STUDY OF KNOWLEDGE, ATTITUDE, AND PRACTICE OF GENERAL POPULATION OF GUNTUR TOWARD SILENT KILLER DISEASES: HYPERTENSION AND DIABETES

ABSTRACTObjectives: The objective was to study the demographic details of hypertensive and diabetic patients and their knowledge, attitude, and practices(KAP) regarding their illness.Methods: We examined KAP on hypertension and diabetes in a sample of 50 adult hypertensive patients and 50 adult diabetic patients aged above20 years. KAP's were assessed during the period from October 2014 to January 2015.Results: Altogether 50 hypertensive and 50 diabetic patients were enrolled in the study. Most of the respondents in the KAP on hypertension wereaged between 31and 40 years (56%) and 94% of the participants knew that hypertension is the disease state whereas in KAP on diabetes 46% areaged in between 31 and 40 years of age, 88% of participants know that the diabetes is a condition in which the body contains increased levels of bloodglucose. We observed poor score in attitude and practice part of the questionnaire. It concludes that the responders had good knowledge but poorattitude and practice toward the diseases. Repeated reinforcement and motivation along with health education will definitely bring about a positivechange in attitude and practices among the patients.Conclusion: We conclude that the motivation and counseling stressing the importance of lifestyle modifications and self-management is required forthe patients suffering with chronic diseases such as hypertension and diabetes. Patient counseling by the clinical pharmacist can play a vital role inimparting education to the diabetic and hypertensive patients.Keywords: Hypertension, Diabetes, Knowledge, Attitude, Practices

An Unusual Presentation of Immunoglobulin G4-Related Disease (IgG4-RD) Causing Subglottic Stenosis

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is known to involve multiple organs and was first described as an entity in 2003. It is characterized by lesions with a dense lymphoplasmacytic infiltrate, IgG4-positive plasma cells, storiform fibrosis, and frequently elevated serum IgG4 levels. Organs that are commonly involved include the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, retroperitoneum, lungs, pleura, thyroid, aorta, and lymph nodes. Rarer manifestations of IgG4-RD include central nervous system (CNS) involvement, prostatitis, mastitis, midline destructive disease, and nasopharyngeal disease. In this report, we discuss an atypical case of a young woman with laryngeal subglottic involvement leading to stenosis and airway obstruction, which was ultimately successfully managed with systemic immunosuppression

Think again: litseria monocytogenes meningitis in a patient with systemic lupus erythematosus

Introduction: Infections are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). An increased susceptibility to infections exists in SLE patients, either related to immunosuppressive therapies or from disease-related immunological dysfunction. Central nervous system (CNS) infections in patients with SLE are rare, affecting approximately 1.4% of patients; however, a death rate of higher than 40% has been reported in this patient group. Case Description: A 68-year-old female with history of SLE, ischemic cardiomyopathy, and chronic diarrhea presented with acute worsening of diarrhea and rectal pain over 3 days. She had been hospitalized the prior month for new choreiform movements and dysarthria believed to be secondary to CNS involvement of SLE; at the time, she had been taking prednisone 40 mg daily and mycophenolate 750 mg twice daily for immunosuppression. Notable labs included leukocytosis 11.9 K/mcL, sodium 128 mmol/L, bicarbonate 18 mmol/L, glucose 273 mg/dL, BUN 30 mg/dL, and creatinine 1.25 mg/dL. Patient developed altered mentation with high fevers shortly after admission and was emergently intubated, then transferred to ICU; CT head was negative and lumbar puncture (LP) was performed. Empiric IV cefepime, vancomycin, ampicillin, acyclovir and oral vancomycin were started. Cerebrospinal fluid (CSF) culture and rapid meningitis panel grew Listeria monocytogenes, as did initial blood cultures. Repeat blood and CSF cultures were negative, and she completed antibiotic treatment for 3 weeks. Patient clinically improved and was transitioned back to her home from skilled nursing facility. Discussion: Due to their similar manifestations, CNS infections and neuropsychiatric systemic lupus erythematosus (NPSLE) may be difficult to distinguish. The most common pathogens involved in CNS infections in SLE patients include M. tuberculosis, C. neoformans, and L. monocytogenes. A transient gastroenteritis may precede Listeria meningitis, providing an important clue for accurate diagnosis and therapy. In order to mitigate high mortality, clinicians must have clinical suspicion for meningitis and respond with early diagnosis and treatment

