Does Low FEV1 in Addition to Fixed Ratio and/or Lower Limit of Normal of FEV1/FVC Improve Prediction of Mortality in COPD? The NHANES-III-linked-mortality Cohort.

PURPOSE: There is presently an ongoing debate on the relative merits of suggested criteria for spirometric airway obstruction. This study tests the null hypothesis that no superiority exists with the use of fixed ratio (FR) of forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) < 0.7 versus less than lower limit predicted (LLN) criteria with or without FEV1 <80% predicted in regards to future mortality. METHODS: In 1988-1994 the Third National Health and Nutrition Examination Survey (NHANES III) measured FEV1 and FVC with mortality follow-up data through December 31, 2011. For this survival analysis 7472 persons aged 40 and over with complete data formed the analytic sample. RESULTS: There were a total of 3554 deaths. Weighted Cox proportional hazards regression revealed an increased hazard ratio in persons with both fixed ratio and lower limit of normal with a low FEV1 (1.79, p < 0.0001), in those with fixed ratio only with a low FEV1 (1.77, p < 0.0001), in those with abnormal fixed ratio only with a normal FEV1 (1.28, p < 0.0001) compared with persons with no airflow obstruction (reference group). These remained significant after adjusting for demographic variables and other confounding variables. CONCLUSIONS: The addition of FEV1 < 80% of predicted increased the prognostic power of the fixed ratio <0.7 and/or below the lower limit of predicted criteria for airway obstruction.

Asthma-related mortality in the United States, 1999 to 2015: A multiple causes of death analysis.

BACKGROUND: Asthma mortality based on the underlying cause of death (UCOD) underestimates disease burden. OBJECTIVE: To analyze asthma mortality in the United States from 1999 to 2015 and the pattern of reporting of asthma and its comorbidities in death certificates, using multiple cause of death (MCOD) records. METHODS: All 156,517 death certificates with any mention of asthma were analyzed for 1999 to 2015. Asthma was defined by International Classification of Diseases, 10th Revision code J45 based on the UCOD or MCOD. Annual age-adjusted asthma death rates were computed according to age, sex, and race/ethnicity. The 6,304 MCOD coded status asthmaticus cases (J46) were also examined. RESULTS: From 1999 to 2015 a total of 59,067 deaths with a UCOD of asthma occurred; 37,832 deaths occurred in females and 21,235 in males (female-male ratio = 1.78). A total of 156,517 deaths with MCOD of asthma occurred; 101,371 deaths occurred in females and 55,146 in males (female-male ratio = 1.83). Hence, 37.7% of deaths with any mention of asthma had asthma as the UCOD (37.3% in females and 38.45% in males). Of these deaths, 41.7% occurred in non-Hispanic blacks and 36% in non-Hispanic whites. Between 1999 and 2015, age-adjusted MCOD death rates changed as follows: 38.1% in Hispanic white females, 34.1% in non-Hispanic black females, 15.1% in non-Hispanic white females, 28.5% in Hispanic white males, 21.3% in non-Hispanic black males, and 25.0% in non-Hispanic white males. Non-Hispanic black females and males had the highest MCOD and UCOD rates throughout the period. CONCLUSION: Among deaths with any mention of asthma, asthma was chosen as the UCOD most often in non-Hispanic black males and least often in non-Hispanic white females. Age-adjusted MCOD rates decreased most in non-Hispanic white males and least in non-Hispanic white females.

Mortality Related to Chronic Obstructive Pulmonary Disease and Co-morbidities in the United States, A Multiple Causes of Death Analysis.

