E-cigarette Use and Severe Coronavirus Disease 2019 (COVID-19) Outcomes: A Meta-Analysis.

E-cigarettes have been known to cause varied poor health outcomes prior to coronavirus disease 2019 (COVID-19), but after the impact of COVID-19, evidence came out that was, in some instances, not as expected regarding the severity of COVID-19 among e-cigarette users (vapers). A meta-analysis was performed on the available evidence to comprehensively find the effect of COVID-19 on existing or past e-cigarette users (vapers). The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were used to perform this meta-analysis. PubMed was searched for observational studies that described outcomes after COVID-19 positivity from December 1, 2019, to December 2023. Medical Subject Headings (MeSH) keywords were used for searching the relevant studies highlighting the relationship between COVID-19 and e-cigarette users. Calculations for pooled prevalence, 95% confidence interval (95% CI), weights for current e-cigarette users and vapers, and outcomes (events) were made. To analyze the data, Review Manager V.5.4 was used. The I² statistic was used to assess statistical heterogeneity. The I² statistic of >50% was considered significant heterogeneity. The "leave-one-out" method was used for sensitivity analysis. Out of 3231 studies, four studies reported data on vaping and non-vaping status and composite outcomes, resulting in a sample size of 653 COVID-19-positive cases. The pooled prevalence of being COVID-19 positive, having symptoms, or visiting an emergency room was 7.78% (653/8392). COVID-19 patients with current vaping status had decreased odds of poor outcomes compared to non-smokers, with a pooled odds ratio (OR) of 0.09 (95% CI 0.00-2.42; p>0.05) with heterogeneity between studies (I²=99%, p=0.15). Because of difficulties related to data collection and other factors, this meta-analysis was unable to conclusively establish the correlation between e-cigarette usage and severe COVID-19 outcomes such as hospitalization, admission to the intensive care unit, and fatality. Additional research using more detailed data is necessary to fully understand this correlation.

Prevalence of active and passive smoking among asthma and asthma-associated emergency admissions: a nationwide prevalence survey study.

Asthma affects 7% of children and 8% of adults in the United States. There is a paucity of studies examining the association between passive smoking and an increased risk of asthma exacerbations that led the authors to examine the association between various modes of smoking and rates of asthma exacerbations. A retrospective cross-sectional/case-control study was conducted using the National Health and Nutrition Examination Survey dataset (2013-2018). Out of 312,979 respondents, 35,758 (11.43%) had a history of asthma, 9083 (2.9%) had asthma attacks in the past year, and 4731 (1.51%) had asthma-related emergency room admissions in the past year. Prevalence of asthma-related emergency admissions were higher among active cigarette smoking (46.25 vs 35.46%), e-cigarette smoking (26.63 vs 16.07%), and passive smoking at home (37.53 vs 25.67%), workplace passive smoking (14.35 vs 12.11%), in bar (32.38 vs 26.16%), and car (26.21 vs 14.44%) (p < 0.0001). In multivariate regression analysis, we found regular cigarette smoking (OR 1.13, 95% confidence interval (CI) 1.009-1.260, p = 0.0252), e-cigarette (OR 2.13, 95% CI 1.92-2.36, p = 0.0043), cigar use (OR 1.21, 95% CI 1.1-1.33, p < 0.001), ultra-long cigarette length (OR 4.85, 95% CI 3.33-7.06, p < 0.0001), and passive smoking (OR 5.25, 95% CI 3.43-8.06, p < 0.0001) were associated with increased rates of asthma exacerbations over last 12 months. The study shows increased odds of asthma exacerbations among those using ultra-long cigarettes, e-cigarettes, and cigars. Consequently, passive inhalation from even a single smoker in the home, workplace, bars and cars is associated with worsening outcomes in asthma patients.

E-cigarette use and prevalence of lung diseases among the U.S. population: a NHANES survey.

