Internal Medicine Commons^™

Outpatient Management Of Urinary Tract Infections By Medical Officers In Nairobi, Kenya: Lack Of Benefit From Audit And Feedback On Adherence To Treatment Guidelines, Florence Mbatia, James Orwa, Mary B. Adam, Gulnaz Mohamoud, Rodney Adam

Family Medicine, East Africa

Introduction: Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specifc diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical ofcers in the region.

Methods: Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical ofcer specifcally assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical ofcer from each of the 16 clinics was recruited from …

Stop-Bang Questionnaire For Screening Obstructive Sleep Apnea Syndrome Among Hypertensive Patients In Kenya, Salim Abdallah, Jasmit Shah, Jumaa Bwika, Sayed Karar

Internal Medicine, East Africa

Introduction: Obstructive sleep apnea (OSA) is a type of breathing problem during sleep caused by the blockage of the upper airway, which can cause cessation of airflow. There is limited research on the prevalence of OSA in hypertensive patients in sub-Saharan Africa (SSA). The study aimed to describe the prevalence and clinical characteristics of OSA among hypertensive patients at a tertiary hospital in Nairobi, Kenya.

Methods: This cross-sectional study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Two hundred and fifty-one hypertensive patients were screened for OSA risk using the STOP-Bang questionnaire (SBQ). Patients with a SBQ …

Kenyan Palliative Care Providers’ And Leaders’ Perceptions Of Palliative Care Research Needs And Support To Facilitate Rigorous Research, K. Cartmell, E. Doherty, Nancy Gikaara, Z. Ali, S. Qanungo, E. S. Melikam, R. A. Powell

Internal Medicine, East Africa

Background: Palliative care (PC) can reduce symptom distress and improve quality of life for patients and their families experiencing life-threatening illness. While the need for PC in Kenya is high, PC service delivery and research is limited. Qualitative research is needed to explore potential areas for PC research and support needed to enable that research. This insight is critical for informing a national PC research agenda and mobilizing limited resources for conducting rigorous PC research in Kenya.

Objectives: To explore perceptions of priority areas for PC research and support needed to facilitate rigorous research from the perspective of Kenyan PC …

Abnormal Motion Capture In Acute Stroke (Bionics): A Low-Cost Tele-Evaluation Tool For Automated Assessment Of Upper Extremity Function In Stroke Patients, Syed A Zamin, Kaichen Tang, Emily A Stevens, Melissa Howard, Dorothea M Parker, Allyson Seals, Xiaoqian Jiang, Sean Savitz, Shayan Shams

Faculty, Staff and Student Publications

BACKGROUND: The incidence of stroke and stroke-related hemiparesis has been steadily increasing and is projected to become a serious social, financial, and physical burden on the aging population. Limited access to outpatient rehabilitation for these stroke survivors further deepens the healthcare issue and estranges the stroke patient demographic in rural areas. However, new advances in motion detection deep learning enable the use of handheld smartphone cameras for body tracking, offering unparalleled levels of accessibility.

METHODS: In this study we want to develop an automated method for evaluation of a shortened variant of the Fugl-Meyer assessment, the standard stroke rehabilitation scale …

An Electronic Health Record System Implementation In A Resource Limited Country—Lessons Learned, Sayed Karar, Muhammad Haroon Khan, Jasmit Shah, Nadeem Ahmed

Internal Medicine, East Africa

Electronic health records have revolutionized the medical world by improving medical care, refining provider documentation, standardizing care, and minimizing sentinel events. Successful implementation of electronic health records remains a daunting task and requires careful strategic planning and buy-in from key stakeholders. Much has been published in resource-rich settings and high-income countries about implementations of electronic health records. However, little is known about the experience in resource-limited settings where challenges remain unique and distinct from other parts of the world. Our intention is to share lessons learned during implementation of a web-based electronic health record at a tertiary care center in …

Inferior Vena Cava Collapsibility Index Versus Passive Leg Raise To Assess Fluid Responsiveness In Non-Intubated Septic Patients A Prospective Observational Study, Anne Githaiga, Wangari Siika, Jeilan Mohamed, Vitalis Mung’Ayi, Idris Chikophe

Anaesthesiology, East Africa

Background: Rapid fluid loading at diagnosis of sepsis is part of standard treatment. Predictive tools of fluid responsiveness are required to guide fluid resuscitation. The Passive Leg Raise [PLR] manoeuvre can predict fluid responsiveness in non-intubated patients with sepsis. The Inferior Vena Cava Collapsibility Index [IVCCI] can also be utilised but is not routinely performed.

Aim: To investigate the correlation between Inferior Vena Cava Collapsibility Index [IVCCI] and a Passive Leg Raise [PLR] manoeuvre for the assessment of fluid responsiveness in non-intubated septic patients in a tertiary referral hospital in Sub-Saharan Africa.

