Health is complex, the solutions are long term

The debate on folic acid fortification of food to prevent neural tube defects in babies, for example, hasn't progressed in more than two decades (doi:10.1136/bmj.p1158).8 The worrying rise in perinatal suicides requires better funded services and support for women and young families to prevent deaths (doi:10.1136/bmj-2023-075414).9 And are the mandatory school inspections that harm the mental health of teaching staff even necessary (doi:10.1136/bmj.p1147)?10 The same applies to overzealous and discriminatory processes implemented by medical regulatory bodies such as the General Medical Council, despite claims of improvement by its chief executive (doi:10.1136/bmj.p1295 doi:10.1136/bmj.p1252).1112 The prevention principle would urge us to support a ban on vaping (doi:10.1136/bmj.p1266) and consider new options for reducing the number of days people experience migraines (doi:10.1136/bmj.p1249).1314 It would also induce bewilderment at the decision to wind down the UK's world leading covid surveillance network when covid-19 is still with us and future pandemics are inevitable (doi:10.1136/bmj.p1157).15 It would not, however, lend support to a non-evidence based screening programme for haemochromatosis (doi:10.1136/bmj.p1264).16 The first steps of an "avoid, reduce, reuse, recycle, research, rethink” framework (doi:10.1136/bmj-2021-069044) focus on better clinical practice that avoids low value care and inappropriate admissions and minimises blood tests and other interventions.17 This latest article in our series on achieving net zero and environmental sustainability in clinical practice examines critical care. The challenge isn't entirely a clinical one, because achieving net zero will depend on commitment across healthcare professions, engineering, waste management, hospital leadership, and beyond. A research paper assessing the value of routine monitoring of people being treated with methotrexate finds that frequency of monitoring should be adjusted according to risk, reducing the burden of work on clinical staff and making life more manageable for patients (doi:10.1136/bmj-2022-074678 doi:10.1136/bmj.p1120).1819 The difficulty here is one of getting research into practice, a timescale of 17 years by some estimates.

A Machine Learning Approach Reveals Distinct Predictors of Vaping Dependence for Adolescent Daily and Non-Daily Vapers in the COVID-19 Era.

Since 2016, there has been a substantial rise in e-cigarette (vaping) dependence among young people. In this prospective cohort study, we aimed to identify the different predictors of vaping dependence over 3 months among adolescents who were baseline daily and non-daily vapers. We recruited ever-vaping Canadian residents aged 16-25 years on social media platforms and asked them to complete a baseline survey in November 2020. A validated vaping dependence score (0-23) summing up their responses to nine questions was calculated at the 3-month follow-up survey. Separate lasso regression models were developed to identify predictors of higher 3-month vaping dependence score among baseline daily and non-daily vapers. Of the 1172 participants, 643 (54.9%) were daily vapers with a mean age of 19.6 ± 2.6 years and 76.4% (n = 895) of them being female. The two models achieved adequate predictive performance. Place of last vape purchase, number of days a pod lasts, and the frequency of nicotine-containing vaping were the most important predictors for dependence among daily vapers, while race, sexual orientation and reporting treatment for heart disease were the most important predictors in non-daily vapers. These findings have implications for vaping control policies that target adolescents at different stages of vape use.

Lung injury associated with an e-cigarette (vaping) use during the COVID-19 pandemic

In recent years, the excessive use of electronic cigarettes (e-cigarettes), and vaping, as a re-placement for traditional tobacco cigarettes, have highlighted potential health risks for users. One such risk is the development of "electronic cigarette (vaping) product use-associated lung injury" (EVALI). This type of lung injury has an unclear cause that may be related to the various components found in e-cigarette fluids. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection (coronavirus disease . 2019 or COVID-19) may worsen EVALI symptoms in individuals with both conditions. This could be due to the increased oxidative stress and inflammation caused by e-cigarette use, as re-search shows increased levels of reactive oxygen species (ROS) and decreased glutathione. In this paper, we present two critical cases of COVID-19 patients with a history of chronic e-cigarette smoking and describe their clinical progression during hospitalization. The findings suggest that their prolonged use of e-cigarettes may have sig-nificantly impacted the severity of the disease.Copyright © 2023, The Indonesian Foundation of Critical Care Medicine. All rights reserved.

Where There Is (No) Smoke, There Is Still Fire: a Review of Trends, Reasons for Use, Preferences and Harm Perceptions of Adolescent and Young Adult Electronic Cigarette Use.

