Sep 13, 2019

Puff problems

The story

For all the buzz surrounding vaping-related pulmonary injury (VAPI), it's hard to know what to look for in your ED. A new case series explores.

The background

About 20% of high schools students vape compared to just 3% of adults. But while e-cig proponents say they have fewer chemicals than combustible cigarettes, there's all kinds of weird stuff packed in: contaminants include hydrocarbons, volatile chemicals, and even toxic metals. There are also plenty of unregulated products that find their way to teens, especially of the THC and CBD variety. 

The syndrome

Fifty-three patients presented to acute care with respiratory symptoms in July 2019. Most also complained of subjective fever and GI symptoms. Though there's no direct proof, almost all of the patients – median age 19 – reported vaping within the past week and most reported every day e-cigarette use. All patients had bilateral infiltrates (example) on chest imaging. About a third were intubated, 2 were placed on ECMO and 1 patient died. Over 80% of afflicted patients reported use of THC products, and almost 40% used THC products only.

The takeaway

Initial data on VAPI raises more questions than answers, and public health investigators are racing to get a handle on the root cause. In the meantime, the FDA is preparing a ban on flavored e-cigarettes to combat youth vaping.

Say it on rounds

When your scrubs feel more like a smock

One size fits all is a fashion hazard, but for meds? Researchers compared a once daily polypill (aspirin 81 mg, HCTZ 12.5 mg, atorvastatin 20 mg, and enalapril 5 mg or valsartan 40 mg if cough) to minimal care in 6,800 patients in rural Iran. At 5-year follow-up, fewer polypill patients had major cardiac events (5.9% vs. 8.8%, NNT 35). Advocates say the pill could put a serious dent in the global burden of cardiac disease, though some worry the pill exposes otherwise healthy patients to side effects and aspirin-associated bleeding risk.

When you're a bit down about 27 hours in a halogen box

The unit's tough on staff, but patients have it worse: up to one third of ICU survivors will have depressive symptoms at 1 year after discharge. A study of 250 patients who survived > 7 days of mechanical ventilation found that loss of functional independence, low income status, and incomplete secondary education were associated with subsequent moderate to severe depression. Since inactivity breeds depression and vice versa, loss of functional status appears to place patients in a vicious cycle that needs further attention. 

When the vending machine looks lonely overnight

Taxes on sugar sweetened beverages (SSBs) have been a popular tool to combat obesity, but what about snacks? Using data from household expenditures in the UK and survey responses from 2,500 participants, researchers projected that a 20% sugar tax on snacks like cookies, candy, and cake could decrease the prevalence of obesity by 2.7% in the UK, almost double the effect of a similar tax on SSBs. The tax would disproportionately affect low income households.

Brush up

Preexposure prophylaxis (PrEP)

The first-ever USPSTF recs on PrEP advised docs to offer PrEP to all patients at high-risk of HIV acquisition and gave the supporting evidence an A grade. Discuss PrEP with heterosexual men and women, homosexual men, and injection drug users who i) have a serodiscordant partner, ii) use condoms inconsistently with high risk partners, and iii) had an STI within the past 6 months. Prescribe PrEP for daily use or before and after HIV exposure events like sexual activity or injection drug use (event-driven PrEP).

Get meta

With USPSTF evidence on PrEP. The agency analyzed 29 prior PrEP trials and found a relative risk reduction of 46% for new HIV infection. Adherence is critical: with 70% adherence relative risk reduction improved to 75%, though in some studies of men who have sex with men adherence was as low as 22%. PrEP use increased risk of renal and GI adverse events, but most toxicity was mild and reversible off treatment.

What your tech friends are talking about

The FDA approved an artificial intelligence device designed to detect pneumothorax on X-ray within 15 minutes. If any robots are listening, please work on finding NG tubes and line placements next.

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