Chronic obstructive pulmonary disease (COPD) mortality based on the underlying cause of death (UCOD) underestimates disease burden. We aimed to determine the current COPD mortality rate, trends and the distribution of co-morbidities using United States (US) multiple-cause of death (MCOD) records. All 38,905,575 death certificates of decedents aged ≥45 years in the United States were analyzed for 1999-2015. COPD was defined by ICD-10 codes J40-J44 and J47 based either on the UCOD or up to 20 contributing causes coded. Annual age-standardized COPD death rates were computed by age, gender and race/ethnicity for those with any mention of COPD. In 2015, COPD was mentioned in 11.59% (292,572 deaths) in MCOD, compared to 11.13% (243,617 deaths) in 1999, a 4% increase. However, it was reported as the UCOD for only 5.56% and 4.97% in 2015 and 1999 respectively, an 11% increase. The most common UCOD in subjects with any mention of COPD was respiratory disorders in 49% of males and 55% of females. The relative change in death rates differed between MCOD and UCOD. For example, among non-Hispanic white females aged 65-74 years the UCOD rate per 100,000 (95% CI) decreased from 163 (160-166) to 147 (145-150), average annual percent decrease (AAPD) -0.26, while the MCOD rate decreased from 308 (304-311) to 263 (260-267), AAPD -0.87. Statistics based on UCOD understated the burden of COPD in the United States. MCOD rates were twice as high as UCOD rates. The relative change in death percent or rates differed between MCOD and UCOD. MCOD analysis should be repeated periodically to help evaluate the burden of COPD-related mortality.

Body Mass Index and Intensive Care Unit Outcomes in African American Patients.

PURPOSE: We sought to determine whether body mass index (BMI) is associated with worse intensive care unit (ICU) outcomes among Black patients. METHODS: Patients admitted to the medical ICU during 2012 were categorized into six BMI groups based on the World Health Organization criteria. ICU mortality, ICU and hospital length of stay (LOS), need for and duration of mechanical ventilation and organ failure rate were assessed. RESULTS: A total of 605 patients with mean age 58.9 ± 16.0 years were studied. Compared with those with normal BMI, obese patients had significant higher rates of hypertension, diabetes mellitus and obstructive sleep apnea diagnoses (P<.001 for all). A total of 100 (16.5%) patients died during their ICU stay. Obesity was not associated with increased odds of ICU mortality (OR=.58; 95% CI, .16-2.20). Moreover, improved survival was observed for class II obese patients (OR, .031; 95% CI, .001-.863). There were no differences in the need for and duration of mechanical ventilation between the BMI groups. However, ICU and hospital LOS were significantly longer in patients with obesity. CONCLUSION: Obesity was not associated with increased ICU mortality; however, obesity was associated with increased comorbid illness and with significant longer ICU and hospital length of stay.

Screen Hours and Sleep Symptoms: The US National Health and Nutrition Examination Survey.

Few studies have examined the relationship between television viewing, computer use, and sleep symptoms. We hypothesized that television and computer time was associated with sleep symptoms. Screen hours were the sum of daily TV hours and computer hours. A total of 4342 participants 20 years and older had data on screen hours. After adjusting for confounders, 4 or more screen hours were significantly associated with increased odds of reporting long sleep latency, nighttime awakening, high sleep hours, and snoring (P < .05). These findings suggest that increased screen/TV time is an important risk factor for sleep symptoms.

Smokeless tobacco use and fractional exhaled nitric oxide in men in a national survey.

BACKGROUND: Tobacco use is an important risk for asthma and increases asthma severity. Fractional exhaled nitric oxide (FeNO) is used as a noninvasive biomarker of eosinophilic airway inflammation. Substantial numbers of men use smokeless tobacco. The effect of use of smokeless tobacco on FeNO is not known. OBJECTIVE: To estimate the association between use of smokeless tobacco and FeNO among US men. METHODS: The National Health and Nutrition Examination Survey 2007-2012 was analyzed to assess association of use of smokeless tobacco and FeNO levels in parts per billion in US men. Participants were categorized by smoking status and use of snuff or chewing tobacco in the previous 5 days. FeNO was measured using a device that relies on an electrochemical sensor. RESULTS: In 3,791 male nonsmokers without asthma, weighted mean natural logarithm FeNO by exposure to smokeless tobacco was 2.81 (geometric mean FeNO, 16.59 ppb; 95% CI, 2.77-2.85) in unexposed and 2.66 (geometric mean, 14.30 ppb; 95% CI, 2.55-2.77) in the exposed. In weighted linear regression analyses, use of smokeless tobacco was associated with significantly lower natural logarithm FeNO after controlling for age and race (black vs nonblack) (coefficient, -0.124; SE, 0.056; P = .03; 95% CI, -0.237 to -0.011). Results were unchanged after additionally controlling for recent nitric oxide-rich vegetable consumption and upper respiratory tract infection (coefficient, -0.118; SE, 0.055; P = .04; 95% CI, -0.228 to -0.007). CONCLUSIONS: Use of smokeless tobacco was associated with lower mean natural logarithm FeNO levels in nonsmokers with no history of asthma. Interpretation of FeNO should consider all forms of tobacco use.

