Evaluating the diagnostic and prognostic ability of ischemia modified albumin in COVID-19.

BACKGROUND: Patients with COVID-19 can rapidly deteriorate and develop acute hypoxic respiratory failure. Prominent features of the disease include severe inflammation, endotheliitis, and thrombosis. OBJECTIVES: The aim of the study was to evaluate the diagnostic and prognostic effectiveness of ischemia modified albumin (ΙΜΑ) in a cohort of COVID-19 patients. METHODS: This prospective observational study included adults with SARS-CoV-2 infection confirmed by reverse transcription polymerase chain reaction test, who were hospitalized specifically for COVID-19. The outcomes of interest were progression to severe acute respiratory failure during the index hospitalization defined as partial pressure of oxygen/fraction of inspired oxygen lower or equal to 150, admission to the intensive care unit (ICU) and in-hospital mortality. Admission IMA levels were determined using the commercially available "IMA Assay Kit" method (Abbexa LTD, Cambridge, UK). Adults without SARS-CoV-2 infection were used as controls. RESULTS: 135 COVID-19 patients and 64 controls were included. Admission IMA levels were significantly higher in COVID-19 patients compared to controls [[24.38 (11.94) ng/ml vs. 14.69 (3.52) ng/ml, p < 0.01]. Receiver operating characteristic analysis of admission IMA showed an area under the curve (AUC) of 94% (p < 0.0001) for COVID-19 diagnosis (cut-off value: 17.5 ng/ml; sensitivity: 90.37%; specificity: 87.5%). Admission IMA was also associated with mortality (AUC: 68%, p = 0.01). However, it was not associated with severe acute respiratory failure (AUC: 47%, p = 0.53) or ICU admission (AUC: 58%, p = 0.41). CONCLUSION: Admission IMA was significantly increased in COVID-19 patients and was associated with in-hospital mortality.

Physical Health-Related Quality of Life in Relation to Mediterranean Diet Adherence in a Sample of Greek Asthma Patients: A Pilot Study.

The role of nutrition in the management of asthma in obese patients is of increasing interest due to their limited response to inhaled corticosteroids. Some studies note that through diet and lifestyle, there can be an improvement in asthma control. The aim of the present study was to investigate the adherence to the Mediterranean Diet and its association with asthma severity and quality of life in patients with bronchial asthma. This is a cross-sectional study of 85 patients (70.6% female), with a mean age of 57 years, from the General University Hospital of Larissa and, more specifically, patients of the outpatient asthma clinic. Data were collected with the use of specific questionnaires. In relation to BMI, 12.9% of participants were of a normal weight, 45.9% were overweight, 25.9% were obese level I, 5.9% were obese level II, and 9.4% were in the morbidly obese range. Based on the Med Diet Score (ranging from 21 to 35), most participants (85.9%) reported moderate adherence to the Mediterranean Diet. Further analysis examined the correlations of the PCS-12 score with the frequency of consumption of each of the 11 food categories, as well as all demographic and health behavior variables. The ranked correlations indicated a significant relationship between PCS-12 score and Med Diet adherence and the consumption of alcoholic beverages (r = 0.437, p < 0.05), in accordance with the Mediterranean Diet suggestions, as well as a negative relationship with BMI score (r = -0.454, p < 0.010). Moreover, significant correlations were also present between the physical quality of life and AQLQ score and work type, as well as gender, age, and marital status. The results of our study showed a high rate of obesity in patients with asthma at the General University Hospital of Larissa and moderate adherence to the Mediterranean Diet. Increased BMI and alcoholic beverage consumption in asthma patients were significant predictors of lower physical health-related quality of life. In conclusion, personal and society-level interventions are required to effectively address obesity and poor diet in patients with asthma.

Multifocal Tuberculosis Verrucosa Cutis: Case Report and Review of the Literature.

