Saint Francis Hospital

IntroductionConsidering the expected decrease in psychiatrists due to retirements and fewer individuals entering the field, it is important to examine the pharmacist’s role in improving mental health outcomes. This study evaluated pharmacist treatment of depression in a behavioral health-integrated virtual (BHIV) clinic where patients were generally followed twice monthly compared with the standard of care, twice-yearly primary care management.MethodsA descriptive report from January 1, 2020, to May 31, 2023, identified patients diagnosed with depression managed in the pharmacist-run BHIV clinic and the internal medicine (IM) clinics. Patients were excluded if they were established with a psychiatric specialist, diagnosed with a severe psychiatric disorder or postpartum depression, pregnant, or only prescribed trazodone at doses less than 100 mg. One hundred forty-two patients were included, with 71 in each group. The primary outcome was the final Patient Health Questionnaire-9 (PHQ-9) score.ResultsThe average initial PHQ-9 score was equal in both groups (13 ± 4.5; 13 ± 5.5; P = 0.8). The average final PHQ-9 score was similar between groups (7 ± 5.6; 6 ± 6.6; P = 0.7). The average time to remission and response in weeks was shorter in the BHIV group (9 ± 6.4; 27 ± 20.5; P ≤ 0.001; 7 ± 5.9; 29 ± 26.0; P ≤ 0.001).DiscussionRemission and response were identified more rapidly in the BHIV group than in the IM group. Clinical outcomes were comparable between cohorts at the final assessment. Overall, this shows that pharmacists can provide close follow-up and improve patients’ quality of life by providing rapid symptom resolution.

IntroductionGlucagon-like Peptide-1 (GLP-1) agonists cause delayed gastric emptying by acting on vagal afferent nerves. Retained gastric contents (RGC) increase the risk of pulmonary aspiration, particularly under anesthesia in endoscopic procedures. This systematic review and meta-analysis aim to summarize the current evidence on pulmonary aspiration in patients receiving GLP-1 agonists undergoing endoscopy.MethodsA systematic review was conducted using Cochrane, Embase, and PubMed from inception to May 2024, including studies and case reports examining GLP-1 agonists and pulmonary aspiration. Data on study characteristics, patient demographics, and GLP-1 agonist use were collected. A pooled analysis of retrospective studies was performed using RevMan version 5.4.1. The study protocol was registered in the PROSPERO database (ID CRD42024595241).ResultsA total of five case reports involving six patients and twelve studies including 210,216 patients were identified. Pulmonary aspiration occurred in 143 of 87,691 patients (0.16%) in the GLP-1 agonist group and 149 of 122,525 patients (0.12%) in the placebo group. Notably, three patients experienced aspiration despite stopping GLP-1 agonists more than six days prior and fasting for over eight hours. The meta-analysis showed an odds ratio of 1.23 (P = 0.59; 95% CI, 0.58 to 2.60) for pulmonary aspiration associated with GLP-1 agonist use, which was not statistically significant.DiscussionThis analysis did not find a statistically significant association between GLP-1 agonist use and pulmonary aspiration risk during endoscopic procedures. While the findings align with some existing studies suggesting minimal increased risk, the presence of aspiration cases despite prolonged fasting highlights potential gaps in current peri-procedural management. Limitations include reliance on retrospective data and case reports, as well as variability in fasting protocols.ConclusionThe study found no significant association between GLP-1 agonist use and pulmonary aspiration risk during endoscopy. Further research is warranted to develop evidence-based fasting guidelines and optimize peri-procedural management for patients on GLP-1 agonists.

Introduction: This work evaluated outcomes of robotic inguinal hernia repair (RIHR) in a single-institution study comparing surgeons with varying robotic experience. Methods: A retrospective study of all patients with RIHR performed between July 2016 and September 2021 at a single institution was performed. Baseline characteristics and outcomes between surgeons with >5 years of robotic experience (ERS) were compared with those with <5 years (NRS). Results: A total of 297 cases of RIHR were performed. Mean age was 58.3 years (standard deviation [SD] 15.3) with a strong male predominance (88.2%). Forty-four patients (14.8%) had a previous repair, 87 (29.3%) underwent bilateral repair, and mean body mass index was 27.7 (SD 4.8). Sixty cases were performed by one ERS surgeon, and the remaining 237 cases were performed by eight NRS. ERS had more recurrent hernias (38.3% versus 8.9%, P < .001), previous abdominal surgery (48% versus 25%, P < .001), and more often had bilateral inguinal hernias (42% versus 26%, P = .018). Incarcerated hernias were more commonly repaired by ERS compared with NRS (35% versus 8.9%, P < .001). Mean operative time was higher for ERS (132.8 minutes versus 106.2, P < .001). ERS was associated with more intraoperative complications (10% versus 0%, P < .001) as well as 30-day complications (6.7% versus 1.7%, P = .033); however, these were of minimal clinical significance. While ERS had a higher rate of radiographical recurrence (6.7% versus 3.0%, P < .001) after 30 days, there was no difference in clinical concern for recurrence. Conclusions: While ERS may approach more complex situations, RIHR is a safe approach for both novice and experienced robotic surgeons.

