Ayoub Innabi

Is vaping a gateway to smoking: a review of the longitudinal studies

Abstract Background: The use of e-cigarettes (ECs) is rising globally. There is concern that e-cigarette may actually lead to smoking, especially amongst adolescents. Objective: To perform a comprehensive review of literature reporting the longitudinal effects of e-cigarette use on onset of smoking among adolescents and young adults. Methods: A search was conducted using PubMed, Google Scholar, Scopus, and Web of Science in February 2016 to identify the studies containing data on EC use among adolescents and young adults (age<30 years). We then narrowed our search to only include longitudinal studies with data on EC and conventional cigarette smoking among this population. Results: Four longitudinal studies were identified that analyzed the use of ECs and smoking at both baseline and follow-ups in the target population. These studies demonstrated that EC use is associated with an increase in combustible cigarette smoking, even amongst the adolescents who were not susceptible to smoking. Conclusion: This review highlights the strong evidence that not only are ECs are not an effective tool for smoking cessation among adolescents, they actually are associated with higher incidence of combustible cigarette smoking. Policy makers need to recognize of the insidious nature of this campaign by the tobacco industry and design policies to regulate it.

A bronchoscopic approach to benign subglottic stenosis

Objectives: Subglottic stenosis is an abnormal narrowing of the tracheal lumen at the level of subglottis (the area in between the vocal cords and the cricoid cartilage). It can cause significant symptoms due to severe attenuation of airflow. We describe our experience in alleviating symptoms by addressing the stenosis using fibreoptic bronchoscopic methods. Methods: We report all concurrent cases performed between September 2015 and July 2016. We use a combination of balloon dilation, electro-surgery knife to dilate and incise stenotic segments followed by steroid injection to modulate healing. Results: We treated 10 patients in the study period, 8 of which were women. A total of 39 procedures were performed on these patients during this period. Gastro-esophageal reflux was the most common comorbidity associated with stenosis. The majority of the patients required more than 2 therapeutic procedures, but none required more than 4 procedures. There were no complications. Conclusion: Tracheal stenosis and in particular subglottic stenosis is a recurrent process and its management requires extensive collaboration amongst treating specialties. Our technique of steroid injection after dilation of the stenosis was effective in symptom control and decreased the number of repeat procedures.

Rethinking the Doses of Tissue Plasminogen Activator and Deoxyribonuclease Administrated Concurrently for Intrapleural Therapy for Complicated Pleural Effusion and Empyema

Background Complicated parapneumonic effusions empyema (CPEE) is fairly common and associated with increased morbidity and mortality. The Multicenter Intrapleural Sepsis Trial 2 (MIST 2) established the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (tPA) as an effective treatment for CPEE, thereby avoiding surgery and decreasing the length of hospitalization. MIST 2, however, used a labor-intensive protocol with some risk of bleeding. We hypothesize the simpler regimen of concurrent administration of intrapleural tPA and DNase (lower dose of tPA and a higher DNAse dose) to be equally effective with a decreased risk of bleeding. Methods Retrospective analysis of the concurrent administration of intrapleural tPA and DNase for CPEE during November 2014 to February 2016 was done at a tertiary care center. The inclusion criteria included 1) pleural fluid with any of the following: (a) exudative and loculated effusion in a patient with pneumonia, (b) gram stain/culture positive, (c) macroscopically purulent 2) chest tube placement during current hospitalization 3) concurrent administration of intrapleural tPA and DNase (4mg and 10mg per instillation respectively). The exclusion criteria was 1) chest tube placement prior to current hospitalization and 2) age < eighteen. Results Seventeen patients received concurrent tPA and DNase therapy for CPEE in the study period. Two had chest tubes placed prior to current hospitalization and were excluded. Twelve patients (80%) were successfully discharged with clinical resolution of CPEE with medical therapy. One (7%) patient required surgery. No mortality due to pleural sepsis was noted. The median number of concurrent tPA and DNase treatment was two. Median cumulative tPA dose was 8 mg (mean: 14.1±17 mg) and median cumulative DNase dose was 20mg (mean: 19.7 ± 12.2 mg). The median dwell time for the chest tubes was 8.5 days. Our regimen had similar success when compared to MIST 2 and allowed for lesser treatments and cumulative doses. No complication of intrapleural therapy with hemorrhagic conversion of CPEE, or worsening pain leading to discontinuation of therapy was noted. Conclusion The concurrent administration of intrapleural therapy at lower doses than the current standard MIST 2 protocol is practical, efficient and effective. We suggest a higher DNase dose with a lower tPA dose which may further decrease hemorrhagic complications. Further randomized trials are required to establish the optimal dose of intrapleural therapy for CPEE.