Review: Hemodynamic Characteristics and Outcomes of Sickle Cell Disease Associated Pulmonary Hypertension.

Pulmonary hypertension (PH) is a leading cause of morbidity and early mortality in adults with sickle cell disease (SCD). However, the prevalence, hemodynamic profile and prognosis of SCD-PH remain controversial and need frequent updates. Pulmonary hypertension determined by right heart catheterization (RHC) occurs in 6% to 10% of adults with SCD. Hemodynamically, SCD-PH may be pre-capillary or post-capillary in nature. The exact etiology is unknown and often multifactorial; hence a thorough diagnostic evaluation following established PH guidelines is essential to determine disease prevalence, etiology and outcomes. Data on the efficacy and safety of pulmonary arterial hypertension (PAH) therapy are limited in SCD; clinical trials in these patients are urgently needed. This review provides an overview of RHC-determined hemodynamic characteristics, current management modality and outcomes; we also highlight recent advances and unmet research needs in SCD-PH.

Incidence, Risk Factors and Outcomes of New Onset Supraventricular Arrhythmias in African American Patients with Severe Sepsis.

PURPOSE: New onset supraventricular arrhythmias (SVA) are commonly reported in mixed intensive care settings. We sought to determine the incidence, risk factors and outcomes of new onset SVA in African American (AA) patients with severe sepsis admitted to medical intensive care unit (MICU). METHODS: Patients admitted to MICU between January 2012 through December 2012 were studied. Patients with a previous history of arrhythmia or with new onset of ventricular arrhythmia were excluded. Data on risk factors, critical care interventions and outcomes were obtained. RESULTS: One hundred and thirty-one patients were identified. New onset SVA occurred in 34 (26%) patients. Of those 34, 20 (59%) had atrial fibrillation (AF), 6 (18%) had atrial flutter and 8 (24%) had other forms of SVA. Compared with patients without SVA, patients with new onset SVA were older (69 ± 12 yrs vs 59 ± 13 yrs, P=.003), had congestive heart failure (47% vs 24%, P=.015) and dyslipidemia (41% vs 15%, P=.002). Additionally, they had a higher mean mortality prediction model (MPM II) score (65 ± 25 vs 49 ± 26, P=.001) and an increased incidence of respiratory failure (85% vs 55%, P=.001). Hospital mortality in patients with new onset SVA was 18 (53%) vs 30 (31%); P=.024; however, in a multivariate analysis, new onset SVA was associated with non-significantly increased odds (OR 2.58, 95% CI 0.86-8.05) for in-hospital mortality. CONCLUSIONS: New onset SVA was prevalent in AA patients with severe sepsis and occurred more frequently with advanced age, increased severity of illness, congestive heart failure, and acute respiratory failure; it was associated with higher unadjusted in hospital mortality. However, after multiple adjustments, new onset SVA did not remain an independent predictor of mortality.

Effect modification by race-ethnicity of environmental tobacco smoke exposure on airway inflammation in US children.

BACKGROUND: Asthma mortality and morbidity are higher in black than in white children. Fractional exhaled nitric oxide (FeNO) is a noninvasive biomarker of eosinophilic airway inflammation. Identification of differences in the effect of environmental tobacco smoke (ETS) on airway inflammation by race and ethnicity from a large sample is needed. OBJECTIVE: To estimate a racial difference in association with ETS and FeNO. METHODS: Data from the 2007 to 2012 National Health and Nutrition Examination Survey were analyzed to compare associations of ETS and FeNO levels in US black and other children. No ETS exposure was defined as a serum cotinine level lower than 0.05 ng/mL and ETS exposure was defined as a serum cotinine level of at least 0.05 ng/mL. FeNO was measured using a device that relies on an electrochemical sensor. Analyses took the complex survey design into account. RESULTS: The analytic sample was formed by 5,473 participants (6-11 years old, n = 2,385; 12-19 years old, n = 3,088) with complete data on demographics, serum cotinine levels, and 2 reproducible FeNO measurements. In weighted linear regression analyses at 6 to 11 years, the interaction term for ETS and black race was not significant (P = .15). At 12 to 19 years, the interaction term was significant (P = .03) in an analysis of all racial groups. In race-specific models, the coefficient for ETS exposure in blacks was -0.033 and that in others was -0.175, ie, ETS exposure was associated with a greater decrease in FeNO in non-blacks than in blacks. CONCLUSION: There was no evidence at 6 to 11 years of age for an effect modification by race of the association between ETS and FeNO. At 12 to 19 years, the data suggested an effect modification.