Cutaneous tuberculosis (TB) is still a major public health problem worldwide. Tuberculosis verrucosa cutis (TBVC) is a cutaneous form of exogenous TB caused by exogenous reinfection in previously sensitized individuals. TBVC typically presents as a unifocal condition. Multifocal cutaneous lesions without any other tubercular foci are extremely rare in exogenous TB and few cases are reported in the literature. We describe the first case of multifocal TBVC in an 81-year-old Greek man. In total, 14 cases of multifocal TBVC have been reported in the literature (8 males and 6 females), with mean age 47.64 years (SD = 20.75) and mean time to diagnosis of 9.69 years (SD = 15.31). Most cases (11/12) responded rapidly to treatment, implying the accuracy of diagnosis, while no one was reported to be immunocompromised. Finally, in 10 cases (71.4%), history of skin microtrauma was reported (related either to daily life habits or to professional praxis), confirming it as the main risk factor. The tuberculin skin test was positive in 10 cases and tissue culture for mycobacteria was negative in all cases. TBVC can present with multiple lesions, even in countries where TB prevalence is not high, especially in patients with history of skin abrasions. Prompt specialist assessment can expedite the establishment of diagnosis.

D-ROMs and PAT Tests Reveal a High Level of Oxidative Stress in Patients with Severe Well-Controlled Asthma, and D-ROMs Are Positively Correlated with R20 Values That Indicate Approximate Central Airway Resistance.

BACKGROUND: The derivatives-reactive oxygen metabolites (d-ROMs) and plasma antioxidant capacity (PAT) tests are oxidative indexes. Severe asthma has been related to oxidative stress. We aimed to investigate d-ROMs and PAT values in severely controlled asthmatics and the correlation of these values with lung function. METHODS: Blood samples were collected from severely controlled asthmatics and centrifuged at 3000 rpm for 10 min. The supernatant was collected. The assays were performed within three hours of collection. The fraction of exhaled nitric oxide (FeNO), impulse oscillometry (IOS), and spirometry were determined. Symptom control was recorded using the asthma control test (ACT). RESULTS: Approximately 40 patients with severe controlled asthma (75%: women), mean age of 62 ± 12 years, were recruited. Approximately 5% had obstructive spirometry. The IOS revealed airway abnormalities even though the spirometric results were within the normal range, with it being more sensitive than spirometry. The D-ROMs and PAT test values were higher than normal, indicating oxidative stress in severe asthmatics with controlled asthma. D-ROMs were positively correlated with R20 values, indicating central airway resistance. CONCLUSIONS: The IOS technique revealed an otherwise hidden airway obstruction with spirometry. The D-ROMs and PAT tests revealed a high level of oxidative stress in severe controlled asthmatics. D-ROMs correlate with R20, indicating central airway resistance.

Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study.

OBJECTIVE: To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19. DESIGN: International, multicenter, retrospective study. PARTICIPANTS: Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe. MAIN OUTCOME AND MEASURES: Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days. RESULTS: 171 patients with a median age of 68 (IQR 58-73) years were included (ET, n = 98; OA, n = 73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p = 0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p = 0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p = 0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p = 0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p = 0.301), after adjusting for creatinine (p = 0.695), blood urea nitrogen (p = 0.153), age (p = 0.055), oxygen saturation of hemoglobin (SpO2) (p = 0.941), and fraction of inspired oxygen (FiO2) (p = 0.712). CONCLUSIONS: Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.

Serum Levels of Urokinase Plasminogen Activator Receptor (suPAR) Discriminate Moderate Uncontrolled from Severe Asthma.