Purpose of the review: To review the current prevalence, trends, perceptions, and effects of e-cigarette or vaping product use associated lung injury (EVALI) on e-cigarette use among US adolescents and young adults. Recent findings: COVID-19 diagnosis was more likely among the current/ever dual cigarette and e-cigarettes users, as well as ever e-cigarette only users. Additionally, the EVALI outbreak may have influenced harm perceptions, as daily nicotine vaping declined significantly from 2019 to 2020, and more youth and young adults perceived vaping as harmful. Summary: The prevalence of e-cigarette use, specifically flavored use, remains high among adolescents and young adults, which is concerning due to the short-term and unknown long-term effects of e-cigarettes and their association with future cigarette and other substance use.

Oral epithelium response of electronic cigarette users to electronic cigarette.

BACKGROUND: Electronic cigarettes are increasing in popularity, but there is only little information on their biologic effects on the oral epithelium, the initial site exposed to electronic cigarette smoke. METHODS: We assessed the oral epithelium response to electronic cigarettes by comparing the histology and RNA transcriptome (mRNA and miRNA) of healthy electronic cigarette vapers to nonsmokers. mRNA was assessed based on: (1) genome-wide; (2) genes previously identified as dysregulated in the oral epithelium of electronic cigarette vapers versus nonsmokers; (3) immune and inflammatory-related genes previously identified as dysregulated in the nasal epithelium of electronic cigarette vapers compared to nonsmokers; (4) genes previously identified as dysregulated in the small airway epithelium of nonsmokers following an acute exposure to electronic cigarette; and (5) genes related to the initial steps of COVID-19 infection. In addition, miRNA was assessed genome-wide. Comparisons were performed using analysis of variance, and Benajmini-Hochberg corrected p < 0.05 was considered significant. RESULTS: The histology of the epithelium, lamina propria and basal layer in electronic cigarette vapers appeared normal. Assessment of mRNA and miRNA, based on all gene lists, did not identify any genes significantly modified in the oral epithelium of electronic cigarette vapers in response to electronic cigarette use. CONCLUSION: An average history of 2 years of vaping results in no detectable histologic or transcriptome abnormalities in the buccal mucosa.

Adolescent E-cigarette use: Rates, concerns, and policy implications

While US consumption of conventional cigarettes has declined steadily, electronic cigarettes have been the most commonly used tobacco product among adolescents since 2014, with a particular surge in use starting in 2017. The 2021 National Youth Tobacco Survey (NYTS) found that even during the COVID-19 pandemic, 2 million adolescents were current e-cigarette users. Just prior to the pandemic in 2020, one in five high school students and one in ten middle school students were using e-cigarettes every day, about the same level as in 2018 when adolescent e-cigarette use was declared an epidemic. Daily use is a strong indicator of nicotine dependence, raising concerns that e-cigarettes will hook a new generation on nicotine, including combustible cigarettes and other tobacco products. E-cigarettes are associated with a number of significant health consequences, including nicotine addiction, toxic effects of flavors, and psychological, social, and educational effects. Adolescents are especially attracted to e-cigarettes because of their youth-friendly flavors and salt-based nicotine which makes the device easier to use with less harsh throat hit, and allows users to more readily inhale large amount of nicotine. Adolescents are also attracted to the appealing designs and ability to conceal the e-cigarette devices;aggressive marketing that targets adolescents;misperceptions about the products' nicotine levels and health effects;and ease of access. Previous successful efforts to reduce tobacco use have been washed away due to the adolescent e-cigarette epidemic. This chapter discusses rates of adolescent e-cigarette use, health effects, why adolescents use e-cigarettes, and then ends with a discussion of the policy implications. © 2023 Elsevier Inc. All rights reserved

Barriers and facilitators to address vaping in Massachusetts schools: a mixed-methods study of school-based stakeholders.

We assessed vaping behaviors, environments, COVID-19 influences, and barriers and facilitators of existing approaches that address adolescent vaping in Massachusetts middle and high schools. Findings from this study will provide considerations for individual schools or districts as they advance adolescent vaping prevention and treatment efforts. We analyzed 310 open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine semi-structured interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. Informed by Green's PRECEDE model, we conducted a framework analysis using deductive codes based on the model constructs (enabling, reinforcing, and predisposing factors) and inductive codes of key themes emerging from the interviews. Challenges to addressing adolescent vaping included staff capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Facilitators of vaping interventions included peer-led initiatives and parental involvement. Participants discussed the importance of educating adolescents on the harms of vaping and the move toward alternatives-to-suspension programs rather than disciplinary action. School-based anti-vaping program implementers-such as school districts, state departments of education, or local health departments-will need to leverage facilitators such as peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of these programs.

