Update on E-cigarette Vaping Associated Lung Disease.

States with Reported Cases of EVALI

Disclaimer: The information contained in this post is up to date as of this writing. For the latest information, visit the CDC website on outbreak of ecigarette related vaping associated lung injury.

In September of 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health published the results of their investigation into a new clinical syndrome. This initial series involved a cluster of 53 cases of ecigarette vaping associated lung injury (EVALI). Since the initial study, the syndrome was found to be a national epidemic. Nearly 1900 people have been affected by vaping associated lung disease, there have been 37 deaths. Cases have been reported in all states except Alaska.

Case Definition: The first step in evaluating a new disease is determining the characteristics that make up that disease. In the case of EVALI, CDC has issued this publication to define cases of Confirmed or Probable EVALI for surveillance purposes. In general, this involves the presence of pulmonary infiltrates in the presence of vaping in the past 90 days and in the absence of infection or other plausible causes.

Presenting Symptoms: Interestingly, patients with EVALI appear to present in a number of ways. These include not only respiratory symptoms, but also with constitutional symptoms and gastrointestinal symptoms. In the initial series of patients in Wisconsin and Illinois, all patients had constitutional symptoms at presentation, most commonly subjective fever. Nearly all (98%) had respiratory symptoms at presentation, and 81% had gastrointestinal symptoms, of which nausea and vomiting were most common.

Exposures: While the particular vaping component that leads to EVALI is not yet known, there are a few common factors. 87% of patients with EVALI reported vaping THC, while only a small minority (<15%) reported vaping nicotine without any THC. However as many have pointed out, vaping THC in most states is illegal. In addition many of these patients are under the age of 18, thus it is reasonable to think that many who claimed not to have used THC use simply did not want to divulge that they had. So why would vaping THC lead to EVALI, when people have been smoking THC for decades? Vape liquids contain several chemicals including propylene glycol, terpenoids, cutting agents, and flavorings. These solvents are used to keep THC and other components, such as flavoring agents in solution. These solutions are prepared in different ways in back yards, garages, and back seats, often cut with unknown substances to reduce their cost. They are then sold as cartridges to people who use them in a variety of different vaping devices which themselves which may heat the fluid at different temperatures and for a different duration.

Radiologic Findings: Ct findings are often heterogenous in EVALI. They can include mild infiltrates to diffuse findings suggestive of ARDS/DAD.

Spectrum of radiological findings in EVALI. Presented by Dr. Kevin Davidson M.D. at CHEST2019.

What Social Media Apps Work In China?

So you’re planning a trip to China. . . congratulations! You’re going to have an incredible experience visiting majestic sites, learning about China’s incredible history and delving into China’s amazing culture. Of course no vacation experience is complete in this age without sharing your experiences in real-time via social media. As someone who spends much of his time at the intersection between health care and social media, I was particularly interested in learning more about how American social media and tech apps would work in China. As I am sure you have learned when researching your trip, China blocks several social media sites. Plus, many things that we take for granted, like paying with a credit card are things that we may not be able to do in China. 

During a recent trip to China, I wanted to look at exactly how social media and technology apps that are ubiquitous to life in the U.S. would work in China. I’ve compiled my findings into this quick and to-the-point guide. If your findings are different, or if you have questions, please let me know. 

Does Facebook work in China?

–The facebook app can opened and old posts can be viewed. 

–Timeline will not update and new posts can not be uploaded. 

–Facebook Messenger will not work for chat, audio or video calls. 

Verdict: Facebook has almost no functionality in China. Your timeline can be viewed but is essentially frozen from the moment you enter China. 

Does Instagram work in China?

–Similar to Facebook, the app will open and display old posts, but will not update. 

–You can not post new content to Instagram. 

Verdict: Like Facebook, Instagram has almost no functionality in China. 

Does WhatsApp work in China?

–WhatsApp app will open, new posts can be viewed and updates can be posted. 

–WhatsApp messaging, audio and video calls will work in China. 

Verdict: Surprisingly, and despite what many sites on the internet will tell you, WhatsApp maintains excellent functionality in China. 

Does LinkedIn work in China?

–The LinkedIn app will open, but will generate an error message. Old posts can not be viewed. 

–You can not post to LinkedIn when in China. You can not communicate with contacts. 

Verdict: LinkedIn has no functionality in China. 

Should I download WeChat for my trip to China?

–Most Chinese tourists companies use WeChat to communicate with their customers. 

–WeChat’s interface works similarly to WhatsApp or Facebook Messenger. Like those apps, it supports instant messaging and web calling. 

Verdict: WeChat is an indispensable tool for tourists travelling to China, and the best way to keep in touch with your tour agency. 

