Pulmonology Commons^™

The Utility Of The Pap Nap For Increasing Patient Utilization Of Positive Airway Pressure Therapy, Erin Creighton, Md, Nicole Molin, Md, Dimitri Markov, Md, Ritu Grewal, Md

Health Equity and Quality Improvement (HEQI) Summit

Background

Problem Statement:

• An estimated 9-38% of adults have obstructive sleep apnea (OSA), and about 80% is undiagnosed.
• OSA has been linked to excessive sleepiness, neurocognitive impairments, reduced quality of life, diabetes, heart disease, stroke, hypertension, and motor vehicle and workplace accidents
• Approximately85% of people with diagnosed OSA receive PAP and only 35-60% remain compliant long term
• Many factors impact CPAP use: disease and patient characteristics, titration procedures, device factors, side effects, psychological and social factors

Project AIM: Evaluate whether a daytime, abbreviated cardio-respiratory sleep study (AKA the PAP NAP -developed to help improve adherence in patients with OSA and …

Pleural Epithelioid Hemangioendothelioma: An Ultra Rare Etiology For Recurrent Pleural Effusion, Ali Khreisat, Paul Bozyk

Conference Presentation Abstracts

Introduction Epithelioid hemangioendothelioma (EHE) is an extremely rare sarcoma of vascular origin. EHE has an incidence of less than 0.1 per 100,000 patients per year. It can involve multiple organs; pleural involvement is relatively rare and under-reported in the medical literature. We present a unique case of pleural EHE presenting with recurrent pleural effusion, severe pleuritis, scarring, and trapped lung syndrome. Case presentation A 54-year-old Caucasian female was referred to the pulmonary clinic for two months of progressive dyspnea, fatigue, and right pleuritic chest pain. Initial chest x-ray showed a large right pleural effusion. Thoracentesis identified exudative lymphocyte predominant pleural …

Case Report: Post-Obstructive Pneumonia Secondary To Foreign Body Aspiration, Aashna Chaudhry, Andrew Vasta

Rowan-Virtua Research Day

Post-obstructive pneumonia is described as a pulmonary infiltrate that occurs proximal to the site of an obstructed bronchus. Studies show that post-obstructive pneumonia most commonly secondary to obstruction caused by neoplasms. According to a study done on post obstructive pneumonia in lung cancer, most cases of post obstructive pneumonias are associated with advanced neoplasms with up to 50% of those with advanced cancer getting endobronchial compromise. While neoplasms are the most common cause of post obstructive pneumonia, research is scarce on other potential causes of post obstructive pneumonia. This case reports presents a unique clinical case in which an adult …

Issue 8: Pulmonary & Critical Care Insider, Bharat Bajantri Md, Sarah Ellsworth-Hoffman Mls, Caterina Elliott Np, Pa, Donna Cota Md

Critical Care & Pulmonary

Pulmonary & Critical Care Insider Issue 8

Compiled by Bharat Bajantri, MD, and librarian Sarah Ellsworth, MLS for the clinicians of the Pulmonary and Critical Care team of Parkview.

The Pulmonary & Critical Care Insider newsletter was created by Dr. Bharat Bajantri, MD and Sarah Ellsworth, MLS in 2023 as a form of current awareness for current practice at our hospital, Parkview Health. The content resides within critical care and pulmonary related topics and this information is compiled into four main formats.

1. Original Study Summaries: New research publications are read, reviewed, then concisely summarized for clinical interpretation with professional …

Age At Lung Cancer Diagnosis In Females Versus Males Who Never Smoke By Race And Ethnicity, Batel Blechter, Jason Y Y Wong, Li-Hsin Chien, Kouya Shiraishi, Xiao-Ou Shu, Qiuyin Cai, Wei Zheng, Bu-Tian Ji, Wei Hu, Mohammad L Rahman, Hsin-Fang Jiang, Fang-Yu Tsai, Wen-Yi Huang, Yu-Tang Gao, Xijing Han, Mark D Steinwandel, Gong Yang, Yihe G Daida, Su-Ying Liang, Scarlett L Gomez, Mindy C Derouen, W Ryan Diver, Ananya G Reddy, Alpa V Patel, Loïc Le Marchand, Christopher Haiman, Takashi Kohno, Iona Cheng, I-Shou Chang, Chao Agnes Hsiung, Nathaniel Rothman, Qing Lan

Faculty, Staff and Student Publications

BACKGROUND: We characterized age at diagnosis and estimated sex differences for lung cancer and its histological subtypes among individuals who never smoke.

