The Vaping Epidemic in Adolescents.

Electronic cigarette (e-cigarette) use has recently risen to the forefront of medical discussions across the country. A significant increase in e-cigarette use by adolescents has been observed over the last decade. This article discusses the targeting of adolescents by e-cigarette companies. It looks at how teenagers are uniquely affected by nicotine and at risk for progressing to using combustible cigarettes and marijuana. Lastly, it discusses the role of physicians in combating the spread of e-cigarettes.

The Dangers of Vaping.

As our nation turns away from smoking tobacco and toward legalization of marijuana, vaporization of both plants has increased in popularity. There are medical and cultural implications of this new trend which are just recently being reported and investigated. The purpose of this article is to review the scientific and sociological literature as it pertains to the vaporization of both marijuana and tobacco products and the potential medical and cultural implications of this new phenomenon.

Vaping Associated Lung Injury (EVALI): An Explosive United States Epidemic.

As of November 5, 2019, there have been 2051 cases of e-cigarette, or vaping, product use associated lung injury (EVALI), with 39 deaths reported in the United States, over four months. The rapidly increasing popular habits of vaping and e-cigarette use has suddenly turned deadly in the United States. This epidemic of vaping-associated illness appears to be limited to the United States with few reported cases and no deaths from the rest of the world.

Factors associated with depressive symptoms in uncontrolled asthmatics.

RATIONALE: Recent epidemiological data indicate that approximately 6.7% of US adults suffer from depression in any given year. The purpose of the study is to identify factors associated with depressive symptoms in a large diverse group of patients with poorly controlled asthma. The factors include quality of life (QOL), lung function, asthma knowledge, attitudes, self-efficacy, symptoms and control of disease. METHODS: Baseline characteristics of a cohort of 599 subjects with asthma recruited from twenty Asthma Clinical Research Centers across the United States were examined. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to stratify subjects into those with depressive symptoms (CES-D score ≥ 16) and those without depressive symptoms (CES-D < 16). Bivariate statistics were used to compare the two groups; additionally, logistic regression was used to determine factors that have the greatest association with depressive symptoms. RESULTS: Subjects with depressive symptoms had significantly lower QOL scores and less knowledge about their disease than subjects with no depression; however, lung function (FEV1%) and asthma control were not significantly associated with depressive symptoms in the logistic regression analysis. Subjects who were non-white had lower household income, high school diploma or less, and those who were unemployed or disabled had significantly higher scores for depressive symptoms. CONCLUSION: Subjects with depressive symptoms have significantly less knowledge of their disease and poorer QOL compared to those without depressive symptoms. Evaluating depressive symptoms in subjects with asthma will provide a more complete picture of their overall condition. The role of asthma education on depressive symptoms in this population needs to be further investigated. The effect of QOL on treating depression in asthma patients also needs to be studied.

Evaluation of the pulmonary embolism rule-out criteria in a retrospective cohort at an urban academic hospital.

BACKGROUND: The pulmonary embolism rule-out criteria (PERC) is an 8-variable clinical decision rule that identifies patients at low risk for pulmonary embolism (PE) to prevent unnecessary diagnostic testing in the evaluation of suspected PE in the emergency department (ED). The objective of this study was to determine PERC's safety and diagnostic use in our institution's ED population. METHODS: We performed a retrospective analysis on consecutive adult patients evaluated with computed tomographic angiography (CTA) for suspicion of PE at our ED during the dates January 1, 2011, to December 31, 2011. Patients negative for all 8 PERC criteria (ie, "PERC [-]") were considered to be at low risk for PE. All data were analyzed using SPSS-20 (SPSS Inc, Chicago, IL) to calculate the variables of interest and their respective 95% confidence intervals (95% CIs). RESULTS: During the 12-month study period, 729 subjects were evaluated with CTA for suspicion of PE. Ten subjects were excluded because of nondiagnostic imaging studies. After exclusion, 719 subjects were available for analysis. Prevalence of PE was 4.5%. PERC (-) had a sensitivity of 96.9% (95% CI, 84.3%-99.4%), a negative predictive value of 98.8% (95% CI, 93.5%-99.8%), and a negative likelihood ratio of 0.26 (95% CI, 0.04-1.82) when used as an independent diagnostic test to exclude PE. CONCLUSIONS: Use of PERC could have safely avoided 11.5% of CTAs, reducing potential patient harm, health care costs, and unnecessary diagnostic testing. Consistent with prior studies, PERC can be safely used to identify low-risk patients for whom further testing can be deferred.