Abstract Introduction: Non-neoformans cryptococcal species are typically saprophytes and rarely infect humans; among these, Cryptococcus uniguttulatus can occasionally cause lung or brain infections. In this case, we present a 51-year-old female with dyspnea whose workup incidentally uncovered a pulmonary mass, later diagnosed as Cryptococcus uniguttulatus infection. Case: A 51-year-old female with a medical history of hypertension and hyperlipidemia presented with hemoptysis. She leads an active lifestyle however complained of dyspnea on exertion for one month with night sweats. She has no recent travel history aside from trips to Florida, including a zoo visit without direct animal contact, and a single visit to Aruba decades prior. Her occupational history includes handling immunosuppressive medications, and environmental history noted past exposure to mold in her childhood home, though her current residence in Southington, Connecticut was without obvious mold exposure. She owns a dog that is occasionally allowed off leash. No personal reports of gardening or hiking. She denies smoking, alcohol, or illicit drug use. Dyspnea was initially thought to be cardiac; a stress test performed a week prior to admission was followed by a coronary computed tomography (CT) that incidentally revealed a left lower lobe mass. Endobronchial ultrasound (EBUS) bronchoscopy with biopsy was performed while initiation of empiric doxycycline two days prior to presentation.Physical examination was unremarkable, and the patient was afebrile and hemodynamically stable on room air. Laboratory results showed a WBC of 6.6, hemoglobin of 13.5, platelets of 280, and unremarkable renal and liver function tests. HIV and hepatitis screening were negative. Chest CT showed a dense consolidation in the mid-lower left lobe. Pathology from prior specimen revealed yeast and hyphae on GMS fungal staining. Doxycycline was stopped and she was transitioned to voriconazole with good clinical improvement. After discharge, fungal cultures confirmed Cryptococcus uniguttulatus. Discussion: Although non-neoformans cryptococci are typically environmental saprophytes and rarely cause human disease, they can occasionally lead to severe infections, particularly in the lungs or central nervous system. Her exposure was ambiguous as she had no strong history of gardening or direct contact with animals along with no evidence of an immunocompromising condition. This case highlights the importance of considering rare fungal pathogens in pulmonary masses even in immunocompetent patients and in non-endemic regions. The use of EBUS bronchoscopy with biopsy was essential in obtaining the definitive diagnosis. Early recognition and prompt anti-fungal therapy are essential for improving patient outcomes in such atypical presentations.

Introduction: Areas where people disproportionately die at home from cardiovascular disease (CVD) are incompletely described. The United States (US) Centers for Disease Control and Prevention (CDC) developed the Social Vulnerability Index (SVI) using 16 US census measures clustered into four themes of vulnerability. The SVI and its themes may be utilized to score counties based on county-level social determinants of health. We conducted a county-level ecological study on the association of county SVI and its themes with CVD-related deaths occurring at home. Method: We used 2016–2020 CDC Wide-ranging Online Data for Epidemiologic Research data on county-level CVD-related (ischemic heart disease, heart failure, stroke, and hypertension) deaths in persons ≥18 years of age, and location of death (home, etc.), available for 92.4% of 3,226 US counties. The SVI and its themes (socioeconomic status [theme 1], household composition&amp;disability [theme 2], minority status&amp;language [theme 3], and housing type&amp;transportation [theme 4]) are scored from 0 to 1 (low to high vulnerability) based on their national percentile ranking. We grouped county-level SVI from 2018 into quartiles (Q1 [least] to Q4 [most vulnerable]). Due to overdispersion, we used negative binomial regression to estimate the likelihood of CVD-related deaths at home in Q4 vs Q1, offset by the total county CVD-related deaths. We reported rate ratios (RR [95% Confidence Interval], p-value). Results: CVD-related home death rates increased in a stepwise manner from SVI Q1 to Q4 (Fig). For overall SVI, the likelihood of death at home was 15% higher in Q4 vs Q1 (RR 1.15 [1.12–1.18], p&lt;0.0001). The greatest disparity was seen in theme 1, with Q4 vs Q1 having 27% higher likelihood of death at home (RR 1.27 [1.22–1.33], p&lt;0.0001). For theme 2, there was no statistically significant difference in the likelihood of death at home in Q4 vs Q1 (RR 0.98 [0.95–1.01], p=0.36). For theme 3, Q4 vs Q1 had 6% higher likelihood of death at home (RR 1.06 [1.03–1.09], p&lt;0.0001). For theme 4, Q4 vs Q1 had a 6% lower likelihood of death at home (RR 0.94 [0.91–0.97], p&lt;0.001). Conclusion: In US counties, higher social vulnerability was associated with a higher likelihood of CVD-related death at home, with the strength and direction of this association varying between the themes of vulnerability. SVI and its themes may be utilized to target interventions to improve access to hospital or hospice care.