METHODS: We analyzed the distribution of age at lung cancer diagnosis in 33,793 individuals across 8 cohort studies and two national registries from East Asia, the United States (US) and the United Kingdom (UK). Student's t-tests were used to assess the study population differences (Δ years) in age at diagnosis comparing females and males who never smoke across subgroups defined by race/ethnicity, geographic location, and histological subtypes.

RESULTS: We found that among Chinese individuals diagnosed with lung cancer …

Clinical Differences In Isolated Post-Capillary Pulmonary Hypertension And Combined Pre- And Postcapillary Pulmonary Hypertension, Emily Schneider, Bhavinkumar D. Dalal

Posters

PULMONARY HYPERTENSION (PH) = RESTING MEAN PULMONARY ARTERY PRESSURE (MPAP) > 20 MMHG.

The World Health Organization recognizes five groups of pulmonary hypertensions:

• • Estimated that > 50% of patients with left heart disease are also affected by pulmonary hypertension.1
• 1 in 4 Americans will develop heart failure in their lifetime.
• Gold standard for diagnosis of PH is a right heart catheterization (RHC).3
• Global burden of PH remains unknown as this illness is poorly surveilled and cases remain underestimated.4,5

Pulmonary Embolism In Pregnancy And Early Postpartum – Identifying Significant Variables To Improve Risk Stratification, Nida Haider, Bhavinkumar Dalal

Posters

• Pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is one of the leading causes of maternal deaths in developed countries1
• The causative Virchow triad (venous stasis, endothelial injury, and hypercoagulable state) is enhanced in pregnancy making pregnancy an independent risk factor1
• Due to significant overlap between normal physiological changes in pregnancy and clinical symptoms of PE, the threshold for CTPA, confirmatory imaging for PE with potentially harmful effects due to ionizing radiation, is low with increasing incidence of false positives2

Understanding Infectious Disease Consultation Role For Septic Patients In The Medical Intensive Care Unit, Marisa Stratelak, Cloe Nazeer, Bhavinkumar Dalal

Posters

• Sepsis is a medical emergency requiring immediate recognition and prompt treatment.
• 1 in every 3 hospitalized patients who die have sepsis1.
• The mortality rate for patients with severe sepsis in the intensive care unit (ICU) is 32.2%2.
• Early intervention with fluid resuscitation and intravenous antibiotics can reduce mortality rates by 7-9%3.
• Infectious disease (ID) consultation on antimicrobial therapy in the ICU is associated with reduced ICU mortality and ICU length of stay (LOS)4.
• Gaps in literature exist regarding frequency of ID consultation for septic patients in the ICU, including comparing outcomes of patients with and without ID consultation.
• It is …

The American Thoracic Society Research Program: Twenty Years Of Driving Discovery In Respiratory Medicine, Kamran Atabai, M. Safwan Badr, Jack Costello, Karen Ridge, Sharon Rounds, Michelle Turenne, Eric White, Jesse Roman

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

No abstract provided.

Safety And Efficacy Of Ivacaftor In Infants Aged 1 To Less Than 4 Months With Cystic Fibrosis., Paul Mcnally, Alvin Singh, Susanna A. Mccolley, Jane C. Davies, Mark Higgins, Meng Liu, Jennifer Lu, Violeta Rodriguez-Romero, Judy L. Shih, Margaret Rosenfeld, Vx15-770-124 Study Group

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Ivacaftor (IVA) has been shown to be safe and efficacious in children aged ≥4 months with cystic fibrosis (CF) and CFTR gating variants. We evaluated safety, pharmacokinetics (PK), and efficacy of IVA in a small cohort of infants aged 1 toCF.