Healthcare access and disparities in chronic medical conditions in urban populations.

OBJECTIVES: The purpose of this study was to identify barriers and disparities in healthcare access and the factors associated with them in an urban population. METHODS: Eligible patients were consented and enrolled randomly from the inpatient internal medicine unit at Truman Medical Center, Kansas City, Missouri, a 250-bed hospital recognized for its broad range of acute and chronic diseases seen in its inpatient and outpatient care. They had one or more of the following chronic medical conditions (CMCs): congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, chest pain, or cirrhosis. One hundred patients were interviewed regarding challenges they have encountered as consumers and their understanding of CMCs. RESULTS: Interview results indicate patients' understanding of their CMC, the associated needs for self-management, and the potential health consequences are contributing factors leading to repeated visits to the emergency department. CONCLUSIONS: Our study suggests that access to the following health-focused services has the potential to reduce the rate of emergency department visits and hospitalizations, morbidity, mortality, and the burden of cost. These services include adequate access to and utilization of primary care characterized by preventive care, early detection of acute illness, ongoing chronic disease management through easy access to primary providers, and adequate health literacy about CMC.

Infectious spondylodiscitis: diagnosis and treatment.

Infectious spondylodiscitis presents a diagnostic conundrum, and establishing the diagnosis often requires expensive testing and workup. But because of the potentially irreversible neurologic consequences and the great expense and time required to adequately treat this rare infection, establishing a diagnosis is paramount. Below, we present a representative case from clinical practice and examine the prevalence of certain signs and symptoms and the utility of various diagnostic modalities health care providers can use to accurately diagnose afflicted patients and avoid disastrous complications.

Evaluation and management of acute kidney injury in the intensive care unit.

Acute disorders of the kidney occur in up to two-thirds of patients in the intensive care unit. The diagnosis is associated with increased mortality and increased hospital stay. Often recognized but less frequently defined, it is commonly encountered by physicians caring for critically-ill patients. A standardized definition regarding acute kidney injury was published in 2004. This has led to improvements in measuring mortality and treatment outcomes with a more targeted approach to caring for these difficult to treat patients.

Acute chest syndrome in sickle cell disease.

Acute chest syndrome (ACS) is a leading complication of sickle cell disease (SCD) with significant morbidity and mortality. ACS is the most common cause of death and the second most common cause of hospitalization in patients with SCD. Delineating the specific cause of ACS is often difficult, and multiple risk factors that precipitate ACS frequently coexist. The prominent risk factors include infection, hypoxia, bronchial hyperresponsiveness, the SCD genotype, and opioid use. The key to the successful treatment of ACS is early recognition and initiation of treatment without delay. The main goal is to prevent and treat acute respiratory failure and, thus, minimize irreversible lung damage. This review focuses on the risk factors, pathogenesis, clinical presentation, and management of ACS.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial.

Importance: Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation. Objective: To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD. Design, Setting, and Participants: This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017. Interventions: Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis. Main Outcomes and Measures: The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events. Results: Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups. Conclusions and Relevance: Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure. Trial Registration: ClinicalTrials.gov Identifier: NCT02148445.

Novel Oral Anticoagulants for Venous Thromboembolism with Special Emphasis on Risk of Hemorrhagic Complications and Reversal Agents.