Methodology: A prospective observational study which recruited non-intubated …

Outcomes Of Transcatheter Aortic Valve Replacement In Patients With Cardiogenic Shock, Kashish Goel, Pinak Shah, Brandon M Jones, Ethan Korngold, Anju Bhardwaj, Biswajit Kar, Colin Barker, Molly Szerlip, Richard Smalling, Abhijeet Dhoble

Faculty, Staff and Student Publications

AIMS: The safety and efficacy of transcatheter aortic valve replacement (TAVR) with contemporary balloon expandable transcatheter valves in patients with cardiogenic shock (CS) remain largely unknown. In this study, the TAVRs performed for CS between June 2015 and September 2022 using SAPIEN 3 and SAPIEN 3 Ultra bioprosthesis from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were analysed.

METHODS AND RESULTS: CS was defined as: (i) coding of CS within 24 h on Transcatheter Valve Therapy Registry form; and/or (ii) pre-procedural use of inotropes or mechanical circulatory support devices and/or (iii) cardiac arrest within 24 …

Complete Enucleation Of A Complicated Solid Pseudopapillary Neoplasm Of Pancreas: A Case Report, Mohammad Saydul Aman, Bidhan Chandra Das, Md Najmul Haque, Sarwar Ahmed Sobhan, Ashis Saha

Faculty, Staff and Student Publications

INTRODUCTION: Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare pancreatic tumor, usually affecting young females. It is categorized as a low-grade malignant tumor without any specific epithelial differentiation, which can occur anywhere in the pancreas.

CASE PRESENTATION: Here, we present the case of a 35-year-old lady who presented to us with abdominal pain and a pancreatic mass. She had a prior laparotomy at a different center without any specific intervention for the lump. After presenting to our center, she was managed through proper evaluation and adequate preparation for surgery. The diagnosis was challenging, and so was the surgery. …

Early Prediction Of Massive Transfusion For Patients With Traumatic Hemorrhage: Development Of A Multivariable Machine Learning Model, Andrew J Benjamin, Andrew J Young, John B Holcomb, Erin E Fox, Charles E Wade, Chris Meador, Jeremy W Cannon

Faculty, Staff and Student Publications

OBJECTIVE: Develop a novel machine learning (ML) model to rapidly identify trauma patients with severe hemorrhage at risk of early mortality.

BACKGROUND: The critical administration threshold (CAT, 3 or more units of red blood cells in a 60-minute period) indicates severe hemorrhage and predicts mortality, whereas early identification of such patients improves survival.

METHODS: Patients from the PRospective, Observational, Multicenter, Major Trauma Transfusion and Pragmatic, Randomized Optimal Platelet, and Plasma Ratio studies were identified as either CAT+ or CAT-. Candidate variables were separated into 4 tiers based on the anticipated time of availability during the patient's assessment. ML models were …

Rare Case Of Pediatric Post-Transplant Lymphoproliferative Disorder Presenting With Pleural Masses Complicated By Pleural Effusions, Erini Nessim Kostandy, David Wan, Essam Imseis

Faculty, Staff and Student Publications

Post-transplant lymphoproliferative disorder is a complication in organ transplant recipients characterized by uncontrolled proliferation of B-lymphocytes, occurring in 6% of pediatric patients, with risk factors including primary Epstein-Barr virus infection, intensity of immunosuppression, and cytomegalovirus infection. The clinical symptoms are often nonspecific, and it is associated with a high mortality rate if left untreated. We describe a rare case of post-transplant lymphoproliferative disorder who presented with pleural-based masses resulting in pleural effusions.

Trial Participation And Outcomes Among English-Speaking And Spanish-Speaking Patients With Appendicitis Randomized To Antibiotics: A Secondary Analysis Of The Coda Randomized Clinical Trial, Elina Serrano, Emily C Voldal, David Machado-Aranda, Daniel A Deugarte, Lillian Kao, Thurston Drake, Robert Winchell, Joseph Cuschieri, Anusha Krishnadasan, David A Talan, Nicole Siparsky, Patricia Ayoung-Chee, Wesley H Self, Patrick Mcgonagill, Katherine A Mandell, Mike K Liang, Shan-Jahan Dodwad, Callie M Thompson, Reynaldo M Padilla, Ross Fleischman, Thea P Price, Alan Jones, Karla Bernardi, Luis Garcia, Heather L Evans, Sabrina E Sanchez, Stephen Odom, Bryan A Comstock, Patrick J Heagerty, Sarah O Lawrence, Sarah E Monsell, Erin E C Fannon, Larry G Kessler, David R Flum, Giana H Davidson

Faculty, Staff and Student Publications

IMPORTANCE: Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants.