INTRODUCTION: The most clinically useful concept in asthma is based on the intensity of treatment required to achieve good asthma control. Biomarkers to guide therapy are needed. AIMS: To investigate the role of circulating levels of soluble urokinase plasminogen activator receptor suPAR as a marker for asthma severity. METHODS: We recruited patients evaluated at the Asthma Clinic, University of Thessaly, Greece. Asthma severity and control were defined according to the GINA strategy and Asthma Contro Test (ACT). Anthropometrics, spirometry, fractional exhaled nitric oxide (FeNO), suPAR, blood cell count, c-reactive protein (CRP), and analyses of kidney and liver function were obtained. Patients with a history of inflammatory, infectious, or malignant disease or other lung disease, more than 5 pack years of smoking history, or corticosteroid therapy were excluded. RESULTS: We evaluated 74 asthma patients (69% female, mean age 57 ± 17 years, mean body mass index (BMI) 29 ± 6 kg/m2). In total, 24%, 13%, 6%, 5%, 29% and 23% of the participants had mild well-controlled, mild uncontrolled, moderate well-controlled, moderate uncontrolled, severe well-controlled, and severe uncontrolled asthma, respectively. Overall, 67% had T2-high asthma, 26% received biologics (15% and 85% received omalizumab and mepolizumab, respectively), and 34% had persistent airway obstruction. suPAR levels were significantly lower in asthmatics with moderate uncontrolled asthma than in patients with severe uncontrolled asthma without (2.1 ± 0.4 vs. 3.3 ± 0.7 ng/mL, p = 0.023) or with biologics (2.1 ± 0.4 vs. 3.6 ± 0.8 ng/mL, p = 0.029). No correlations were found between suPAR levels and age, BMI, T2 biomarkers, CRP, or spirometric parameters. CONCLUSIONS: suPAR levels were higher in asthmatics with severe disease than in those with moderate uncontrolled asthma.

Perceived Symptoms, Mental Health and Quality of Life after Hospitalization in COVID-19 Patients.

Patients recovering from novel coronavirus are reporting a variety of symptoms such as cough, dyspnea, myalgia as well as psychological distress and poor quality of life. The aim of this study is to assess quality of life and psychological distress in COVID-19 survivors and the sociodemographic and clinical characteristics that affect COVID-19 survivors' mental health status and quality of life. A quantitative study was conducted among COVID-19 survivors, who had previously been admitted to the University Hospital of Larissa, Greece. Data were collected via a questionnaire consisting of three-parts. The first part consisted of questions about the demographic characteristics. The second part was the SF-36 QoL index. The third part was the Symptom Checklist-90r (SCL 90-R). In addition, clinical information such as the length and the department of hospitalization, days since discharge and pulmonary function (spirometry values) were recorded. From a total of 145 patients, 60% were male, aged 59.72 ± 12.74 and 78.6% of them were married; the majority had completed secondary education, 35.9% were pensioners and 58.6 were living in urban areas. The most frequently reported symptoms were fatigue (67.6%) and pain (44.8%) and 11.7% were experiencing psychological distress. Pain, loss of smell, mandatory education, ICU admission, female gender and the experiencing of skin disturbance are associated with poor physical QoL among COVID-19 recovered patients. Greek COVID-19 previously hospitalized patients were reporting several symptoms associated with COVID-19. Good QoL and mental health were also reported. Physical pain, loss of smell and female gender were associated with poor QoL and psychological distress.

Circulating suPAR associates with severity and in-hospital progression of COVID-19.

BACKGROUND: COVID-19 disease progression is characterized by hyperinflammation and risk stratification may aid in early aggressive treatment and advanced planning. The aim of this study was to assess whether suPAR and other markers measured at hospital admission can predict the severity of COVID-19. METHODS: The primary outcome measure in this international, multi-centre, prospective, observational study with adult patients hospitalized primarily for COVID-19 was the association of WHO Clinical Progression Scale (WHO-CPS) with suPAR, ferritin, CRP, albumin, LDH, eGFR, age, procalcitonin, and interleukin-6. Admission plasma suPAR levels were determined using the suPARnostic® ELISA and suPARnostic® Turbilatex assays. RESULTS: Seven hundred and sixty-seven patients, 440 (57.4%) males and 327 (42.6%) females, were included with a median age of 64 years. Log-suPAR levels significantly correlated with WHO-CPS score, with each doubling of suPAR increasing the score by one point (p < .001). All the other markers were also correlated with WHO-CPS score. Admission suPAR levels were significantly lower in survivors (7.10 vs. 9.63, 95% CI 1.47-3.59, p < .001). A linear model (SALGA) including suPAR, serum albumin, serum lactate dehydrogenase, eGFR, and age can best estimate the WHO-CPS score and survival. Combining all five parameters in the SALGA model can improve the accuracy of discrimination with an AUC of 0.80 (95% CI: 0.759-0.836). CONCLUSIONS: suPAR levels significantly correlated with WHO-CPS score, with each doubling of suPAR increasing the score by one point. The SALGA model may serve as a quick tool for predicting disease severity and survival at admission.