ABSTRACTIntroductionNeurodevelopmental delay has been reported among preterm infants who survive beyond the neonatal period. However, there is paucity of data regarding neurodevelopmental outcomes in preterm infants in Africa, including Uganda.ObjectivesThis study aimed at determining the prevalence and factors associated with neurodevelopment delay (NDD) in preterm infants aged 6 to 24 months of adjusted gestation age.MethodsA cross-sectional study was conducted among 206 preterm infants, aged between 6 and 24 months of adjusted gestation age in the preterm follow up clinics at St. Francis Hospital Nsambya and Mulago Specialized Women and Neonatal Hospital in Kampala-Uganda from 1stJanuary 2021 to 1stJanuary 2022.ResultsThe prevalence of NDD was 13.6% (28/206), with social delay comprising 12.1% (25/206), fine motor delay 11.7% (24/206), language delay 10.7% (22/206) and gross motor delay 7.8% (16/206). Factors associated with NDD included microcephaly [aPR=6.2, CI: 2.6-33.5, P=0.0002], severe acute malnutrition (SAM) [aPR=4.6, CI: 1.87-12.56, P=0.021], incomplete immunization [aPR=2.8, CI: 1.23-4.76, P=0.013], neonatal sepsis [aPR=3.8, CI: 1.1-9.3, P=0.026], neonatal hypoglycemia [aPR=6.2, CI: 1.8-16.4, P=0.002], lack of caretaker social support [aPR=8.3, CI: 2.43-37.9, P=0.002] and families with more than 5 children [aPR=6.8, CI: 2.24-22.7, P=0.002]ConclusionsThe 13.6% prevalence of NDD is noteworthy, with the social and fine motor domains affected most. Modifiable factors like malnutrition, lack of caretaker social support and incomplete immunization should be screened and addressed to reduce NDD among preterm infants in Uganda.

Femoral-popliteal bypass (FPB) surgery is a common lower extremity revascularization procedure. As the population continues to age, this procedure is being performed increasingly on older patients. This study investigated whether outcomes differ in this population. Patients over and less than 80 years old who underwent FPB between 2009-2013 were queried using an existing hospital registry. Demographics, comorbidities, intraoperative complications, perioperative outcomes, and two-year patencies were compared. Twenty-four patients in the octogenarian cohort (OC) and 72 patients in the non-octogenarian cohort (NOC) were identified. There was a lower prevalence of smoking (p=0.018) and higher prevalence of hypertension (p=0.021) among octogenarians. Other medical characteristics were similar (p<0.05). There were no differences in use of vein versus PTFE (p=0.002) as a conduit, or above (OC 20.0% vs. NOC 36.7%), versus below knee (OC 80.0% vs. NOC 63.3%) distal anastomosis (p>0.05) between the groups. There was a difference (p<0.01) in indication for procedure (OC/NOC): claudication (0%/44%), limb salvage (71%/31%), and rest pain (29%/25%). There were no differences in 30-day readmissions (17% vs. 21%; p=0.59) or incidence of postoperative (25% vs. 19%; p=0.56) or intraoperative complications (8.3% vs. 4.2%; p=0.52). Length of stay (LOS) was longer and statistically significant in octogenarians (12 days vs. 7 days; p=0.032) and remained significant after multivariate linear regression (p=0.015). Patencies in OC were lower and dropped faster after six months; however, there were no statistically significant differences in patencies at any time interval (p>0.05). The position of the distal anastomosis relative to the knee, conduit type, and indication were not independently predictive of patency outcomes (p>0.05). The safety and efficacy of FPB in octogenarians is similar to the general population despite LOS in octogenarians being 5.98 days longer. While the difference in indication suggests that vascular surgeons are more conservative in treating octogenarians, our analysis did not reveal significant differences between populations and suggests that lower extremity bypass can be performed safely with comparable results in this cohort. A larger cohort is needed to validate these results.