647: DECREASING PREVALENCE OF VAP IN AN ADMINISTRATIVE DATABASE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) are potentially fatal infections in ICU patients. The primary aim of our study was to evaluate the combination of biomarkers: Procalcitonin (PCT) for antibiotic stewardship and MR-proADM, CT-proAVP and MRproANP to predict 28-day and 1-year survival. Methods: Single center, retrospective cohort study of ICU patients with CAP and HAP admitted to our ICU from 2009–2011. This study is a pre-planned sub-analysis of the Stop Antibiotics on Procalcitonin guidance Study (SAPS). Demographics, APACHE IV, duration of antibiotic treatment (DOT) in 24 h periods, PCT values, 28-day and 1-year survival were collected. Patients were randomized in 2 groups with daily PCT in the intervention group. Stop antibiotics criteria were PCT ≤ 0,5 μg/L or ≤ 20% peak value. Blood samples on admission were analysed for MRproADM, CT-proAVP and MR-proANP. Data were expressed as median and quartile range. MannWhitney U test compared DOT in both groups. Multiple logistic regression analysis using 28-day and 1-year survival was performed and Odds ratios (OR) were computed. Results: 158 patients were selected, 97 males, age 65 [54–74] years, APACHE IV 73 [53–86], 59 with CAP and 99 with HAP. A pathogen was found in 66 patients, S. pneumoniae, K. pneumoniae and E. coli were most common. There were 111 survivors at 28 days and 95 survivors after 1 year. 79 (50%) patients had daily PCT. DOT was 5 days [4–7] and 6 days [5–10] in PCT and control group (p = 0.03). In a logistic regression model for 28-day survival only APACHE IV made a significant contribution (OR 0.98, p = 0.01), OR for MR-proADM (0.91), CT-proAVP (1.0), MRproANP (1.0), all non-significant. As for 1-year survival APACHE IV OR 0.98 (p = 0.02) and OR for MR-proADM (0.92), CT-proAVP (1.0), MR-proANP (1.0), all non-significant. Conclusions: Antibiotic stewardship with daily PCT resulted in a reduction in antibiotics of 1 day in CAP and HAP patients admitted to the ICU. Novel biomarkers such as MR-proADM, CTproAVP and MR-proANP had no value in predicting 28-day and 1-year survival.

Prevalence and predictors of readmissions among adults with cystic fibrosis in the United States

INTRODUCTION Patients with Cystic Fibrosis (CF) have increasing rates of hospitalization. We analyzed the burden and predictors of thirty-day readmission among patients with CF in the U.S. MATERIAL AND METHODS Nationwide Readmission Database (NRD) 2013 was used to identify adults with CF who were hospitalized. These individuals were followed to determine the prevalence of readmission within thirty days of index discharge. Cox proportional hazard regression was used to identify independent predictors of readmission. RESULTS There were 14,616 index admissions of adults with CF in 2013. Of these, 2,606 (17.8%) patients were readmitted within 30 days of discharge. Female sex and chronic anemia were independent predictors of readmission. The most common causes of readmission were pulmonary exacerbation (31%), lung transplant complications (5.2%), and septicemia (3.4%). CONCLUSION Readmissions are frequent among adults with CF and contribute to significant healthcare burden and cost among this population.

Iatrogenic Right-Sided Pneumothorax Presenting as ST-Segment Elevation: A Rare Case Report and Review of Literature

Pneumothorax is a well-recognized complication of central venous line insertion (CVL). Rarely, pneumothorax can lead to electrocardiogram (ECG) findings mimicking ST-segment elevation myocardial infarction. We present a 63-year-old man with iatrogenic right-sided pneumothorax who developed ST-segment elevation on a 12-lead ECG suggestive of myocardial infarction. The ECG findings completely resolved after needle decompression and chest tube placement. This case points up this rare electrocardiographic finding with discussion of possible mechanisms and differential diagnosis.

Central Venous Line Insertion Revealing Partial Anomalous Pulmonary Venous Return: Diagnosis and Management

Central venous line malposition is a well-known complication of line insertion. Rarely, it can be mal-positioned in an anomalous pulmonary vein. We present an unusual case of a 56-year-old woman that was found to have partial anomalous pulmonary venous return on central venous line insertion. In this report, we describe a systematic approach to diagnosis and management of this unusual situation.