Warfarin was the only oral anticoagulant available for the treatment of venous thromboembolism for about half a century until the recent approval of novel oral agents dabigatran, rivoraxaban and apixaban. This presents new classes of medications less cumbersome to use. They do not require frequent laboratory monitoring or have nurmerous drug interactions. On the other hand it also poses a challenge to the physicians deciding which agent to use in specific patient populations, how to predict the bleeding risk compared to warfarin and between the different novel agents and how to manage bleeding with relatively recent discovery of few potential antidotes. This review summarizes the major trials that led to the approval of these agents and their exclusion criteria helping physicians understand which patient types might not benefit from these agents. It provides clinical pearls invaluable in everyday practice such as transitioning between traditional and novel anticoagulants, dose adjustments for high risk populations, drug interactions and cost analysis. Futhermore, the review provides direct comparisons with warfarin and indirect comparisons among the novel agents in terms of efficacy and bleeding risk narrating the numbers of patients with intracranial, gastrointestinal and fatal hemorrhages in each of the major trials. We hope that this review will help the physicians inform their patients about the benefits and risks of these agents and enable them to make an informed selection of the most appropriate anticoagulant.

Hepatic hydrothorax: clinical review and update on consensus guidelines.

Hepatic Hydrothorax (HH) is defined as a pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. It is an uncommon complication of cirrhosis, most frequently seen in association with decompensated liver disease. The development of HH remains incompletely understood and involves a complex pathophysiological process with the most acceptable explanation being the passage of the ascetic fluid through small diaphragmatic defects. Given the limited capacity of the pleural space, even the modest pleural effusion can result in significant respiratory symptoms. The diagnosis of HH should be suspected in any patient with established cirrhosis and portal hypertension presenting with unilateral pleural effusion especially on the right side. Diagnostic thoracentesis should be performed in all patients with suspected HH to confirm the diagnosis and rule out infection and alternative diagnoses. Spontaneous bacterial empyema and spontaneous bacterial pleuritis can complicate HH and increase morbidity and mortality. HH can be difficult to treat and in our review below we will list the therapeutic modalities awaiting the evaluation for the only definitive therapy, which is liver transplantation.

A case-based approach to noninvasive positive pressure ventilation.

Noninvasive positive pressure ventilation (NIPPV) has revolutionized the concept of mechanical ventilation with the major benefit of avoiding invasive mechanical ventilation in specific situations, thereby preventing associated complications. Noninvasive positive pressure ventilation has emerged as the first line of management of hypercapnic respiratory failure (due to chronic obstructive pulmonary disease and neuromuscular weakness) and cardiogenic pulmonary edema in addition to standard therapy in the acute setting. There is improvement in gas exchange, relief of respiratory muscle fatigue, and clinical outcome with reduced morbidity and mortality. Nevertheless, contraindications and failures need to be identified early, as delaying endotracheal intubation is associated with increased morbidity and mortality. Despite overwhelming evidence to support its use, NIPPV is underused. Residents and hospitalists need to identify NIPPV as a treatment option in acute respiratory failure.

Design, baseline characteristics, and retention of African American light smokers into a randomized trial involving biological data.

BACKGROUND: African Americans experience significant tobacco-related health disparities despite the fact that over half of African American smokers are light smokers (use ≤ 10 cigarettes per day). African Americans have been under-represented in smoking cessation research, and few studies have evaluated treatment for light smokers. This paper describes the study design, measures, and baseline characteristics from Kick It at Swope III (KIS-III), the first treatment study of bupropion for African American light smokers. METHODS: Five hundred forty African American light smokers were randomly assigned to receive bupropion (150 mg bid) (n = 270) or placebo (n = 270) for 7 weeks. All participants received written materials and health education counseling. Participants responded to survey items and provided blood samples for evaluation of phenotype and genotype of CYP2A6 and CYP2B6 enzymes involved in nicotine and bupropion metabolism. Primary outcome was cotinine-verified 7-day point prevalence smoking abstinence at Week 26 follow-up. RESULTS: Of 2,628 individuals screened, 540 were eligible, consented, and randomized to treatment. Participants had a mean age of 46.5 years and 66.1% were women. Participants smoked an average of 8.0 cigarettes per day, had a mean exhaled carbon monoxide of 16.4 ppm (range 1-55) and a mean serum cotinine of 275.8 ng/ml. The mean Fagerström Test for Nicotine Dependence was 3.2, and 72.2% of participants smoked within 30 minutes of waking. The average number of quit attempts in the past year was 3.7 and 24.2% reported using pharmacotherapy in their most recent quit attempt. Motivation and confidence to quit were high. CONCLUSION: KIS-III is the first study designed to examine both nicotine and bupropion metabolism, evaluating CYP2A6 and CYP2B6 phenotype and genotype in conjunction with psychosocial factors, in the context of treatment of African American light smokers. Of 1629 smokers screened for study participation, only 18 (1.1%) were ineligible to participate in the study because they refused blood draws, demonstrating the feasibility of recruiting and enrolling African American light smokers into a clinical treatment trial involving biological data collection and genetic analyses. Future evaluation of individual factors associated with treatment outcome will contribute to advancing tailored tobacco use treatment with the goal of enhancing treatment and reducing health disparities for African American light smokers. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00666978.