Does email work in China? Does Gmail work in China?

–Email including Gmail, Hotmail, Yahoo mail work in China. Gmail attachments can be problematic to download. 

Verdict: Despite China’s block on Google search, Gmail works in China, though Gmail attachments were difficult to access. I do not know if this was a network issue or something to do with how China blocks Google. 

Do credit cards work in China?

–U.S. credit cards will work in places that accept credit cards, which unfortunately are very few.

–Hotels and some restaurants at tourist sites will accept credit cards, but hardly anybody else does. This includes even “American” places like McDonalds and KFC. Most people in China pay with phone based apps like Alipay or Wepay. 

–You can download the Alipay app, but will need a Chinese bank account to link it to. Alipay offers a way to link to a credit card, but a websearch shows that most American tourists who try this are unsuccessful, and I was no exception.  

Verdict: Cash is king. You should assume that most places you go in China will not accept your credit card. 

Will Apple Pay work in China?

–U.S. based payment apps like Apple Pay, G Pay, Samsung Pay do not work in China. 

Verdict: Again Cash is king for American tourists and you should not rely on electronic payment when travelling in China. 

Does Google work in China?

–Google search will not work in China. 

–Other google services including Google Pay, Google Maps are similarly non-functional. 

–Google Chrome works well in China.  Searches through Chrome are diverted to a local Chinese search engine. Many of the results are in (I assume) Mandarin, hence not very helpful unless you can read Mandarin. 

–Google Maps will not work in China, nor will google reviews or any app which uses Google Maps. 

–Some Google services will work, including the Play Store, Google Drive, Google Photos. 

Verdict: Google’s most useful services, Google Maps, search, G Pay, and Reviews will not work in China. Google’s storage services (Drive, Photos) will still work and can be used to free up storage on your device. 

What do Asthma and COPD inhalers have in common with Mexican food fast food?

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A 67 year old man came to see me recently, he had COPD, and found that it was getting harder to breathe. “I wanted to make sure that I’m on the right inhaler. My doctor switched me from Advair to Breo– is that better?

GSK would certainly say so, in fact their reps often do. Speaking with drug reps about their inhalers often makes me think of food. Actually I think of food quite often, but that’s more of a personal issue. Thinking of inhalers for COPD and asthma make me think of cheap Mexican food, specifically of the fast food variety. I think it has less to do with my poor dietary habits than the fact that I believe expensive inhalers have quite a lot in common with cheap Mexican food. 

Thinking about that patient’s question from the perspective of cheap Mexican fast food, switching from advair to Breo would be like ordering  one beefy rice burrito, only to be provided with two; but they would keep you full all day. Surely that’s an upgrade if there ever was one, and one which I endorsed. The problem though, and the real reason why he was asking, was not because he doubted the expertise of the prescribing physician but something else entirely. “It’s costing me $450 for 3 months. That’s more than triple what  the other one was. I guess I’ll pay for it if you think it’s worth it”

This was an especially unexpected twist, and not of the tasty cinnamon kind. No, that kind of dough busts straight out of the fast food genre into those fancy big-city restaurants, where it’s been said that they don’t even serve french fries. Like, you can’t even order them.  Continue reading “What do Asthma and COPD inhalers have in common with Mexican food fast food?”

The IMPACT trial; What do we do about inhaled steroids in COPD?

 

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“B” is for Bias!

Pity inhaled steroids. Once a favored drug in the treatment of COPD, they were initially advocated to be used in combination LABA’s (long acting beta agonists) to have a “protective” effect against the harms of LABA’s which were,, back  in the day, proposed to have existed in the SMART trial. Things of course have change quite a bit since then. The black box warning for combination inhalers has since been dropped. Ironically it’s now the inhaled steroids that we worry about in the treatment of COPD, as mounting evidence implicates inhaled steroids as increasing the risk of pneumonia.

In the most recent GOLD update, steroids have been relegated as add on therapy to LABA for patients with an exacerbation. However GOLD recommends LABA/LAMA combination as preferred due to evidence that the combination reduces exacerbations better than LABA/ICS, as demonstrated in the FLAME trial. In fact ICS is recommended only as add-on therapy to LABA/LAMA in patients who are highly symptomatic and at high risk of exacerbations.

The Impact trial may be changing that. It compared a single inhaler triple therapy LABA/LAMA/ICS to dual combinations of LABA/LAMA and LABA/ICS. Interestingly, and also quite confusingly, the triple therapy group had reduced exacerbations and reduced COPD related hospitalizations. These results are of course in conflict with the results of the Wisdom Trial, which saw no significant difference in the rate of exacerbations between LABA/LAMA combination vs. triple therapy with LAMA/LAMA/ICS. GSK, of course, has wasted no time telling us this,  touting the results of their newest inhaler far and wide. Continue reading “The IMPACT trial; What do we do about inhaled steroids in COPD?”