The primary aim of this study was to evaluate epidemiological characteristics and prevalence of lung disease among e-cigarettes users in the United States. A population-based, cross-sectional survey was performed using the National Health and Nutrition Examination Survey (NHANES) of 2015-2018. Adults using e-cigarettes (SMQ900), traditional smoking (SMQ020: > 100 cigarettes in lifetime or SMQ040: current cigarettes use), and dual smoking (e-cigarettes and traditional smoking) were identified and compared in their sociodemographic characteristics and prevalence of lung diseases (Asthma: MCQ010 and COPD: MCQ160O). We used the chi square test (categorical variables) and Mann-Whitney test and unpaired-student t test (continuous variables). p-value <0.05 was used as a reference. We excluded respondents <18 years and missing data on demographics and outcomes. Out of 178,157 respondents, 7745 (4.35%), 48,570 (27.26%), and 23,444 (13.16%) were e-cigarette smokers, traditional smokers, and dual smokers, respectively. Overall prevalence of asthma was 15.16% and COPD was 4.26%. E-cigarette smokers were younger in comparison to traditional smokers (median: 25 years vs 62 years; p < 0.0001). In females (49.34% vs 37.97%), Mexican (19.82% vs 13.35%), annual household income above $100,000 (23.97% vs 15.56%), prevalence of e-cigarette smoking was higher in comparison to traditional smoking (p < 0.0001). The prevalence of COPD was higher among dual smokers in comparison to e-cigarette and traditional smoking (10.14% vs 0.25% vs 8.11%; p < 0.0001). Prevalence of asthma was higher among dual and e-cigarette smokers in comparison with traditional smokers and non-smokers (22.44% vs 21.10% vs 14.46% vs 13.30%; p < 0.0001). Median age (Q1-Q3) was lower at which asthma (7 years (4-12) vs 25 years (8-50)) was diagnosed first among e-cigarettes smokers in comparison with traditional smokers. In a mixed effect multivariable logistic regression analysis, we found higher odds of asthma among e-cigarette users in comparison with non-smokers (Odds ratio (OR): 1.47; 95% Confidence Interval (CI): 1.21-1.78; p = 0.0001). Chronic Obstructive Pulmonary Disease (COPD) respondents were also associated with 11.28 higher odds of e-cigarette utilization (Oddsratio (OR): 11.28; 95% Confidence Interval (CI): 5.59-22.72; p < 0.0001). We conclude the higher prevalence of e-cigarette users is seen among the younger population, female, Mexican race, and annual income above $100,000 in comparison to traditional smokers. Chronic Obstructive Pulmonary Disease (COPD) and asthma were both more prevalent in dual smokers. As asthma was more prevalent and diagnosed at an early age in e-cigarette smokers, more prospective studies are needed to understand the effects of e-cigarette among the population at risk to mitigate the sudden rise in utilization and to create awareness.

Unmasking the Common Thief: A Rare Cause of Isolated Hypoglossal Nerve Palsy.

Multiple cranial nerve palsies frequently accompany hypoglossal nerve palsy, potentially indicating malignancy, such as lymphoma, nasopharyngeal carcinoma, or metastases. However, when solely the hypoglossal nerve is affected, the causes may involve Chiari malformation, arachnoid cyst, or infectious mononucleosis, suggesting a positive prognosis. Craniocervical junction tuberculosis (TB), is an uncommon cause of isolated hypoglossal nerve palsy and has been reported infrequently in the literature. Craniocervical junction tuberculosis accounts for only 0.5% of TB cases overall and 6% of extra-pulmonary TB cases. We present here one such case of a 17-year-old male of Indian origin with a subacute history of tongue deviation and neck pain. Additionally, the patient reported loss of weight and appetite. The patient had significant posterior cervical lymphadenopathy. Neurological examination revealed findings suggestive of right peripheral hypoglossal nerve involvement. Blood investigations showed lymphocytosis along with an elevated erythrocyte sedimentation rate of 45 mm/h and elevated lactate dehydrogenase levels of 325 U/L. Tuberculin skin testing was positive and sputum acid-fast staining confirmed acid-fast bacilli. Magnetic Resonance Imaging of the cervical spine revealed a soft tissue component in the prevertebral space measuring 3.5×4.8 cm with a right paraspinal component adjoining the hypoglossal canal with peripheral contrast enhancement. Histological findings on the lymph node showed granulomatous lymphadenitis, suggestive of tuberculosis. The patient was started on 4-drug anti-tubercular therapy consisting of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol for a period of 18 months. He was subsequently followed up for 6 months till the resolution of palsy. This case emphasizes the importance of thorough evaluation and a meticulous workup to identify the underlying cause of hypoglossal nerve palsy and the importance of considering tuberculosis as a potential cause of isolated hypoglossal nerve palsy in everyday practice.