Physical Fitness Differences, Amenable to Hypoxia-Driven and Sarcopenia Pathophysiology, between Sleep Apnea and COVID-19.

Handgrip strength is an indirect indicator of physical fitness that is used in medical rehabilitation for its potential prognostic value. An increasing number of studies indicate that COVID-19 survivors experience impaired physical fitness for months following hospitalization. The aim of our study was to assess physical fitness indicator differences with another prevalent and hypoxia-driven disease, Obstructive Sleep Apnea Syndrome (OSAS). Our findings showed differences between post-COVID-19 and OSAS groups in cardiovascular responses, with post-COVID-19 patients exhibiting higher values for heart rate and in mean arterial blood pressure. Oxygen saturation (SpO2) was lower in post-COVID-19 patients during a six-minute walking test (6MWT), whereas the ΔSpO2 (the difference between the baseline to end of the 6MWT) was higher compared to OSAS patients. In patients of both groups, statistically significant correlations were detected between handgrip strength and distance during the 6MWT, anthropometric characteristics, and body composition parameters. In our study, COVID-19 survivors demonstrated a long-term reduction in muscle strength compared to OSAS patients. Lower handgrip strength has been independently associated with a prior COVID-19 hospitalization. The differences in muscle strength and oxygenation could be attributed to the abrupt onset of the disorder, which does not allow compensatory mechanisms to act effectively. Targeted rehabilitation focusing on such residual impairments may thus be indispensable within the setting of post-COVID-19 syndrome.

Eight Weeks Unsupervised Pulmonary Rehabilitation in Previously Hospitalized of SARS-CoV-2 Infection.

The aim of our study was to determine the impact of unsupervised Pulmonary Rehabilitation (uns-PR) on patients recovering from COVID-19, and determine its anthropometric, biological, demographic and fitness correlates. All patients (n = 20, age: 64.1 ± 9.9 years, 75% male) participated in unsupervised Pulmonary Rehabilitation program for eight weeks. We recorded anthropometric characteristics, pulmonary function parameters, while we performed 6 min walk test (6 MWT) and blood sampling for oxidative stress measurement before and after uns-PR. We observed differences before and after uns-PR during 6 MWT in hemodynamic parameters [systolic blood pressure in resting (138.7 ± 16.3 vs. 128.8 ± 8.6 mmHg, p = 0.005) and end of test (159.8 ± 13.5 vs. 152.0 ± 12.2 mmHg, p = 0.025), heart rate (5th min: 111.6 ± 16.9 vs. 105.4 ± 15.9 bpm, p = 0.049 and 6th min: 112.5 ± 18.3 vs. 106.9 ± 17.9 bpm, p = 0.039)], in oxygen saturation (4th min: 94.6 ± 2.9 vs. 95.8 ± 3.2%, p = 0.013 and 1st min of recovery: 97.8 ± 0.9 vs. 97.3 ± 0.9%), in dyspnea at the end of 6 MWT (1.3 ± 1.5 vs. 0.6 ± 0.9 score, p = 0.005), in distance (433.8 ± 102.2 vs. 519.2 ± 95.4 m, p < 0.001), in estimated O2 uptake (14.9 ± 2.4 vs. 16.9 ± 2.2 mL/min/kg, p < 0.001) in 30 s sit to stand (11.4 ± 3.2 vs. 14.1 ± 2.7 repetitions, p < 0.001)] Moreover, in plasma antioxidant capacity (2528.3 ± 303.2 vs. 2864.7 ± 574.8 U.cor., p = 0.027), in body composition parameters [body fat (32.2 ± 9.4 vs. 29.5 ± 8.2%, p = 0.003), visceral fat (14.0 ± 4.4 vs. 13.3 ± 4.2 score, p = 0.021), neck circumference (39.9 ± 3.4 vs. 37.8 ± 4.2 cm, p = 0.006) and muscle mass (30.1 ± 4.6 vs. 34.6 ± 7.4 kg, p = 0.030)] and sleep quality (6.7 ± 3.9 vs. 5.6 ± 3.3 score, p = 0.036) we observed differences before and after uns-PR. Our findings support the implementation of unsupervised pulmonary rehabilitation programs in patients following COVID-19 recovery, targeting the improvement of many aspects of long COVID-19 syndrome.