METHODS: In this phase 3, open-label study, infants 1 toinfants, doses were adjusted at day 15 to better match median adult exposures based on individual PK measurements taken on day 4. Primary endpoints were safety and PK measurements.

RESULTS: Seven infants (residual function CFTR variants [n=5]; minimal function CFTR variants [n=2]) received ≥1 dose of IVA. Six infants …

Pulmonary Endobronchial Hamartoma Presenting With Post-Obstructive Pneumonia, Diane S Habib, Pushan Jani, Bihong Zhao, Elakiya Anjali Jayaraman, Ramesh Kesavan

Faculty, Staff and Student Publications

Pulmonary hamartomas (PH) are rare but are the most common benign tumors found in the lungs. They are slow-growing and are usually found incidentally on chest imaging during the sixth decade of life. Approximately 10% of pulmonary hamartomas are endobronchial. Rarely, pulmonary hamartomas can cause a spectrum of pulmonary symptoms depending on their size and location. We present a case of endobronchial hamartoma causing airway obstruction and recurrent post-obstructive pneumonia.

Proteomic Biomarkers Of Quantitative Interstitial Abnormalities In Copdgene And Cardia Lung Study, Bina Choi, Gabrielle Y Liu, Quanhu Sheng, Kaushik Amancherla, Andrew Perry, Xiaoning Huang, Ruben San José Estépar, Samuel Y Ash, Weihua Guan, David R Jacobs, Fernando J Martinez, Ivan O Rosas, Russell P Bowler, Jonathan A Kropski, Nicholas E Banovich, Sadiya S Khan, Raúl San José Estépar, Ravi Shah, Bharat Thyagarajan, Ravi Kalhan, George R Washko

Faculty, Staff and Students Publications

Rationale: Quantitative interstitial abnormalities (QIAs) are early measures of lung injury automatically detected on chest computed tomography scans. QIAs are associated with impaired respiratory health and share features with advanced lung diseases, but their biological underpinnings are not well understood. Objectives: To identify novel protein biomarkers of QIAs using high-throughput plasma proteomic panels within two multicenter cohorts.

Methods: We measured the plasma proteomics of 4,383 participants in an older, ever-smoker cohort (COPDGene [Genetic Epidemiology of Chronic Obstructive Pulmonary Disease]) and 2,925 participants in a younger population cohort (CARDIA [Coronary Artery Disease Risk in Young Adults]) using the SomaLogic SomaScan assays. …

Evaluating The Association Of Influenza Vaccination On Long-Term Covid-19 Symptoms In U.S. Adults, Ratnakar Pingili

Capstone Experience: Master of Public Health

Objective. To evaluate the association of influenza vaccination in the past 12 months with Long COVID effects and clinical and sociodemographic factors.

Methods. Cross-sectional study with data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), covering 415,132 non-institutionalized U.S. adults with a confirmed COVID-19 diagnosis and influenza vaccination reported within the last 12 months. Logistic regression was conducted between influenza vaccination (exposure) and Long COVID (outcome), controlling for demographic variables, pre-existing health conditions, and socioeconomic status.

Results. Of 120,603 participants, 21.89% reported Long COVID symptoms and 42.04% had received an influenza vaccine. Findings indicate a statistically significant 13% reduction …

Educating Nurses On Frequent Oral Care For Mechanically Ventilated Patients: An Evidence-Based Practice Project Proposal, Grace Alford, Susan Butz, Ruth Chavez, Joy Shoemaker

Doctor of Nursing Practice Scholarly Projects

The final scholarly project proposal is to implement oral care education for nurses in an intensive care unit (ICU). The proposal aims to create a guideline for an investigator to implement oral care recommendations for mechanically ventilated patients in order to reduce ventilator-associated pneumonia (VAP). The proposal consists of obtaining VAP data and oral care charting data for the unit studied, steps for providing oral care education, and analysis recommendations. Oral care involves swabbing the patient’s mouth every two hours with a swab and mouthwash. Oral care education would include handouts and direct teaching. The proposal aims to increase oral …