Pulmonary alveolar proteinosis: an overview for internists and hospital physicians.

Pulmonary alveolar proteinosis (PAP) is a rare diffuse lung disease characterized by abnormal accumulation of surfactant-associated phospholipoproteinaceous material in the pulmonary alveoli. The clinical findings of slow-onset dyspnea or dyspnea on exertion and persistent dry cough are nonspecific; radiographic findings of "bat-wing configuration" and "crazy paving" appearance in high-resolution computed tomography are suggestive, but not diagnostic of PAP. The current gold standard of PAP diagnosis involves histopathological examination of alveolar specimens obtained from bronchoalveolar lavage and transbronchial lung biopsy. The characteristic histopathological features are intraalveolar periodic acid Schiff (PAS)-positive eosinophilic homogeneous material with well-preserved architecture ofalveolar septa. The current standard medical treatment of PAP involves the physical removal of the surfactant-associated phospholipoproteinaceous alveolar deposit by whole lung lavage, which causes clinical and radiological improvement in a majority of patients. Some patients have been successfully treated with recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF).

Electronic asthma action plan database: asthma action plan development using Microsoft Access.

We created a user-friendly database for use with asthma management consistent with the national guidelines for asthma. A database was designed by using Microsoft Access for the creation of asthma action plans that can be shared between providers caring for patients with asthma. This database and the use of "form entry" improved documentation of asthma action plans, which are increasingly being used to assess appropriateness of care. We currently have 400 asthma action plans in the database. These action plans can be queried to document compliance with accepted best practices. Asthma action plans can be created and stored in an Access database that is both user-friendly and that can be networked to provide more consistent asthma care.

Cost-effectiveness analysis of omalizumab in adults and adolescents with moderate-to-severe allergic asthma.

BACKGROUND: Omalizumab can reduce hospitalization and emergency department visits and improve quality of life in patients with moderate-to-severe, suboptimally controlled allergic asthma. Given the high cost and modest efficacy of this agent, it is not clear that it is cost-effective if given to a broad population with asthma. OBJECTIVE: The purpose of this study was to evaluate the cost-effectiveness of omalizumab in adults and adolescents with moderate-to-severe allergic asthma. METHODS: A retrospective economic analysis was performed to determine the cost-effectiveness of omalizumab using 52-week data from 2 randomized controlled clinical trials in adults and adolescents with moderate-to-severe allergic asthma. The analysis was conducted from a third-party payer's perspective, and only direct costs were considered. RESULTS: The incremental cost-effectiveness ratios showed that the cost to achieve an additional successfully controlled day was $523, and the daily cost to achieve at least a 0.5-point increase in Asthma Quality of Life Questionnaire score was $378 in 2003 dollars. CONCLUSION: From a pharmacoeconomic standpoint, omalizumab would be better used in allergic asthmatic patients with poorly controlled symptoms despite maximal therapy, given the high cost and modest efficacy of this agent. It could be cost saving if given to nonsmoking patients who are hospitalized 5 or more times or 20 days or longer per year despite maximal asthma therapy.