Programmed Death-Ligand 1 (PD-L1) Positivity and Factors Associated with Poor Prognosis in Patients with Gastric Cancer: An Umbrella Meta-Analysis.

Gastric cancer (GC) is one of the most common malignancies throughout the world with late diagnosis and poor prognosis. The expression of programmed death-ligand 1 (PD-L1) in GC is attributed to immune evasion and tumor progression. PD-L1 positivity has both predictive and prognostic biomarker potential. Aiming to summarize a large amount of research and to provide a definitive conclusion to the conflicting results on the prognostic significance of PD-L1 expression in GC, we performed an umbrella review based on existing meta-analyses which were published recently (2016-2021) and indexed in the PubMed database. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used in August 2021 to screen articles, and data extraction with quality assessment was performed on the selected meta-analyses. Review Manager (RevMan) 5.3 software was used to analyze the HR and OR with a 95% confidence interval (CI) among PD-L1 positive GC patients. We also assessed the between-study heterogeneity (I 2). Forest and Funnel plots were obtained, and a P-value of <0.05 was considered statistically significant. A total of 567 articles were screened, and we selected three meta-analyses with a total of 40 studies conducted over a period of 14 years. In our umbrella review, a total of 8,419 GC patients with an average PD-L1 positivity of 39% were analyzed. We found that PD-L1 positivity in GC patients is associated with poor prognosis (pooled HR =1.44, 95% CI: 1.24-1.68, P<0.00001) having higher mortality reducing the chances of overall survival (OS). However, there are no significant differences in PD-L1 expression among different lymph node (LN) metastases (OR=1.31, 95% CI: 0.98-1.74, P=0.07) and tumor, node, and metastasis (TNM) stages (OR=1.13, 95% CI: 0.80-1.58, P=0.50). Early identification of PD-L1 expression may help tailor cost-effective and targeted immunotherapy among GC patients. More research is needed to further understand how PD-L1 affects LN metastasis and tumor invasion.

An Adrenocortical Carcinoma Evolving After Nine Years of Latency From a Small Adrenal Incidentaloma.

Adrenal incidentalomas (AIs) are common incidental findings in medical practice with clinical significance. Although most AIs are nonsecretory and nonmalignant, they require a short course of follow-up over one to two years to rule out malignancy or hormonal secretion according to clinical practice guidelines. However, this can result in some adrenocortical carcinomas (ACCs) being missed if they transform at a later stage or evolve slowly. Here, we report one such case of an AI, which although remained indolent, eventually transformed into an ACC many years after the initial detection.

Examining the Clinical Prognosis of Critically Ill Patients with COVID-19 Admitted to Intensive Care Units: A Nationwide Saudi Study.

Backgroundand Objectives: COVID-19 is a novel infectious disease caused by a single-stranded RNA coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to conduct a nationwide multicenter study to determine the characteristics and the clinical prognostic outcome of critically ill COVID-19 patients admitted to intensive care units (ICUs). Materials and Methods: This is a nationwide cohort retrospective study conducted in twenty Saudi hospitals. Results: An analysis of 1470 critically ill COVID-19 patients demonstrated that the majority of patients were male with a mean age of 55.9 ± 15.1 years. Most of our patients presented with a shortness of breath (SOB) (81.3%), followed by a fever (73.7%) and a cough (65.1%). Diabetes and hypertension were the most common comorbidities in the study (52.4% and 46.0%, respectively). Multiple complications were observed substantially more among non-survivors. The length and frequency of mechanical ventilation use were significantly greater (83%) in the non-survivors compared with the survivors (31%). The mean Sequential Organ Failure Assessment (SOFA) score was 6 ± 5. The overall mortality rate of the cohort associated with patients that had diabetes, hypertension and ischemic heart disease was 41.8%. Conclusion: Age; a pre-existing medical history of hypertension, diabetes and ischemic heart disease; smoking cigarettes; a BMI ≥ 29; a long mechanical ventilation and ICU stay; the need of ventilatory support; a high SOFA score; fungal co-infections and extracorporeal membrane oxygenation (ECMO) use were key clinical characteristics that predicted a high mortality in our population.