Educating Nurses On Frequent Oral Care For Mechanically Ventilated Patients: An Evidence-Based Practice Project Proposal, Grace Alford, Susan Butz, Ruth Chavez, Joy Shoemaker

Doctor of Nursing Practice Scholarly Projects

The final scholarly project proposal is to implement oral care education for nurses in an intensive care unit (ICU). The proposal aims to create a guideline for an investigator to implement oral care recommendations for mechanically ventilated patients in order to reduce ventilator-associated pneumonia (VAP). The proposal consists of obtaining VAP data and oral care charting data for the unit studied, steps for providing oral care education, and analysis recommendations. Oral care involves swabbing the patient’s mouth every two hours with a swab and mouthwash. Oral care education would include handouts and direct teaching. The proposal aims to increase oral …

Perspectives From Patients With Chronic Lung Disease On A Telehealth-Facilitated Integrated Palliative Care Model: A Qualitative Content Analysis Study, Jeannette Kates, Carrie Tompkins Stricker, Kristin L. Rising, Alexzandra Gentsch, Ellen Solomon, Victoria Powers, Venise J. Salcedo, Brooke Worster

Department of Medicine Faculty Papers

BACKGROUND: Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS: For this qualitative …

Latent Tb Treatment Regimens In 2023: Wetmore Tb Clinic In New Orleans, Amy Wolfe, Priyanka Jadhav, Amber May, Shandrica Seymour, Angela Blanchard, Juzar Ali

School of Medicine Faculty Publications

The USPSTF has updated Latent TB Infection (LTBI) screening and treatment recommendations in 2023; describing treatment courses, side effects and benefits associated with each regimen. Overall, rifampin-containing shortened regimens are the preferred modality for LTBI treatment. A recent study in 2023 evaluated adherence and tolerance of the isoniazid(INH) + rifapentine(RPT), or “3HP” regimen and identified patient groups that may be at higher risk for non-completion of this regimen. It emphasized the need for targeted education at the beginning of treatment, to avoid early discontinuation. Our experience in New Orleans demonstrated that the 3HP is well-tolerated, with higher completion rates than …

Clearing The Air: Innovations In Imaging For Early Detection And Management Of Chronic Obstructive Pulmonary Disease, Francesca Polverino

Faculty, Staff and Students Publications

No abstract provided.

Hiding In Plain Sight; Dermatologic Manifestation Of A Systemic Disease, Christopher Ignatz, David Young Do, Brian Chwiecko Md

Tower Health Research Day

No abstract provided.

A Rare Case Of Anti-Mda5 Associated Progressive Interstitial Lung Diseases Without Classical Features Of Dermatomyositis., Nimesh Khanal Md, Ayushma Acharya Md, Bharosha Bhattarai Mbbs, Devi Parvathy Jyothi Ramachandran Nair Md, Peter Daniel Nicholas Iii Do

Tower Health Research Day

No abstract provided.

Understanding Patient-Reported Outcome Measures Used In Adult Survivors Experiencing Long-Term Effects After Covid-19 Infection: A Rapid Review, Egle Barilaite, Harry Watson, Mevhibe B. Hocaoglu

Journal of Patient-Centered Research and Reviews

Purpose

Patient-reported outcome measures (PROMs) are used in individuals experiencing long-term effects from COVID-19 infection, or Long COVID, to evaluate the quality of life and functional status of these individuals. However, little is known about which PROMs are being utilised and the psychometric properties of these PROMs. Our purpose was thus to explore which PROMs are used in Long COVID patients and to discuss the psychometric properties of the PROMs.

