costs to the tracheotomy dependent child and family

Methods A tracheotomy database was created in 2000 and reviewed for incidence of major and minor complications.

Setting Tertiary Care Pediatric Referral Center

Results We identified a post-tracheotomy complication rate of 19.9%, of which the most common complication was wound breakdown (65% of complications).

Conclusion Rate of post-tracheotomy wound-care complications is 12.9%. Wound description is subjective and prone to inter-observer variability. A …

Expression And Function Of Pannexins In The Inner Ear And Hearing, Hong-Bo Zhao

Otolaryngology--Head & Neck Surgery Faculty Publications

Pannexin (Panx) is a gene family encoding gap junction proteins in vertebrates. So far, three isoforms (Panx1, 2 and 3) have been identified. All of three Panx isoforms express in the cochlea with distinct expression patterns. Panx1 expresses in the cochlea extensively, including the spiral limbus, the organ of Corti, and the cochlear lateral wall, whereas Panx2 and Panx3 restrict to the basal cells of the stria vascularis in the lateral wall and the cochlear bony structure, respectively. However, there is no pannexin expression in auditory sensory hair cells. Recent studies demonstrated that like connexin gap junction gene, Panx1 deficiency …

Cancer Stem Cell Metabolism., Maria Peiris-Pagès, Ubaldo E. Martinez-Outshoorn, Richard G. Pestell, Federica Sotgia, Michael P Lisanti

Kimmel Cancer Center Papers, Presentations, and Grand Rounds

Cancer is now viewed as a stem cell disease. There is still no consensus on the metabolic characteristics of cancer stem cells, with several studies indicating that they are mainly glycolytic and others pointing instead to mitochondrial metabolism as their principal source of energy. Cancer stem cells also seem to adapt their metabolism to microenvironmental changes by conveniently shifting energy production from one pathway to another, or by acquiring intermediate metabolic phenotypes. Determining the role of cancer stem cell metabolism in carcinogenesis has become a major focus in cancer research, and substantial efforts are conducted towards discovering clinical targets.

The Antenatal Corticosteroids Trial (Act)'S Explanations For Neonatal Mortality - A Secondary Analysis., Fernando Althabe, Vanessa Thorsten, Karen Klein, Elizabeth M. Mcclure, Patricia L. Hibberd, Robert L. Goldenberg, Waldemar A. Carlo, Ana Garces, Archana Patel, Omrana Pasha, Elwyn Chomba, Nancy F. Krebs, Shivaprasad Goudar, Richard J. Derman, Fabian Esamai, Edward A. Liechty, Nellie I. Hansen, Sreelatha Meleth, Dennis D. Wallace, Marion Koso-Thomas, Alan H. Jobe, Pierre M. Buekens, José M. Belizán

Community Health Sciences

BACKGROUND:

The Antenatal Corticosteroid Trial assessed the feasibility, effectiveness, and safety of a multifaceted intervention to increase the use of antenatal corticosteroids (ACS) in mothers at risk of preterm birth at all levels of care in low and middle-income countries. The intervention effectively increased the use of ACS but was associated with an overall increase in neonatal deaths. We aimed to explore plausible pathways through which this intervention increased neonatal mortality.

METHODS:

We conducted a series of secondary analyses to assess whether ACS or other components of the multifaceted intervention that might have affected the quality of care contributed to …

Serratia Fonticola, Pathogen Or Bystander? A Case Series And Review Of The Literature, Roberto Viau, Robin L.P. Jump

Faculty Scholarship

Serratia fonticola is an unusual human pathogen, previously described primarily as causing skin and soft tissue infections following trauma. There is little information in the literature about its treatment or susceptibilities. We describe the case of a 67-year-old male with paraplegia who developed urosepsis due to S. fonticola. Blood and urine cultures obtained prior to the initiation of antimicrobials both grew S. fonticola. The patient completed a 15-day course of antimicrobials and had an uneventful recovery.We reviewed 17 other patients with clinical cultures positive for S. fonticola. Of these, 11 isolates were from the genitourinary system, most often as part …