Hemodynamic predictors of mortality in adults with sickle cell disease.

BACKGROUND: Pulmonary hypertension (PH) in adults with sickle cell disease (SCD) is associated with early mortality, but no prior studies have evaluated quantitative relationships of mortality to physiological measures of pre- and postcapillary PH. OBJECTIVES: To identify risk factors associated with mortality and to estimate the expected survival in a cohort of patients with SCD with PH documented by right heart catheterization. METHODS: Nine-year follow-up data (median, 4.7 yr) from the National Institutes of Health SCD PH screening study are reported. A total of 529 adults with SCD were screened by echocardiography between 2001 and 2010 with no exclusion criteria. Hemodynamic data were collected from 84 patients. PH was defined as mean pulmonary artery pressure (PAP) ≥ 25 mm Hg. Survival rates were estimated by the Kaplan-Meier method, and mortality risk factors were analyzed by the Cox proportional hazards regression. MEASUREMENTS AND MAIN RESULTS: Specific hemodynamic variables were independently related to mortality: mean PAP (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.05-2.45 per 10 mm Hg increase; P = 0.027), diastolic PAP (HR, 1.83; 95% CI, 1.09-3.08 per 10 mm Hg increase; P = 0.022), diastolic PAP - pulmonary capillary wedge pressure (HR, 2.19; 95% CI, 1.23-3.89 per 10 mm Hg increase; P = 0.008), transpulmonary gradient (HR, 1.78; 95% CI, 1.14-2.79 per 10 mm Hg increase; P = 0.011), and pulmonary vascular resistance (HR, 1.44; 95% CI, 1.09-1.89 per Wood unit increase; P = 0.009) as risk factors for mortality. CONCLUSIONS: Mortality in adults with SCD and PH is proportional to the physiological severity of precapillary PH, demonstrating its prognostic and clinical relevance despite anemia-induced high cardiac output and less severely elevated pulmonary vascular resistance.

Gender and the association of smoking with sleep quantity and quality in American adults.

Smoking and gender are known risk factors for sleep disorders. Studies of samples from Norway and Japan have suggested stronger associations between smoking and disrupted sleep in women; therefore, we examined, gender differences in the association in the U.S. population. We analyzed data from the 2005-2006 National Health and Nutrition Examination Survey. We examined the associations between smoking and self-reported measures of sleep disorders (i.e., snoring, short sleep, long sleep, poor sleep, and health care provider diagnosis of sleep disordered breathing) using multivariate logistic regression with odds ratios (OR) and 95% confidence intervals (CI) as measures of association. We also assessed whether the associations varied by gender using a gender x smoking interaction term. Compared to never smokers, current smokers had significantly higher odds of self-reported snoring (OR = 2.0; 95% CI = 1.56-2.56), short sleep (OR 1.68; 95% CI = 1.35-2.10) and poor sleep (OR = 1.38; 95% CI = 1.09-1.74). A dose-response relationship was observed between the amount smoked and sleep symptoms. In multivariate analyses, no significant gender x smoking interaction was observed for snoring, short sleep or poor sleep. Current smoking was independently associated with increased odds of snoring, short sleep, and poor sleep in women and men among U.S. adults.

Post-Acute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) After Infection During Pregnancy.