A rare case of community acquired serratia lung abscess in a patient with cardiac bronchus

The incidence of lung abscess caused by Serratia marcescens is extremely low and is only reported in the immunocompromised population. We present a previously healthy woman with Serratia lung abscess in close proximity with an accessory cardiac bronchus. The patient was treated with appropriate antibiotics which led to complete resolution of the lesion. Our case highlights that individuals without medical co-morbidities may develop atypical lung infections like Serratia when associated with anatomic anomalies.

Caution! Self-supplementation may be injurious to your health.

To the Editor, Copper is an essential trace element in key metalloenzymes that have an important role in the structure and function of the nervous system [1]. Copper deficiency is rare due to its ubiquitous distribution and low dietary requirements. It can result from gastrointestinal surgery, zinc excess, malabsorption syndromes and parenteral nutrition. Copper deficiency causes an ataxic myelopathy in ruminant animals but in 2001 a relationship to myelopathy in humans was described [1, 2]. Copper deficiency myelopathy can affect the pyramidal tracts and dorsal columns in the spinal cord mimicking subacute combined degeneration [1, 2]. Here, we present a case of a 66-year-old woman who had undergone gastric bypass surgery 32 years ago. She presented with a 1-year history of numbness in her hands and leg that progressed over months from her toes to her waist, and 6 months of progressive gait difficulty requiring her to use a walker for support. She had been taking parenteral vitamin B12 monthly for 2 years and zinc supplements (50 mg of zinc gluconate for 4 years and 25 mg of zinc in a multivitamin for 1 year). On neurologic examination, her cranial nerves were intact, motor testing showed 5/5 strength except for 4/5 in right first dorsal interosseous (FDI), 4-/5 left FDI, 4/5 hip flexors, knee flexors/extensors, and big toe extensors. Lower extremity tone was mildly spastic sensation was diminished to pin prick to the mid ankles, vibration sensation was absent to the knees bilaterally and proprioception was impaired in the bilateral big toes. Her left toe was extensor on plantar testing. She had mild dysmetria on finger nose finger and mild truncal titubation. Gait was wide based and ataxic. Laboratories at presentation included normal complete blood count, electrolytes, liver function test. vitamin B12 level (1161 pg/ml; normal 180–914 pg/ml), serum methylmalonic acid (0.2 lmol/L; normal 0.00–0.40 lmol/ L), vitamin B1, folic acid, HbA1c, serum protein immunoelectrophoresis and urine protein immunoelectrophoresis. Antinuclear antibody, SS-A, SS-B, anti-smithanti-ds DNA antibodies were negative and rheumatoid factor level was normal. Syphilis serology was negative. Her copper level was undetectable (\10 lg/dl; normal 80–155 lg/dL). Ceruloplasmin level was low (\3, normal 17–54 mg/dL). Zinc levels were normal (91 lg/dl; normal 60–120 lg/dL). Magnetic resonance imaging (MRI) revealed hyperintense T2 signal in the dorsal columns of the cervical and thoracic spine (Fig. 1a, b) with no evidence of compressive myelopathy. Nerve conduction studies with EMG revealed markedly slow sensory nerve conduction velocities and normal motor nerve conduction potentials suggesting a sensory demyelinating neuropathy. Diagnosis of myelopathy secondary to copper deficiency was made. Zinc supplements were stopped and she was started on intravenous cupric chloride (2 mg/day elemental copper) for 5 days. On day 6 copper levels had improved to 63 ug/dl and oral copper supplementation was started. On 3-month follow-up after hospital discharge, she had subjective and objective improvement in signs and symptoms, while repeat imaging studies were unchanged. & Kaustubh Limaye limayekaustubh@gmail.com

A novel technique of needle setting for curvilinear endobronchial ultrasound: Improved efficiency with no cost.

Background: Standard instructions for biopsy using the convex curvilinear endobronchial ultrasound scope include visualization and adjustment of the sheath housing the biopsy needle before every puncture. In our practice, we pre-set this relationship before inserting the endobronchial ultrasound scope and leave it fixed for every puncture. Objective: We postulated that this approach is more efficient than repeated re-adjustment and aimed to show that it would not increase the frequency of endobronchial ultrasound scope damage. Methods: Retrospective review of every biopsy using the endobronchial ultrasound scope over a 6-year period with documentation of damages and costs. Results: There were 15 scope damages out of 1792 procedures (0.8%). Eight damages were determined to be due to needle damage, one due to patient bite, three due to Williams airway abrasions, and three were camera failures. All damages occurred during the first 5 years of the study. Costs totaled US