Methods

For this rapid review, a systematic literature search was performed in the PubMed, Embase, and CINAHL databases. The found studies were screened using the PRISMA flowchart. We then performed …

Outcomes Of Extracorporeal Cardiopulmonary Resuscitation For In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories, Morgann Loaec, Adam S Himebauch, Ron Reeder, Jessica S Alvey, Jonathan A Race, Lillian Su, Javier J Lasa, Julia C Slovis, Tia T Raymond, Ryan Coleman, Bradley J Barney, Todd J Kilbaugh, Alexis A Topjian, Robert M Sutton, Ryan W Morgan

Faculty, Staff and Students Publications

Objectives: The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years.

Design: Retrospective multicenter cohort study.

Setting: Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021.

Patients: Children (< 18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest.

Interventions: None.

Measurements and main results: Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating …

Alveolar Epithelial Cell Dysfunction In Idiopathic Pulmonary Fibrosis Linked To Lipid Alterations: Therapeutic Implications, Francesca Polverino, Ana Mora

Faculty, Staff and Students Publications

No abstract provided.

Gambaran Klinis Pasien Terduga Tuberkulosis Paru Resisten Obat (Tb-Ro) Dengan Kolonisasi Candida Sp. Di Rumah Sakit Hasan Sadikin Bandung, Hasna Rafifah Zahira Zalfa, Iceu Dimas Kulsum, Hendarsyah Suryadinata, Chrysanti Chrysanti, Intan Mauli Warma Dewi

Jurnal Penyakit Dalam Indonesia

Introduction. Candida sp. is a fungus that lives as a commensal in human body, but may cause infection upon immune suppression. The decrease in immunity due to TB infection and long-term use of antibiotics in TB patients may increase the risk of the Candida sp. colonization in patient. Data regarding the prevalence of Candida sp. colonization in TB patients and its impact has not been widely reported. This study was conducted to determine the prevalence and clinical characteristics of presumptive drug-resistance TB patients with Candida sp. colonization.

Methods. A cross-sectional study was conducted using secondary data from a …

Pulmonary Alveolar Proteinosis Following Severe Covid - 19 Infection: A Case Report, Samina Martin Md, Shivu Kaushik Md, Bharat Bajantri Md

Internal Medicine Residency

A 67-year-old male, with a history of severe COVID-19 infection and exposure to talc was seen for worsening shortness of breath for months, requiring supplemental oxygen. He was treated for COVID-19 infection and suspected pneumonia with no improvement. His pulmonary function test (PFT) worsened and computed tomography (CT) showing bilateral airspace opacities with ground-glass opacities (GGO), also worsened over time. He underwent bronchoscopy, bronchoalveolar lavage and pathology revealed pulmonary alveolar proteinosis (PAP). He subsequently underwent whole lung lavage (WLL) which significantly improved his crazy paving pattern on CT and was successfully weaned off supplemental oxygen.

Attenuation Of Polycyclic Aromatic Hydrocarbon (Pah)-Induced Carcinogenesis And Tumorigenesis By Omega-3 Fatty Acids In Mice In Vivo, Guobin Xia, Guodong Zhou, Weiwu Jiang, Chun Chu, Lihua Wang, Bhagavatula Moorthy

Faculty, Staff and Students Publications

Lung cancer is the leading cause of cancer death worldwide. Polycyclic aromatic hydrocarbons (PAHs) are metabolized by the cytochrome P450 (CYP)1A and 1B1 to DNA-reactive metabolites, which could lead to mutations in critical genes, eventually resulting in cancer. Omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are beneficial against cancers. In this investigation, we elucidated the mechanisms by which omega-3 fatty acids EPA and DHA will attenuate PAH-DNA adducts and lung carcinogenesis and tumorigenesis mediated by the PAHs BP and MC. Adult wild-type (WT) (A/J) mice, Cyp1a1-null, Cyp1a2-null, or Cyp1b1-null mice were exposed …

Advancing Primary Ciliary Dyskinesia Diagnosis Through High-Speed Video Microscopy Analysis, Wilfredo De Jesús-Rojas, Zachary J Demetriou, José Muñiz-Hernández, Gabriel Rosario-Ortiz, Frances M Quiñones, Marcos J Ramos-Benitez, Ricardo A Mosquera