The Advice That Every New Medical Grad Needs to Hear? Get Out Now (while you still can)!

 

Author’s Note:  This is a satirical tongue-in-cheek article  that tries to highlight physician burnout. More physicians are making the transition to physician executive as the practice of medicine has become increasingly frustrating. If you are a physician executive reading this, please note that I have neither owned, nor have ever slept on a yoga mat. 

Get out, get out while you can! It won’t be easy, it requires a lot of practice and preparation. Which is why I am talking to you now, this is something that you need to start planning soon, before it’s too late. . . like it is for me.  

The key to happiness in clinical medicine is to not practice it, but rather to tell other doctors how to practice it.

So I am imparting to you this wisdom of the hairless; the key to happiness in clinical medicine is to not practice it, but rather to tell other doctors how to practice it. To accomplish this you must get through your training and then begin the process of positioning yourself as “non-essential staff”, or as we call it in the parlance, Physician Executive Leadership. (The term “non-essential”  is a general term referring to those who don’t need to come in on a snow-day. As you will soon learn,  most of those people are actually more “essential” than  you are!). 

Earnings? Don’t be so short-sighted. What you give up in earnings will be repaid  in nights, weekends, and holidays of blissful nothingness. As “non-essential” staff you will not find yourself up at 4:30 am on a freezing and moonless night to dig your car out from the snowbank it got stuck in on your way home from work just a few hours earlier. (See figure 1).

FIGURE 1

Continue reading “The Advice That Every New Medical Grad Needs to Hear? Get Out Now (while you still can)!”

African Americans Are Less Accepting of Hospice and Palliative Care at End of Life; What Can ICU Doctors Do?

I grew up in a small town in the gently rolling hills of Connecticut. Previously unheard of, but now infamous, my hometown, Newtown, was a sleepy small New England town of mostly white people for whom my lone brown face served as diversity. I went to college at a mostly white college in said state, and went on to an Indian Medical School with predominantly other brown people. So you might imagine that July 1st, 2001 proved to be quite a shock. That was the day when I started my residency in Detroit, Michigan. Only I didn’t think there would be much culture shock, after all I was great guy who gets along with everybody. I was smart too, so naturally all patients would bow to my obvious mastery of medicine. It’s true that I had never really spent much time around African Americans, however I was an avid fan of both the Cosby show AND Fresh Prince of Bel Air. So really, what could go wrong?

Over the past 2 decades I’ve learned alot about how African Americans view health care and physicians. This is particularly important for anyone in the field of critical care where clinicians   often need to discuss end of life care decisions with patients and their families. Many of these conversations revolve around changing the goals of care from cure to comfort. These conversations are difficult, emotionally charged, and put tremendous strain on patients and their families. They also put a strain on medical teams–it becomes demoralizing to continue to care for someone who is obviously suffering and has no real chance of getting better. These conversations can be even more frustrating with African American patients and families.

As someone who provides care to the African American community I can certainly endorse what the literature shows; African Americans are more likely to choose life sustaining therapies over palliative or hospice approaches. The literature also suggests that African Americans have less awareness of hospice and advance care planning, and are less likely to enroll in hospice.  They are also more likely to withdraw from hospice to seek further life sustaining medical care. This is problematic as African Americans often have a greater illness burden at baseline, often have less access to medical care, and thus may have a greater need for palliative care services. Continue reading “African Americans Are Less Accepting of Hospice and Palliative Care at End of Life; What Can ICU Doctors Do?”

PulmCC COPD Impact Study

The Impact study showed that inhaled steroids reduced the incidence of COPD exacerbation, in contrast to previous studies which suggested that LABA/LAMA combinations (Anoro, Stiolto, Bevespi) reduced exacerbations similar or greater degree. However the study’s findings are not without controversy. Should you prescribe a triple inhaler (Trelegy), or stick with dual LABA/LAMA, or dual LAMA/ICS like Breo, advair? I discuss these issues in our first Pulmonary, Critical Care (PulmCC) Podcast and how Trelegy might fit into the treatment of people with COPD.

Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.

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May lay in a hospital bed, her wrinkled and mottled skin covered with leads, and sensors that monitored her every breath and heartbeat. A camera that was mounted on the wall allowed a doctor to zoom in closely enough to count her tattered eyelashes. Her husband  sat at her bedside, gently stroking her withering gray hair  as her chest moved slowly up and down accompanied by the soft whoosh-whoosh of the ventilator that breathed for her. He stared expectantly at her face as if at any moment she would rise and free herself from the myriad tubes that sustained her.  Her adult daughters sat and stared blankly at the floor, waiting for something, anything. The streams of data transmitted from her body were monitored closely both by a team in a remote electronic-ICU bunker 50 miles away and her ICU nurse 15 feet away. Yet what May could not have realized was that despite her family’s presence at her bedside and the twenty-four hour care she received, she had been abandoned. She was alone. 