COVID-19 and mucormycosis superinfection: the perfect storm.

BACKGROUND: The recent emergence of the Coronavirus Disease (COVID-19) disease had been associated with reports of fungal infections such as aspergillosis and mucormycosis especially among critically ill patients treated with steroids. The recent surge in cases of COVID-19 in India during the second wave of the pandemic had been associated with increased reporting of invasive mucormycosis post COVID-19. There are multiple case reports and case series describing mucormycosis in COVID-19. PURPOSE: In this review, we included most recent reported case reports and case-series of mucormycosis among patients with COVID-19 and describe the clinical features and outcome. RESULTS: Many  of the mucormycosis reports were eported from India, especially in COVID-19 patients who were treated and recovered patients. The most commonly reported infection sites were rhino-orbital/rhino-cerebral mucormycosis. Those patients  were diabetic and had corticosteroids therapy for controlling the severity of COVID-19, leading to a higher fatality in such cases and complicating the pandemic scenario. The triad of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), corticosteroid use and uncontrolled diabetes mellitus have been evident for significant increase in the incidence of angioinvasive maxillofacial mucormycosis.  In addition, the presence of spores and other factors might play a role as well. CONCLUSION: With the ongoing COVID-19 pandemic and increasing number of critically ill patients infected with SARS-CoV-2, it is important to develop a risk-based approach for patients at risk of mucormycosis based on the epidemiological burden of mucormycosis, prevalence of diabetes mellitus, COVID-19 disease severity and use of immune modulating agents including the combined use of corticosteroids and immunosuppressive agents in patients with cancer and transplants.

Risk Factors and Incidence of Acute Ischemic Stroke: A Comparative Study Between Young Adults and Older Adults.

Introduction Approximately 5-10% of strokes occur in adults of less than 45 years of age. The rising prevalence of stroke risk factors may increase stroke rates in young adults (YA). We aimed to compare risk factors and outcomes of acute ischemic stroke (AIS) among YA. Methods Adult hospitalizations for AIS and concurrent risk factors were found in the Nationwide Inpatient Sample database. Weighted analysis using chi-square and multivariable survey logistic regression was performed to evaluate AIS-related outcomes and risk factors among YA (18-45 years) and older patients. Results A total of 4,224,924 AIS hospitalizations were identified from 2003 to 2014, out of which 198,378 (4.7%) were YA. Prevalence trend of YA with AIS showed incremental pattern over time (2003: 4.36% to 2014: 4.7%; pTrend<0.0001). In regression analysis, the risk factors associated with AIS in YA were obesity (adjusted odds ratio {aOR}: 2.26; p<0.0001), drug abuse (aOR: 2.56; p<0.0001), history of smoking (aOR: 1.20; p<0.0001), infective endocarditis (aOR: 2.08; p<0.0001), cardiomyopathy (aOR: 2.11; p<0.0001), rheumatic fever (aOR: 4.27; p=0.0014), atrial septal disease (aOR: 2.46; p<0.0001), ventricular septal disease (aOR: 4.99; p<0.0001), HIV infection (aOR: 4.36; p<0.0001), brain tumors (aOR: 7.89; p<0.0001), epilepsy (aOR: 1.43; p<0.0001), end stage renal disease (aOR: 2.19; p<0.0001), systemic lupus erythematous (aOR: 3.76; p<0.0001), polymyositis (aOR: 2.72; p=0.0105), ankylosis spondylosis (aOR: 2.42; p=0.0082), hypercoagulable state (aOR: 4.03; p<0.0001), polyarteritis nodosa (aOR: 5.65; p=0.0004), and fibromuscular dysplasia (aOR: 2.83; p<0.0001). Conclusion There is an increasing trend in AIS prevalence over time among YA. Both traditional and non-traditional risk factors suggest that greater awareness is needed, with prevention strategies for AIS among young adults.

The shortcomings of tocilizumab in COVID-19.

Not available.

Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis.

BACKGROUND: Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. METHODS: Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. RESULTS: All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). CONCLUSION: High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.