Faculty, Staff and Student Publications

Primary ciliary dyskinesia (PCD) is an inherited disorder that impairs motile cilia, essential for respiratory health, with a reported prevalence of 1 in 16,309 within Hispanic populations. Despite 70% of Puerto Rican patients having the RSPH4A [c.921+3_921+6del (intronic)] founder mutation, the characterization of the ciliary dysfunction remains unidentified due to the unavailability of advanced diagnostic modalities like High-Speed Video Microscopy Analysis (HSVA). Our study implemented HSVA for the first time on the island as a tool to better diagnose and characterize the RSPH4A [c.921+3_921+6del (intronic)] founder mutation in Puerto Rican patients. By applying HSVA, we analyzed the ciliary beat frequency …

Design Of The Strive-Ipf Trial-Study Of Therapeutic Plasma Exchange, Rituximab, And Intravenous Immunoglobulin For Acute Exacerbations Of Idiopathic Pulmonary Fibrosis, Tejaswini Kulkarni, Gerard Criner, Daniel Kass, Ivan Rosas, Mary Beth Scholand, Daniel Dilling, Ross Summer, Steven Duncan

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

BACKGROUND: Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) affect a significant proportion of patients with IPF. There are limited data to inform therapeutic strategies for AE-IPF, despite its high mortality. We discuss the rationale and design of STRIVE-IPF, a randomized, multi-center, open-label Phase IIb clinical trial to determine the efficacy of combined therapeutic plasma exchange (TPE), rituximab, and intravenous immunoglobulin (IVIG), in comparison to treatment as usual (TAU), among patients with acute IPF exacerbations.

METHODS: The STRIVE-IPF trial will randomize 51 patients among five sites in the United States. The inclusion criteria have been designed to select a study population …

Utility Of Peripheral Protein Biomarkers For The Prediction Of Incident Interstitial Features: A Multicentre Retrospective Cohort Study, Samuel Ash, Tracy J Doyle, Bina Choi, Ruben San Jose Estepar, Victor Castro, Nicholas Enzer, Ravi Kalhan, Gabrielle Liu, Russell Bowler, David O Wilson, Raul San Jose Estepar, Ivan O Rosas, George R Washko

Faculty, Staff and Students Publications

INTRODUCTION/RATIONALE: Protein biomarkers may help enable the prediction of incident interstitial features on chest CT.

METHODS: We identified which protein biomarkers in a cohort of smokers (COPDGene) differed between those with and without objectively measured interstitial features at baseline using a univariate screen (t-test false discovery rate, FDR p

RESULTS: In COPDGene, 1305 biomarkers were available and 20 differed between those with and without interstitial features at baseline. Of these, 11 were associated with feature progression over a mean of 5.5 years of follow-up, and of these 4 were available in PLuSS, (angiopoietin-2, matrix metalloproteinase 7, macrophage inflammatory protein 1 …

Detection Of Acute Brain Injury In Intensive Care Unit Patients On Ecmo Support Using Ultra-Low-Field Portable Mri: A Retrospective Analysis Compared To Head Ct, Sung-Min Cho, Shivalika Khanduja, Jiah Kim, Jin Kook Kang, Jessica Briscoe, Lori R Arlinghaus, Kha Dinh, Bo Soo Kim, Haris I Sair, Audrey-Carelle N Wandji, Elena Moreno, Glenda Torres, Jose Gavito-Higuera, Huimahn A Choi, John Pitts, Aaron M Gusdon, Glenn J Whitman

Faculty, Staff and Student Publications

Early detection of acute brain injury (ABI) is critical to intensive care unit (ICU) patient management and intervention to decrease major complications. Head CT (HCT) is the standard of care for the assessment of ABI in ICU patients; however, it has limited sensitivity compared to MRI. We retrospectively compared the ability of ultra-low-field portable MR (ULF-pMR) and head HCT, acquired within 24 h of each other, to detect ABI in ICU patients supported on extracorporeal membrane oxygenation (ECMO). A total of 17 adult patients (median age 55 years; 47% male) were included in the analysis. Of the 17 patients assessed, …