Sinus bradycardia is associated with poor outcome in critically ill patients with COVID-19 due to the B.1.1.7 Lineage.

The progress of COVID-19 from moderate to severe may be precipitous, while the characteristics of the disease are heterogenous. The aim of this study was to describe the development of sinus bradycardia in critically ill patients with COVID-19 and its association with outcome in outbreak due to the SARS-CoV-2 B.1.1.7 Lineage. We leveraged the multi-center SuPAR in Adult Patients With COVID-19 (SPARCOL) study and identified patients who required admission to intensive care unit (ICU). Inclusion criteria were: (a) adult (≥18 years old) patients hospitalized primarily for COVID-19; (b) a confirmed SARS-CoV-2 infection diagnosed through reverse transcriptase polymerase chain reaction test of nasopharyngeal or oropharyngeal samples; and (c) at least one blood sample collected at admission and stored for suPAR, hs-CRP, and ferritin testing. All patients had continuous heart rate monitoring during hospitalization. In total, 81 patients were included. Of them, 17 (21 %) and 64 (79 %) were intubated and admitted to the ICU during the first and second wave, respectively. Two (12 %) and 62 (97 %) developed bradycardia before ICU admission, respectively (p < 0.001). Patients with bradycardia had increased suPAR (p < 0.001) and hs-CRP level (p < 0.001). Infusion of isoprenaline and/or noradrenaline was necessary to maintain an adequate rate and peripheral perfusion in all patients. Mortality was significantly higher in patients with bradycardia (p < 0.001). In conclusion, bradycardia was associated with poor outcome. As B.1.1.7 variant strain is spreading more rapidly in many countries, our findings help in the identification of patients who may require early admission to ICU.

Respiratory Muscle Strength: New Technology for Easy Assessment.

Respiratory muscle strength (RMS) is associated with good functionality of the respiratory system. For the general population, it refers to the quality of life, and for the athletes, is related to greater performance. In this study, a comparison was made between two different portable devices, MicroRPM (CareFusion, Kent, United Kingdom) and AirOFit PRO™ (AirOFit, Copenhagen, Denmark), assessing the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP). Twenty-one male professional athletes were evaluated on a voluntary basis and randomly used the devices for RMS assessment, while all athletes underwent Pittsburgh Sleep Quality Index (PSQI), pulmonary function tests and ergospirometry. All measurements of MIP and MEP were made with the same methodology and all participants after the efforts answered the question "easy-operation device-information" and dyspnea and/or respiratory fatigue during trials with the CR10 scale. Results showed statistical differences between VO2max and maximal respiratory strength both for AirOFit PRO™ (r=0.526, p=0.014) and in MicroPRM (r=0.567, p=0.007). The PSQI score showed statistical differences in % of predicted values in MEP with the AirOFit PRO™ device (r=0.478, p=0.028). Athletes reported that the AirOFit PRO™ device is easier in operation as a device and provides more information during trial comparisons to MicroPRM (p=0.001). Athletes reported that the AirOFit PRO™ device is easier in operation as a device and provides more information during the trial compared to MicroPRM. The results did not show differences in RMS (MIP and MEP) between devices (p>0.05). For the people who want to train with tele-exercise and/or tele-rehabilitation, the AirOFit PRO™ device would be an important and safe training solution.

Sleep Quality's Effect on Vigilance and Perceptual Ability in Adolescent and Adult Athletes.