Several weeks earlier, May came to the hospital from her nursing home, “yet another pneumonia”, the note in her chart said.  “She seems to get one of these every few months” said her husband “can’t we give her something for that?”. The Emergency Room physician explained that she had aspiration, essentially choking on her own food and spit. She would continue to get pneumonia, until she eventually passed away. This wasn’t the first time he had heard this. “They told me before to let her die, but I didn’t listen to them, I told them to treat her anyway, and she made it through. I didn’t give up on her then and I’m not going to now”, adding “she’s a fighter”. Her husband Daniels countenance was such that the Emergency physician admitting May to the hospital didn’t bother asking whether his wife should be resuscitated in the event her heart  or lungs stopped working and she needed to be put on life support. May was admitted to the general medical ward, and was started  on antibiotics, but she eventually got worse. Sometime in the middle of the night a nurse found her ashen and struggling to breathe, and called a “code blue”. May’s breathing had gotten so bad that she needed life support, she had a tube put down her trachea and was taken to the ICU where she was put on a ventilator.

Doctors worked on her for more than a week,  treating her pneumonia with powerful antibiotics. But even as her pneumonia cleared, her body withered. Her skin hung from her bones as her muscles wasted away, her eyes hollowed, and the skin of her arms filled with bruises as nurses struggled to find a place from which to draw blood. On the second Sunday of her ICU stay, the doctors tried a “trial extubation”. As the family understood it, her lungs had improved to the point that she might be able to be taken off the ventilator, but her body was now so weak, they did not know whether she would actually be able to breathe on her own. If she had to be put back on the ventilator, the doctors told them, she would require a tracheostomy that would allow her to live on the ventilator long term.  The social worker would then seek placement in a long term facility for patients on long term ventilators, essentially a hybrid hospital, rehab, and nursing home in one. Her breathing failed within minutes of being taken off the ventilator, and she was immediately put back on life support.

It was the following day, Monday morning, that I met with May’s family to discuss what had happened the day before, it was the beginning of my ICU week. For May and her family it was the beginning of their third week in the ICU, and it showed. Her husband, Daniel looked unkept, his thick shock of gray hair was whirled and tangled, his flannel shirt partly tucked into ripped and stained jeans. He gave the impression of someone who had not been taking care of himself, let alone someone who could take care of his chronically ill wife. His visage upon seeing me betrayed both surprise and regret as he recognized me from four months earlier.  I was the doctor who told him that May was going to die. Continue reading “Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.”

Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.

Study Shows That Bariatric Surgery Reduced COPD Exacerbations by More Than Half

I often tell my patients with COPD that quitting smoking can have a greater effect on their respiratory health than any inhaler that I could prescribe them. Should I now also extend that advice to include weight loss for obese patients with COPD? In this journal CHEST® study, researchers used registry data to look at COPD exacerbations for patients both before and after bariatric surgery. In the year before bariatric surgery, risk of COPD exacerbations was 31%. Looking at the rate of COPD exacerbations during the year after bariatric surgery, that rate dropped to 12%, an astounding change.

The accompanying editorial proposes mechanisms explaining why this might be so and postulates whether obesity could be a modifiable risk factor in COPD. While these results are certainly exciting, we look forward to future investigation into whether bariatric surgery, or other weight loss means, could further help reduce risk of COPD exacerbation.

Pneumonia: If You Can’t See It, Does It Still Exist?

The diagnosis of pneumonia requires the radiographic presence of infiltrates on imaging. However, with its greater resolution, CT scanning can often demonstrate infiltrates when none are seen on chest roentgenogram. Do we treat these the same as a regular pneumonia? This study sought to quantify differences between patients with pneumonia as seen on a chest radiograph vs CT scanning. The differences between the two groups appeared to be minor, with procalcitonin levels appearing to be lower in the CT group. Otherwise, it would appear that patients with pneumonia seen only on CT scanning should be managed like other groups.

The accompanying editorial raises the question of what to do with patients who are suspected of pneumonia but have negative chest radiographs. Certainly, exposing them all to CT scanning can’t be the right answer. Perhaps we should err on the side of caution and treat these patients for pneumonia when clinical suspicion is high. Conversely, we should consider CT scanning in this group only if suspicion is low and the presence of an infiltrate would change management. Continue reading “Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.”