The purpose of this study was to understand challenges that school administrators faced in their approaches to address adolescent vaping in Massachusetts middle and high schools. We analyzed open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. We found that challenges to addressing adolescent vaping included school personnel capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Successful approaches included peer-led initiatives and parental involvement, and participants discussed the importance of educating adolescents on the harms of vaping. Based on our findings, school-based anti-vaping program practitioners­such as school districts, state departments of education, or local health departments­should leverage peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of adolescent vaping prevention and treatment efforts.

Cannabis vaping among college students

Introduction: Vaping is a growing industry that has gained popularity among college students (Jones, Hill, Pardini, & Meier, 2016). Current trends indicate that college students frequently use these devices to vape cannabis (Kenne, Fischbein, Tan, & Banks, 2017). Detrimental health effects of vaping are emerging, including the cannabis vaping-related inflammatory disease referred to as Electronic-cigarette, or Vaping, Associated Lung Injury (EVALI) (Centers for Disease Control and Prevention, 2020). Research is lacking on the perceptions and attitudes of cannabis vaping among college students. Additionally, the Integrated Behavioral Model may be useful in explaining and predicting cannabis vaping among this population. Both of the aforementioned issues are addressed in this dissertation.Purpose: This alternative dissertation includes two separate studies. The first study was a qualitative design, which was completed with the purpose of exploring factors that influence college students to initiate and continue to vaporize cannabis instead of traditional combustible cannabis practices. The second study was a result of the first and utilized a quantitative design to determine if the IBM is useful in explaining and predicting cannabis vaping among college students.Methods: (Study 1) Individual telephone interviews were conducted, transcribed, and analyzed for common themes (n=21). (Study 2) An online survey was deployed via Amazon Mechanical Turk containing 35 items to measure the primary constructs of the IBM, including Experiential Attitude, Instrumental Attitude, Injunctive Norms, Descriptive Norms, Perceived Control, Self-Efficacy, and Behavioral Intention (n=423). Confirmatory factor analysis and structural equation modeling were used to determine whether the data fit the proposed IBM model. Inclusion criteria for both studies included college undergraduates, aged 18-25, who self-reported vaping cannabis at least once in the past 30 days.Results: (Study 1) Six primary themes and eighteen subthemes were identified. Main themes included 1) Convenience, 2) Discreetness, 3) Euphoric Experience, 4) Social Acceptability, 5) Health and Safety, and 6) COVID-19 Pandemic Impact. (Study 2) Obtained fit indices confirmed that the data fit the proposed model, accounting for 54.2% of the variance. Structural equation modeling demonstrated the strongest path coefficients between Behavioral Intention and Experiential Attitude, Instrumental Attitude, Injunctive Norms, and Descriptive Norms. There was a weak, positive relationship between vaping cannabis and smoking cannabis within the sample.Conclusions: College students who use cannabis tend to both vape and smoke (dual-use), depending largely on social and physical environment. Overall, the participants tended to underestimate the risks associated with both cannabis and vaping. Additionally, the strongest predictors of vaping were descriptive norms and experiential attitude. The findings indicate that the development of interventions and educational programming specific to this demographic is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Has COVID-19 Changed Marijuana Use in the United States?

Pandemic-related stress, depression, and anxiety might be important motivations for marijuana use. In this paper, we study the impact of the COVID-19 pandemic on the use of marijuana among people aged 12 and older in the United States. We use data from the National Survey on Drug Use and Health (NSDUH) and different econometric models to investigate this impact on national and state levels. We also consider the impact of the pandemic on the use of other illicit drugs such as heroin and methamphetamine. We find evidence that the COVID-19 pandemic has led to an increase in marijuana use at both state and national levels.

2022 ABA Annual Meeting Abstracts/Poster

The proceedings contain 7 papers. The topics discussed include: pediatric burn care: how burn camps survived and thrived during the coronavirus pandemic;a retrospective chart review to determine hypophosphatemia incidence and phosphorus supplementation requirements in patients with severe thermal cutaneous injuries receiving high-volume hemofiltration;setting the standard: using the aba burn registry to benchmark risk adjusted mortality;burn injury from smoking electronic cigarettes while on supplemental oxygen;focused wound care handoff improves burn center physician-nursing communication and wound care education;modified frailty index is an independent predictor of death in the burn population: a secondary analysis of the transfusion requirement in burn care evaluation (TRIBE) study;and topical hemostatic agents in burn surgery: a systematic review.