Nitrous oxide abuse presenting as functional vitamin B12 deficiency

Introduction: Nitrous oxide is used in anesthesia, dental and obstetrical practices. The gas is also inhaled recreationally because of its ability to induce euphoria and reduce anxiety. There have been several reports of disabling neurological consequences due to prolonged nitrous oxide use, resulting in functional inactivation of vitamin B12. Common neurological presentations of nitrous oxide toxicity include paresthesias and gait disturbance. Case Description: A 24-year-old female presented with 4 days of ascending lower extremity weakness and paresthesias in a stocking-glove distribution. Symptoms began in bilateral feet and progressed to the trunk, and she sustained a fall at home secondary to gait instability as well as leg weakness. Patient reported huffing nitrous oxide from “whippet” canisters every other weekend during the previous 9 months. On physical exam she was noted to have instability in gait, symmetrical loss of flexor and extensor strength in lower extremities, absent ankle reflexes and absent proprioception in the toes. CT head was negative and labs were mostly unremarkable except for WBC count 11.9 K/mcL (4.2-11) and magnesium level 1.6 md/dL (1.7-2.4). Neurology recommended high dose methylprednisolone for suspicion of transverse myelitis. MRI of brain and cervical/thoracic spine showed no abnormalities and patient underwent lumbar puncture with negative CSF culture, cell count, MS panel, and meningitis/encephalitis panel. Subsequent lab studies were notable for negative ANA, serum vitamin D 21.2 ng/mL (30-100), vitamin B12 242 pg/mL (211-911), and methylmalonic acid 25,626 nmol/L (79-376). Treatment with high dose intramuscular cyanocobalamin injections was initiated, and her ambulation gradually improved over the next several days. Discussion: Patients with nitrous oxide-induced neurological dysfunction may have normal vitamin B12 levels. In these situations, a functional deficiency can be diagnosed by measuring methlymalonic acid and homocysteine (substrates of reactions catalyzed by vitamin B12). Nitrous oxide is believed to inactivate and deplete vitamin B12, and high dose replacement has been shown to improve neurological symptoms

Running and rapping our way to wellness: internal medicine residency approach to preventing burnout

Background: Physician burnout has led to increased cardiovascular disease, shorter life expectancy, problematic alcohol use, depression, and suicide. A recent meta-analysis on burnout and patient experience highlighted the strong association between physician wellness and the quality of patient care. Unfortunately, burnout in internal medicine ranks among the highest of all specialties, with rates up to 76%. Purpose: To facilitate resident mental and physical well-being through initiatives focused on supportive colleague relationships and exercise. Methods: We implemented two related interventions. 1) RAPS (Resident Advisor for Peer Success) is a structured peer advisor program for incoming interns to jump-start a “connection” with their continuity clinic team shortly after match day. This early and sustained contact provides interns with an immediate resource for questions/support and ongoing connections with senior residents and a faculty advisor. 2) Fit4Life intervention continued to build/ support colleague relationships through personal fitness. Wellness challenges between trainee years were held to promote physical health per American Heart Association (AHA) exercise guidelines. Three measures — a Fit4Life survey, semi-structured interviews with interns, and Mayo Well-Being Index (MWBI) — were used to evaluate process and outcomes. Results: Fit4Life pre-, during, and postchallenge data showed that less than 20% of internal medicine residents met AHA guidelines: 150 minutes/week of aerobic physical activity. Challenge period results showed a modest but not significant increase in exercise. Average completion rate was 83% of internal medicine residents. Exercise, per AHA recommendations, was paired \u3e50% of time with another activity (eg, watch/listen to television, movies, music, podcasts; connecting with family/friends). RAP intern interviews (13 of 13 [100%]) revealed that 85% were supportive of RAPS and 100% met weekly with RAPS team member(s) at continuity clinic. MWBI scores throughout intervention were well below instruments established at risk level for burnout (5.0), with below burnout scores ranging from 3.1 preintervention (February 2018) to 2.3 postintervention (December 2018). Conclusion: The results of our well-being interventions focused on supportive colleague relationships through RAPS and exercise reveal high participation rates and support but no significant impact on physical or mental health as measured by Fit4Life and MWBI