OBJECTIVE: To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics.

DESIGN, SETTING, AND PARTICIPANTS: This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial …

Top Ten Tips Palliative Care Clinicians Should Know About Working With Adults Receiving Extracorporeal Membrane Oxygenation, Astrid Grouls, Krista Dobbie, Kathleen Neuendorf, Shunichi Nakagawa, Alisha Young, William E Rosa, Bindu Akkanti

Faculty, Staff and Student Publications

Extracorporeal membrane oxygenation (ECMO) is an invasive intervention that is both resource- and labor-intensive. It can also be emotionally challenging for all involved. Palliative care (PC) clinicians can support adult patients, families, surrogate decision makers, and the interdisciplinary team (IDT) throughout ECMO, starting at the time of ECMO initiation through discontinuation and to bereavement in the event of a patient's death. In addition to knowing the basics of ECMO circuitry, indications to start ECMO, and the complex decision points throughout treatment, PC clinicians must understand the critical need for specialist and IDT coordination when discussing prognosis and resuscitation, clarifying goals …

Reduced Digestion Of Circulating Genomic Dna In Systemic Sclerosis Patients With The Dnase1l3 R206c Variant\, Brian Skaug, Xinjian Guo, Yuanteng Jeff Li, Julio Charles, Kay T Pham, Jacob Couturier, Dorothy E Lewis, Claudia Bracaglia, Ivan Caiello, Maureen D Mayes, Shervin Assassi

Faculty, Staff and Student Publications

Objectives: Polymorphism in a coding region of deoxyribonuclease I-like III (DNASE1L3), causing amino acid substitution of Arg-206 to Cys (R206C), is a robustly replicated heritable risk factor for SSc and other autoimmune diseases. DNASE1L3 is secreted into the circulation, where it can digest genomic DNA (gDNA) in apoptosis-derived membrane vesicles (AdMVs). We sought to determine the impact of DNASE1L3 R206C on digestion of circulating gDNA in SSc patients and healthy controls (HCs).

Methods: The ability of DNASE1L3 to digest AdMV-associated gDNA was tested in vitro. The effect of R206C substitution on extracellular secretion of DNASE1L3 was determined using a transfected …

Interstitial Lung Abnormalities After Hospitalization For Covid-19 In Patients With Cancer: A Prospective Cohort Study, Sungryong Noh, Christopher Bertini, Isabel Mira-Avendano, Maryam Kaous, Bela Patel, Saadia A Faiz, Vickie R Shannon, Diwakar D Balachandran, Lara Bashoura, Roberto Adachi, Scott E Evans, Burton Dickey, Carol Wu, Girish S Shroff, Joanna-Grace Manzano, Bruno Granwehr, Shannon Holloway, Kodwo Dickson, Alyssa Mohammed, Mayoora Muthu, Hui Song, Caroline Chung, Jia Wu, Lyndon Lee, Ying Jiang, Fareed Khawaja, Ajay Sheshadri

Faculty, Staff and Student Publications

INTRODUCTION: Survivors of SARS-CoV-2 pneumonia often develop persistent respiratory symptom and interstitial lung abnormalities (ILAs) after infection. Risk factors for ILA development and duration of ILA persistence after SARS-CoV-2 infection are not well described in immunocompromised hosts, such as cancer patients.

METHODS: We conducted a prospective cohort study of 95 patients at a major cancer center and 45 patients at a tertiary referral center. We collected clinical and radiographic data during the index hospitalization for COVID-19 pneumonia and measured pneumonia severity using a semi-quantitative radiographic score, the Radiologic Severity Index (RSI). Patients were evaluated in post-COVID-19 clinics at 3 and …

Rare Variants In Ano1, Encoding A Calcium-Activated Chloride Channel, Predispose To Moyamoya Disease, Amélie Pinard, Wenlei Ye, Stuart M Fraser, Jill A Rosenfeld, Pavel Pichurin, Scott E Hickey, Dongchuan Guo, Alana C Cecchi, Maura L Boerio, Stéphanie Guey, Chaker Aloui, Kwanghyuk Lee, Markus Kraemer, Saleh Omar Alyemni, Michael J Bamshad, Deborah A Nickerson, Elisabeth Tournier-Lasserve, Shozeb Haider, Sheng Chih Jin, Edward R Smith, Kristopher T Kahle, Lily Yeh Jan, Mu He, Dianna M Milewicz