Longitudinal study of olfactory dysfunction among COVID-19 patients in a single tertiary centre in Malaysia

Aim: The aim of the study was to outline the longitudinal outcomes of olfactory dysfunction amongst patients with coronavirus disease 2019 (COVID-19) in a single tertiary centre in Malaysia. Material(s) and Method(s): Adults patients who tested positive for COVID-19 via reverse transcription-polymerase chain reaction and were admitted to Hospital Sungai Buloh, Malaysia, were recruited in this study. The patients completed a questionnaire via telephone interview comprising the following details: age, sex, ethnicity, comorbidities, general and otorhinolaryngological symptoms, and onset and duration of olfactory and gustatory dysfunction. The patients with persistent olfactory and gustatory dysfunction at the time of the initial interview were followed up every 3 to 5 days until resolution. Result(s): A total 185 patients were included in this study out of 378 patients contacted. Ninety patients reported olfactory dysfunction symptoms, with 59 of them complaining of anosmia. The mean age of the participants was 39.52 years (age range: 18-66 years). More than half of the patients with olfactory dysfunction had no comorbidities (55.56%). Of the 90 patients with olfactory dysfunction, 66 patients (73.3%), including 40 males and 26 females, regained their olfactory function completely within 2 weeks. The remaining 24 patients were contacted after 4, 8, and 12 weeks. Ten patients (11.1%) were found to have recovered their sense of smell after one month, while 5 patients (5.56%) recovered within 2 months, and 1 patient (1.11%) recovered in 3 months. Conclusion(s): Complete recovery was noted in 73% of the patients within a period of 2 weeks, whereas persistence of symptoms was noted in 6 patients (6.67%) after 3 months.Copyright © Pediatr Med Rodz 2022.

Vaping Behavior in Young Adults During the COVID-19 Pandemic.

BACKGROUND: Electronic nicotine delivery systems (ENDS) continue to be popular among young adults. These devices are often advertised as a healthy alternative to quitting tobacco cigarettes. However, young adults represent a population who view it as a novel behavior that provides a sense of popularity, social acceptance, and desired physiologic properties. The objective of this study was to examine characteristics of vaping behavior among college students and explore possible associations between groups of vaping behavior (stopped, initiated, increased, decreased, stayed the same). METHODS: In a multi-center cross-sectional study, 656 students from University of Tampa in the United States and University of Applied Sciences in Germany (IST) were recruited to answer a 31-item online questionnaire. A chi-square test was used to evaluate associations between the groups. RESULTS: Prevalence rates indicated approximately 31% of all students were currently using ENDS. Even though more negative than positive experiences with ENDS were reported, most students stated their vaping increased during COVID-19 lockdowns. Addiction and stress relief emerged to be predictors (P < .001) of an increase in vaping, whereas social motives were not statistically significant. Living situation (P = .63) and depression (P = .10) were not significantly associated with vaping behavior. CONCLUSIONS: ENDS products continue to yield very high levels of nicotine creating addiction in young adults. Addiction counseling and evidenced-based practices should be employed at every level (individual, community, and school). Additionally, mental health counseling for students in pandemic and high-stress environments may help to combat stress in a more proactive manner than self-medicating.

Commentary on "Increased nicotine vaping due to the COVID-19 pandemic among US young adults: Associations with nicotine dependence, vaping frequency, and reasons for use".

This manuscript is a correspondence referencing an article published in Preventive Medicine.

Factors that influence cannabis vaping habits of college students: A qualitative study.

Objective: The purpose of this study is to examine the attitudes and perceptions of college undergraduates regarding cannabis vaping. Participants: Twenty-one, predominantly male (71.4%; Mage = 22, SD = 2.09), undergraduate college students who reported vaping cannabis in the past 30 days. Methods: Participants were interviewed to determine their attitudes and perceptions regarding cannabis vaping. Findings: Thematic analysis uncovered six primary themes and eighteen subthemes. Main themes included (1) Convenience, (2) Discreetness, (3) Mood-Altering Experience, (4) Social Acceptability, (5) Health and Safety, and (6) COVID-19 Pandemic Impact. Conclusion: College students who use cannabis tend to both vape and use combustible methods, depending upon social and physical environment. This population tends to vaporize cannabis for its perceived mood-altering properties. Additional research is needed to further examine the behaviors and attitudes surrounding cannabis vaping among college undergraduates, as well as the development of interventions specific to this demographic.

E-cigarette or Vaping product use Associated Lung Injury (EVALI) in a 15 year old female patient - case report.