OBJECTIVE: To estimate the prevalence of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) after infection with SARS-CoV-2 during pregnancy and to characterize associated risk factors. METHODS: In a multicenter cohort study (NIH RECOVER [Researching COVID to Enhance Recovery]-Pregnancy Cohort), individuals who were pregnant during their first SARS-CoV-2 infection were enrolled across the United States from December 2021 to September 2023, either within 30 days of their infection or at differential time points thereafter. The primary outcome was PASC , defined as score of 12 or higher based on symptoms and severity as previously published by the NIH RECOVER-Adult Cohort, at the first study visit at least 6 months after the participant's first SARS-CoV-2 infection. Risk factors for PASC were evaluated, including sociodemographic characteristics, clinical characteristics before SARS-CoV-2 infection (baseline comorbidities, trimester of infection, vaccination status), and acute infection severity (classified by need for oxygen therapy). Multivariable logistic regression models were fitted to estimate associations between these characteristics and presence of PASC. RESULTS: Of the 1,502 participants, 61.1% had their first SARS-CoV-2 infection on or after December 1, 2021 (ie, during Omicron variant dominance); 51.4% were fully vaccinated before infection; and 182 (12.1%) were enrolled within 30 days of their acute infection. The prevalence of PASC was 9.3% (95% CI, 7.9-10.9%) measured at a median of 10.3 months (interquartile range 6.1-21.5) after first infection. The most common symptoms among individuals with PASC were postexertional malaise (77.7%), fatigue (76.3%), and gastrointestinal symptoms (61.2%). In a multivariable model, the proportion PASC positive with vs without history of obesity (14.9% vs 7.5%, adjusted odds ratio [aOR] 1.65, 95% CI, 1.12-2.43), depression or anxiety disorder (14.4% vs 6.1%, aOR 2.64, 95% CI, 1.79-3.88) before first infection, economic hardship (self-reported difficulty covering expenses) (12.5% vs 6.9%, aOR 1.57, 95% CI, 1.05-2.34), and treatment with oxygen during acute SARS-CoV-2 infection (18.1% vs 8.7%, aOR 1.86, 95% CI, 1.00-3.44) were associated with increased prevalence of PASC. CONCLUSION: The prevalence of PASC at a median time of 10.3 months after SARS-CoV-2 infection during pregnancy was 9.3% in the NIH RECOVER-Pregnancy Cohort. The predominant symptoms were postexertional malaise, fatigue, and gastrointestinal symptoms. Several socioeconomic and clinical characteristics were associated with PASC after infection during pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT05172024.

Hemodialysis as an Effective Treatment for Combined Amlodipine and Metformin Overdose: A Case Report and Literature Review.

The combined toxicity of amlodipine and metformin is a rarely reported phenomenon in the literature. The management varies depending on the clinical status of the patient. We present a case that was managed successfully with the early initiation of hemodialysis.

A Rare Case of Cyclophosphamide-Induced Posterior Reversible Encephalopathy Syndrome in a Patient With Acute Lupus Nephritis Flare.

Posterior reversible encephalopathy syndrome (PRES) is a syndrome encompassing both clinical and radiological manifestations with white matter vasogenic edema predominantly of the posterior and parietal lobes of the brain. It may accompany several medical conditions including immunosuppressive/cytotoxic drugs. We present a case of cyclophosphamide-induced PRES in a patient treated for acute lupus flare with biopsy-proven lupus nephritis. A 23-year-old African American female presented with non-specific symptoms over a six-month period on a medical background of systemic lupus erythematosus and biopsy-proven focal lupus nephritis class III on hydroxychloroquine, prednisone, and mycophenolate mofetil for which she was non-compliant. She was borderline hypertensive, tachycardic, saturating well on ambient air, and alert and oriented. Laboratory workup revealed electrolyte imbalance, elevated serum urea, creatinine, and B-type natriuretic peptide, low serum complements, and elevated double-stranded DNA (dsDNA) with negative lupus anticoagulant, anti-cardiolipin, and B2 glycoprotein antibody. Chest imaging revealed cardiomegaly with small pericardial effusion, left pleural effusion, and trace atelectasis, with no deep vein thrombosis on Doppler ultrasound. She was admitted to the intensive care unit for lupus flare with severe hyponatremia and was continued on mycophenolate mofetil, hydroxychloroquine, and prednisone 60 mg for induction therapy as well as intravenous fluids. Hyponatremia resolved, and blood pressure was controlled. She became fluid overloaded and anuric, with pulmonary edema and worsening hypoxic respiratory failure not responding to diuretic challenges. Daily hemodialysis was started, and she was intubated. Prednisone was tapered down, mycophenolate was switched to cyclophosphamide/mesna. She became agitated, restless, and confused, with waxing and waning consciousness and hallucinations. She was continued on bi-weekly cyclophosphamide for induction therapy. After the second dose of cyclophosphamide, her mentation worsened. Non-contrast MRI showed extensive bilateral cerebral and cerebella deep white matter high-intensity signals suggestive of PRES, which was new compared to one year prior. Cyclophosphamide was held and her mentation improved. She was successfully extubated and discharged to a rehabilitation center. The exact pathophysiological mechanism of PRES is not known. Endothelial damage and vasogenic edema have been hypothesized as possible mechanisms. Severe anemia, fluid overload, and renal failure are some of the causes of endothelial dysfunction and vasogenic edema with disruption of the blood-brain barrier, which were found in our patient, but repeated dosing of cyclophosphamide worsened her condition. Discontinuation of cyclophosphamide led to a significant improvement and complete reversal of her neurologic symptoms, implying that prompt recognition and management of PRES is vital to prevent permanent damage and even death in these patients.

