Aug 23, 2019

Dust cloud

The story

The wrong wing of the hospital provides its own kind of noxious air, but what happens when you step outside? Here’s the latest on long-term pollution and lung heath.

The background

Your fourth leading cause of death in the United States is chronic lower respiratory disease. Much of this is tied to smoking, but the role of ambient air pollution in emphysema is less clear. For one thing, the concentration of pollutants changes over time in response to environmental regulations. For another, much of the existing data has surveyed traffic-related pollutants or has focused exclusively on patients with COPD. A link between common pollutants and lung function decline in healthy subjects would help.

The study

As part of the MESA Air and Lung Studies, investigators tracked the association of 4 pollutants – ambient ozone (O3), fine particulate matter (PM2.5), oxides of nitrogen (NOx), and black carbon – with emphysematous changes on CT scan and spirometry in 7,000 healthy volunteers over median follow-up of 10 years. O3, the main component of smog, played an outsized role: while all pollutants were associated with emphysema on CT at baseline, O3 was the sole pollutant to be linked to a decrease in forced expiratory volume on follow-up. Worse? The other pollutants declined over the course of the study, but O3 concentrations were stable.

The takeaway

The impact of O3 on lung function decline exceeded long-term pack-per-day smoking, which is definitely grounds to sound the alarm. It's hard to imagine the news will get any better with more studies on air quality in the works.

Say it on rounds

When a patient's family member is standing quietly behind you

Usually creepy, and so are covert strokes. A study of 1,100 elderly adults undergoing non-cardiac elective surgery found that 7% had asymptomatic strokes diagnosed on brain MRI after surgery. Those with occult strokes were more likely to have cognitive impairment at 1 year (42% vs. 29%) and faced an increased risk of perioperative delirium. Rates of overt stroke in this setting are around 1%.

When targeted therapy means wine and a 9 PM bedtime

Residency is kind of different from the onc world. Five-year outcomes from targeted therapy in advanced melanoma – in this case with the oral BRAF and MEK inhibitors dabrafenib and trametinib – found a progression-free survival rate of 19% among 550 patients. The 5-year overall survival rate of 34%, boosted by the availability of immunotherapy for patients who progressed, is astounding for this previously untreatable disease.

When you can stick your needle anywhere and drain fluid

Volume matters. A multinational population based cohort of 40,000 consecutive patients admitted with acute pulmonary embolism found that PE-related mortality was 44% less in high volume hospitals (> 40 acute PEs seen per year) compared to the lowest quartile of hospitals (<15 per year) despite a higher burden of comorbidities in the high volume group. Low-volume hospitals were less likely to adhere to guideline-directed therapy.

Brush up

Medical cannabis

Thirty-three states and DC allow for cannabis use for medical conditions. FDA-approved indications for cannabinoids include chemotherapy-induced nausea, appetite stimulation in chronic weight loss conditions, and 2 forms of pediatric epilepsy. Long-term harms of use are hotly debated and under active investigation, though a significant association has been found between chronic cannabis use and psychotic disorders like schizophrenia.

Get meta

With cannabinoids and chronic pain. A 2018 analysis of 91 studies found that cannabinoids reduced chronic noncancer pain by 30% on average compared to placebo. Number needed to treat for a 50% reduction in pain was 24. Dizziness, drowsiness, nausea, and depressed mood were common side effects, and the authors estimated a number needed to harm of 6 for any adverse event.

What your public health friends are talking about

The CDC is investigating links between vaping and 153 cases of severe lung disease, calling the disorder vaping-associated pulmonary injury (VAPI). Many of the afflicted are teenagers.

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