BACKGROUND: E-cigarettes are devices which allow to aerosolize liquids containing nicotine or other substances. Ever since they were released on the market in 2006, the number of users have been constantly increasing, especially among adolescents, ranging from 7,6% to 9,3% in the age group 18-24 years old from 2014 to 2019. Hand in hand with the spread of E-cigarettes many have been the efforts to understand their impact on health. EVALI (E-cigarette or Vaping product use Associated Lung Injury) is an emerging condition with a heterogeneous presentation with several reported cases worldwide. We mean to report a case of EVALI in a 15-year-old female Caucasian patient, who's currently attending her clinic follow-up at Bambino Gesù Pediatric Hospital in Rome. CASE PRESENTATION: The patient was admitted to the Emergency Room due to acute respiratory failure in November 2020. At admittance, she was severely dyspneic (HR 120 bpm, SatO2 75%). As she was hospitalized amid the COVID-19 pandemics, she underwent a nasopharyngeal swab for SARS-CoV2, which turned out negative, and a chest CT scan. Chest CT scan showed a central ground grass pattern with peripheral sparing. At the anamnestic recall, it was disclosed she was an e-cigarette smoker and occasional marijuana user. The microbiological work-up proved only positive for Rhinovirus. Her clinical and radiological case was discussed with our radiologist who suspected EVALI. She was assisted through HFNC, antibiotical therapy and corticosteroids with a dramatic recovery within the first 48 h. CONCLUSIONS: EVALI started being recognized a specifically nosological entity in summer 2019, with increasing cases being reported. No diagnostic criteria have been agreed upon yet, but its usual presentation includes respiratory, gastrointestinal and systemic symptoms of different degree and the diagnosis can be hypothesised in case the patient has an evocative clinical and radiological presentation and has been an E-cigarette smoker in previous 90 days. Due to the novelty of the condition and its heterogeneous presentation it is of interest to report the cases in which EVALI is identified to raise awareness about this emerging new-age disease.

Clinical manifestations of EVALI in adolescents before and during the COVID-19 pandemic.

INTRODUCTION: E-cigarette, or vaping, product use-associated lung injury (EVALI) results from inhaling the aerosol of e-cigarettes and has similar clinical features to coronavirus disease 2019 (COVID-19). EVALI case counts since the declaration of the COVID-19 pandemic is unknown. METHODS: A retrospective electronic health record chart review of adolescents hospitalized at one institution with EVALI was conducted. Clinical characteristics and hospital course of patients hospitalized during the pandemic were compared to those prepandemic. RESULTS: The clinical presentation of adolescents hospitalized prior-to (n = 19) and during the COVID-19 pandemic (n = 22) were similar with respect to constitutional, respiratory, and gastrointestinal symptoms. All patients hospitalized during the pandemic were tested for COVID-19 at least once. Only one patient had a positive SARS-CoV-2 RT-PCR test result. Thirty-one out of 39 patients treated with corticosteroids had clinical improvement within 24 h (79%). Patients hospitalized during the pandemic had a shorter median length of stay (5 vs. 7 days, p < 0.01), and were less often discharged with home oxygen (1 vs. 6 patients, p = 0.04). Pulmonary function tests improved pre- to postcorticosteroid treatment and postcorticosteroid to follow-up. CONCLUSIONS: Eliciting a history of vaping in adolescents presenting with constitutional, respiratory, and gastrointestinal symptoms is important to identify EVALI cases, which have continued throughout the COVID-19 pandemic. A shorter length of stay with less need for mechanical ventilation and home oxygen in adolescents hospitalized during the pandemic may reflect increased familiarity with EVALI characteristics. Corticosteroids led to clinical and pulmonary function improvement.

Impact of COVID-19 lockdown on smoking and vaping: systematic review and meta-analysis.

OBJECTIVES: COVID-19 and the implementation of lockdowns have impacted daily lives worldwide. This systematic review and meta-analysis aimed to investigate the impact of lockdowns on the smoking and vaping behaviours of adults during the pandemic. STUDY DESIGN: This was a systematic review and meta-analysis. METHODS: A systematic literature search was conducted up to 28 April 2022 in the following databases: PubMed, Embase and Web of Science. RESULTS: In total, 77 studies met the inclusion criteria for this review. In 34 studies, an increase in smoking behaviour was reported for the majority of participants; however, in 21 and 18 studies, 'no change' and 'decrease' in smoking were the predominant responses, respectively. The results from the meta-analysis, which examined the change in the number of cigarettes smoked per day, showed no difference between the pre- and post-lockdown periods: 0.81 weighted mean difference (95% confidence interval, -0.59 to 2.21). Regarding vaping, three of seven studies reported an increase in smoking for the majority of participants, whereas 'no change' and 'decrease' were the predominant answers in the other four studies. CONCLUSIONS: The results show that lockdowns led most participants to increase smoking/vaping, whereas a decrease or cessation of smoking/vaping was only reported in the minority of participants. Attention should be given to the non-communicable diseases that could arise as a result of the increase in smoking/vaping during lockdowns, and further research in this area is needed.