Faculty, Staff and Student Publications

Moyamoya disease, a cerebrovascular disease leading to strokes in children and young adults, is characterized by progressive occlusion of the distal internal carotid arteries and the formation of collateral vessels. Altered genes play a prominent role in the aetiology of moyamoya disease, but a causative gene is not identified in the majority of cases. Exome sequencing data from 151 individuals from 84 unsolved families were analysed to identify further genes for moyamoya disease, then candidate genes assessed in additional cases (150 probands). Two families had the same rare variant in ANO1, which encodes a calcium-activated chloride channel, anoctamin-1. Haplotype analyses …

Atopic Dermatitis And The Risk Of Myocardial Infarction And All-Cause Mortality: A Nationwide Population-Based Cohort Study, Yu Ri Woo, Minah Cho, Kyung Do Han, Sang Hyun Cho, Ji Hyun Lee

Faculty, Staff and Student Publications

PURPOSE: Atopic dermatitis (AD) is a chronic inflammatory skin disorder associated with various comorbidities. However, inconsistent results on the risk of myocardial infarction (MI) and mortality have been reported in patients with AD. This study was aimed to evaluate the risk of MI and all-cause mortality in patients with AD.

METHODS: This nationwide population-based retrospective cohort study enrolled 56,205 adults ≥ 20 years of age with AD and 3,825,609 controls without AD from the Korean National Health Service (NHIS) database from 2009 to 2016.

RESULTS: The risk of MI (adjusted hazard ratio [aHR], 1.111, 95% confidence interval [CI], 1.050-1.176) was …

Life’S Essential 8: Optimizing Health In Older Adults, Manish Kumar, Ariela Orkaby, Caitlan Tighe, Dennis T Villareal, Hayley Billingsley, Michael G Nanna, Min Ji Kwak, Namit Rohant, Shreya Patel, Parag Goyal, Scott Hummel, Christina Al-Malouf, Amie Kolimas, Ashok Krishnaswami, Mike W Rich, James Kirkpatrick, Abdulla A Damluji, George A Kuchel, Daniel E Forman, Karen P Alexander

Faculty, Staff and Student Publications

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to …

Who Left The Hospital Against Medical Advice During The Early Covid-19 Pandemic?, Bryan Werner, Se Won Lee

HCA Healthcare Journal of Medicine

Background

Patients leaving against medical advice (AMA) presents a challenge to hospitals as they try to manage costs and improve patient outcomes in an ever-increasing competitive market. Investigating AMA discharges that occurred during the early COVID-19 pandemic presents a unique opportunity to better understand this phenomenon and be better prepared for the future.

Methods

This retrospective analysis of 34 379 patients from a nationwide private healthcare system across 20 states analyzed patients during the early stages of the pandemic who chose to leave against medical advice (AMA) after being admitted with COVID-19 infection and identified several patient characteristics associated with …

An Unusual Presentation Of Infective Endocarditis, Ethan J. Peterson, Jordan Jackson, Syed M. Zaidi, Jorge Perez

HCA Healthcare Journal of Medicine

Introduction

Leukocytoclastic vasculitis is the inflammation of small blood vessels due to leukocyte migration that comprises a wide range of differentials. It can be caused by autoimmune disorders, infections, neoplasms, or certain medications and warrants prompt recognition and therapy for optimal patient outcomes.

Case Presentation

Here we present a case of a 37-year-old male who presented with a painful, petechial rash on his torso and extremities. Skin biopsy revealed leukocytoclastic vasculitis, thereby prompting a comprehensive investigation into the underlying etiology leading to the diagnosis of Pseudomonas aeruginosa infective endocarditis.

Conclusion

Pseudomonas aeruginosa is a rare cause of infective endocarditis with …

Sex-Specific Associations Between Adipokine Profiles And Carotid-Intima Media Thickness In The Cameron County Hispanic Cohort (Cchc), Daeeun Kim, Aylin Memili, Hung-Hsin Chen, Heather M Highland, Hannah G Polikowsky, Mohammad Yaser Anwar, Susan T Laing, Miryoung Lee, Joseph B Mccormick, Susan P Fisher-Hoch, Jennifer E Below, Kari E North, Absalon D Gutierrez

Faculty, Staff and Student Publications

Background: Adipokines are hormones secreted from adipose tissue and are associated with cardiometabolic diseases (CMD). Functional differences between adipokines (leptin, adiponectin, and resistin) are known, but inconsistently reported associations with CMD and lack of studies in Hispanic populations are research gaps. We investigated the relationship between subclinical atherosclerosis and multiple adipokine measures.

Methods: Cross-sectional data from the Cameron County Hispanic Cohort (N = 624; mean age = 50; Female = 70.8%) were utilized to assess associations between adipokines [continuous measures of adiponectin, leptin, resistin, leptin-to-adiponectin ratio (LAR), and adiponectin-resistin index (ARI)] and early atherosclerosis [carotid-intima media thickness (cIMT)]. We adjusted …