The aim of the study was to investigate the effect of sleep quality in cognitive domains of perceptual ability after exhausting exercise in adolescent and adult athletes. Eighty-six male professional soccer players were included in our study and divided into two groups: adolescents (age: 17.3 ± 0.2 yrs, body mass: 68.9 ± 7.9 kg, body fat: 9.9 ± 3.6 %) versus adults (age: 26.3 ± 5.2 yrs, body mass: 76.5 ± 7.2 kg, body fat: 10.3 ± 3.1 %). For each athlete, prior to cardiopulmonary exercise testing (CPET), anthropometric and morphological characteristics were recorded and Pittsburgh Sleep Quality Index (PSQI) questionnaire was answered. Immediately after CPET, all athletes underwent the perceptual ability test (PATest) for 30 sec and the sum of hits (rep/30 sec) and the time between a visual stimulus and the following stimulus (mean reaction time; RT, sec) were recorded. Oxygen uptake in maximal effort and in anaerobic threshold showed differences between hits (P=0.037) and RT (P=0.025). The variable of PSQI questionnaire "had bad dreams" showed correlation with hits (P=0.021) and RT (P=0.011) and the RT showed correlation with variables "cannot breathe comfortably" (P=0.041) and "...enthusiasm to get things done" (P=0.041). Adolescents showed poorer sleep quality (PSQI score: 5.7 ± 3.6 vs. 2.4 ± 2.6) compared to adults and slower reaction time (0.9 ± 0.1 vs. 0.8 ± 0.1 sec, P=0.029) compared to adolescent athletes with PSQI score ≥5.5. The variable of PSQI score in adolescents is related to HR in maximal effort (r = -0.364, P=0.032) and in adults is related to speed (r = -0.335, P=0.016). Perceptual ability, which requires sustained attention, vigilance, and motor coordination, is often negatively affected by restricted sleep, especially in adolescents.

Obstructive Sleep Apnea Syndrome: The Effect of Acute and Chronic Responses of Exercise.

Obstructive Sleep Apnea Syndrome (OSAS) is a sleep disorder with high prevalence in general population, but alarmingly low in clinicians' differential diagnosis. We reviewed the literature on PubMed and Scopus from June 1980-2021 in order to describe the altered systematic pathophysiologic mechanisms in OSAS patients as well as to propose an exercise program for these patients. Exercise prevents a dysregulation of both daytime and nighttime cardiovascular autonomic function, reduces body weight, halts the onset and progress of insulin resistance, while it ameliorates excessive daytime sleepiness, cognitive decline, and mood disturbances, contributing to an overall greater sleep quality and quality of life.

Prevalence of tobacco use, exposure to secondhand smoke and knowledge on smoking cessation among students of health professions in Central Greece: a cross-sectional study.

OBJECTIVES: The aim of this study was to assess the prevalence of tobacco use and exposure to secondhand smoke among students of health professions (SHPs) and determine possible risk factors for current smoking. In addition, we sought to investigate the level of students' knowledge regarding smoking cessation. DESIGN: Cross-sectional. SETTING: Central Greece. PARTICIPANTS: A convenient sample of 822 SHP volunteers were used, composed of 365 medical students, 123 students from a biochemistry department, 71 students from a nursing department, 176 from medical laboratory department and 84 students from a veterinary medicine department. PRIMARY AND SECONDARY OUTCOME MEASURES: We investigated the prevalence of current smoking and secondhand smoke, their determinants and SHP's knowledge and attitudes regarding smoking cessation. Univariate and logistic regression statistical analysis were used in order to identify risk factors associated with current smoking. RESULTS: The prevalence of current smoking was estimated at 23.5% (95% CI 20.7% to 26.5%), while 49% of current smokers reported they wanted to quit smoking. The prevalence of current e-cigarette use was 1.2%. In addition, 96.5% (95% CI 94.9% to 97.5%) of SHP have been exposed to secondhand smoke at least 1 day per week. Logistic regression analysis showed that increasing age (p<0.001), alcohol consumption (p<0.001) and exposure to secondhand smoke in the home (p<0.001) were independent risk factors for current smoking. Notably, only 11.6% of the participants had learnt about methods to be used for smoking cessation. CONCLUSIONS: Our results underline the need for integrated tobacco control initiatives that should discourage tobacco use among SHP, promote smoke free schools of health science, and implement programs that train SHP in effective cessation-counseling techniques.