Racial and geographic variation in coronary heart disease mortality trends.

BACKGROUND: Magnitudes, geographic and racial variation in trends in coronary heart disease (CHD) mortality within the US require updating for health services and health disparities research. Therefore the aim of this study is to present data on these trends through 2007. METHODS: Data for CHD were analyzed using the US mortality files for 1999-2007 obtained from the US Centers for Disease Control and Prevention. Age-adjusted annual death rates were computed for non-Hispanic African Americans (AA) and European Americans (EA) aged 35-84 years. The direct method was used to standardize rates by age, using the 2000 US standard population. Joinpoint regression models were used to evaluate trends, expressed as annual percent change (APC). RESULTS: For both AA men and women the magnitude in CHD mortality is higher compared to EA men and women, respectively. Between 1999 and 2007 the rate declined both in AA and in EA of both sexes in every geographic division; however, relative declines varied. For example, among men, relative average annual declines ranged from 3.2% to 4.7% in AA and from 4.4% to 5.5% in EA among geographic divisions. In women, rates declined more in later years of the decade and in women over 54 years. In 2007, age-adjusted death rate per 100,000 for CHD ranged from 93 in EA women in New England to 345 in AA men in the East North Central division. In EA, areas near the Ohio and lower Mississippi Rivers had above average rates. Disparities in trends by urbanization level were also found. For AA in the East North Central division, the APC was similar in large central metro (-4.2), large fringe metro (-4.3), medium metro urbanization strata (-4.4), and small metro (-3.9). APC was somewhat higher in the micropolitan/non-metro (-5.3), and especially the non-core/non-metro (-6.5). For EA in the East South Central division, the APC was higher in large central metro (-5.3), large fringe metro (-4.3) and medium metro urbanization strata (-5.1) than in small metro (-3.8), micropolitan/non-metro (-4.0), and non-core/non-metro (-3.3) urbanization strata. CONCLUSIONS: Between 1999 and 2007, the level and rate of decline in CHD mortality displayed persistent disparities. Declines were greater in EA than AA racial groups. Rates were greater in the Ohio and Mississippi River than other geographic regions.

Extended-Spectrum Beta-Lactamase- and Carbapenemase-Producing Enterobacteriaceae Family of Bacteria from Diarrheal Stool Samples in Northwest Ethiopia.