Running and rapping our way to wellness: internal medicine residency approach to preventing burnout

Background: Physician burnout has led to increased cardiovascular disease, shorter life expectancy, problematic alcohol use, depression, and suicide. A recent meta-analysis on burnout and patient experience highlighted the strong association between physician wellness and the quality of patient care. Unfortunately, burnout in internal medicine ranks among the highest of all specialties, with rates up to 76%. Purpose: To facilitate resident mental and physical well-being through initiatives focused on supportive colleague relationships and exercise. Methods: We implemented two related interventions. 1) RAPS (Resident Advisor for Peer Success) is a structured peer advisor program for incoming interns to jump-start a “connection” with their continuity clinic team shortly after match day. This early and sustained contact provides interns with an immediate resource for questions/support and ongoing connections with senior residents and a faculty advisor. 2) Fit4Life intervention continued to build/ support colleague relationships through personal fitness. Wellness challenges between trainee years were held to promote physical health per American Heart Association (AHA) exercise guidelines. Three measures — a Fit4Life survey, semi-structured interviews with interns, and Mayo Well-Being Index (MWBI) — were used to evaluate process and outcomes. Results: Fit4Life pre-, during, and postchallenge data showed that less than 20% of internal medicine residents met AHA guidelines: 150 minutes/week of aerobic physical activity. Challenge period results showed a modest but not significant increase in exercise. Average completion rate was 83% of internal medicine residents. Exercise, per AHA recommendations, was paired \u3e50% of time with another activity (eg, watch/listen to television, movies, music, podcasts; connecting with family/friends). RAP intern interviews (13 of 13 [100%]) revealed that 85% were supportive of RAPS and 100% met weekly with RAPS team member(s) at continuity clinic. MWBI scores throughout intervention were well below instruments established at risk level for burnout (5.0), with below burnout scores ranging from 3.1 preintervention (February 2018) to 2.3 postintervention (December 2018). Conclusion: The results of our well-being interventions focused on supportive colleague relationships through RAPS and exercise reveal high participation rates and support but no significant impact on physical or mental health as measured by Fit4Life and MWBI

One-year mortality in type 2 MI: Patient characteristics from a large clinical series

Background: Type 2 MI is caused by an imbalance in oxygen supply/demand. Little is known about the patient characteristics associated with Type 2 MI. Objective: This study aimed to define patient characteristics of Type 2 MI. Methods: We retrospectively studied patients older than 18 years presented to our health care facilities between 9/2011-12/2015. All patients determined to have Type 2 MI (i.e., if the patient had an elevated troponin greater than or equal to 0.05 ng/mL or diagnosis of demand ischemia) were included. We excluded those with troponin greater than 20.0 ng/mL, ST-elevation MI diagnosis, cardiogenic shock, or non-ST-elevation MI with percutaneous coronary intervention, stent placement, or coronary artery bypass surgery. Hospice discharges were also excluded. Cox proportional hazards model, Chi-squared and Fishers exact tests were used for statistical analysis for one-year mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were also computed. Results: A total of 21,139 patients [mean age 71+/- 16 years, females 10,565(49.9%)] fulfilled the study cohort. Univariate analysis showed that one-year mortality (28.5%) was high and associated with older age and White race (P’s\u3c0.0001). A history of diabetes (P=0.037), aortic aneurysm (P=0.0008), congestive heart failure, atrial fibrillation, anemia, chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD; P’s\u3c0.0001) were also associated with one-year mortality. One-year death rate was lower in patients with known history of coronary artery disease (CAD; P’s\u3c0.0001). Multivariate analysis showed that anemia (P=\u3c0.0001; HR=1.29, CI[1.22- 1.38]), COPD (P=\u3c0.0001; HR=1.26, CI[1.16-1.37]) ,CKD (P=\u3c0.0001; HR=1.16, CI[1.08- 1.24]), and diabetes (P=0.012; HR=1.08 CI[1.02-1.15]) were significantly associated with oneyear mortality. Additionally, a five year increase in age increases the risk of one-year mortality (HR=1.15, CI[1.14-1.16]). Conclusion: Patients with Type 2 MI have several common characteristics which increases their likelihood of one-year mortality and a history of CAD is somewhat protective