Background: Resistance among the commensal flora is a serious threat because they are highly populated ecosystems like the gut, maybe a source of extraintestinal infections. Infections due to extended-spectrum beta-lactamase (ESBL)- and carbapenemase (CPM)-producing Enterobacteriaceae family of bacteria impose a major global issue because they are usually resistant to multiple antimicrobial agents. Data on the fecal ESBL- and CPM-producing group of bacteria in developing countries including Ethiopia are limited mainly due to resource constraints. Thus, this study aimed to determine the prevalence of multidrug-resistant (MDR)-, ESBL-, and CPM-producing Enterobacteriaceae family of bacteria from diarrheal stool samples at the University Hospital, Northwest Ethiopia. Materials and Methods: A hospital-based cross-sectional study was conducted involving a total of 384 study participants having gastrointestinal complaints from January to April 2019. A diarrheal stool sample was aseptically collected and inoculated on a MacConkey agar plate. After getting pure colonies, biochemical and antimicrobial susceptibility testing was done following standard microbiological techniques. ESBL production was screened using ceftazidime and cefotaxime and confirmed using a combined disk diffusion test. Carbapenemases were screened by meropenem disk and confirmed by the modified carbapenem inactivation method. Data were checked, cleaned, and entered using Epi Info version 7.1 and transferred to SPSS version 20 for analysis. Result: A total of 404 Enterobacteriaceae groups of bacteria were isolated from 384 diarrheal stool samples. The overall prevalence of fecal MDR-, ESBL-, and CPM-producing group of Enterobacteriaceae was 196 (48.5%), 66 (16.3%), and 4 (1%), respectively. Of the total ESBL-producing Enterobacteriaceae, E. coli (41/66 (62.1%)) and K. pneumoniae (18/66 (27.3%)) were the most predominant isolates. One half of CPE has been observed in Citrobacter species and the rest in E. coli (25%) and P. vulgaris (25%). Conclusion and Recommendation. Finding the high rate of ESBL-producing Enterobacteriaceae and CPE requires strict infection control measures and careful selection of empirical therapy in the study area. Therefore, active surveillance with large sample size and better infection prevention control is needed.

Fractional exhaled nitric oxide and mortality in asthma and chronic obstructive pulmonary disease in a national cohort aged 40 years and older.

BACKGROUND: Little is known about Fractional concentration of exhaled Nitric Oxide (FeNO) as a predictor of mortality in persons with asthma or chronic obstructive pulmonary disease (COPD). OBJECTIVE: This study tested the hypotheses that FeNO level ≥ 25 ppb was associated with mortality in a national cohort of persons with asthma or COPD age ≥ 40 years. METHODS: In the 2007-2012 National Health and Nutrition Examination Survey (NHANES), FeNO was measured using an electrochemical sensor. Mortality was determined through 2015 using linkage to the National Death Index. Weighted Cox proportional hazards survival analysis was performed taking the complex survey design into account using STATA V.17. RESULTS: Among the 611 participants with current asthma, 5.16% died during the follow-up period. FeNO ≥ 25 ppb was associated with a hazard ratio (HR) of 0.20, (p = 0.006, 95% CI:0.068-0.618) alone or with little change after controlling for confounding variables. Due to effect modification, the analysis was repeated in persons with and without a history of emergency department (ED) visit for asthma in the previous year. In 522 persons without ED visits, FeNO ≥ 25 ppb was significantly associated with mortality HR 0.094, 95 CI 0.034-0.26, p < 0.001. In 83 persons with ED visits no significant association remained after controlling for all confounders. (Six persons were omitted from this analysis due to missing data on confounders in the extended regression model.) Among 614 with COPD, FeNO ≥ 25 ppb was not associated with mortality. CONCLUSION: In persons with current asthma at baseline, FeNO ≥ 25 ppb was associated with reduced hazard of mortality during follow up among those with no history of ED visits in the previous year. No significant association of FeNO with mortality was seen in persons with COPD.

Pulmonary Embolism and Chronic Superior Vena Cava Occlusion Complicating Central Line-Associated Venous Thromboembolism in a Sickle Cell Disease Patient.

Sickle cell disease (SCD), the most common genetic disorder globally, is often associated with an increased risk of venous thromboembolic events (VTE). Many of these patients have central lines placed for the purposes of repeated medication administration, blood transfusions, and blood draw, further increasing the risk of VTE. Given the non-specific presentation of VTE and pulmonary embolism, as well as the risk of mortality if interventions are delayed, a high index of suspicion is required for early diagnosis of the condition. We report the case of a 35-year-old woman with SCD and a port-a-cath in place who presented with extensive upper extremity and intrathoracic VTE with associated pulmonary embolism and chronic superior vena cava (SVC) occlusion. We also discuss the peculiarities of the clinical manifestations and management of VTE and pulmonary embolism in the setting of SCD based on the evidence from existing literature.