Charles B. Sherman

The health consequences of cigarette smoking. Pulmonary diseases.

Cigarette smoking has significant detrimental effects on both the structure and function of the lung; it is the single most important risk factor for the development of COPD. Uncertainty remains concerning the mechanisms by which smokers develop obstructive lung disease. It is speculated, however, that an imbalance between proteolytic and antiproteolytic forces in the lung or an increase in heightened airways responsiveness is responsible. Population-based studies have documented lower levels of FEV1, accelerated loss of ventilatory function, and increased respiratory symptoms and infections among smokers compared with nonsmokers. Data from both prospective and retrospective studies have consistently shown increased mortality from COPD, pneumonia, and influenza among cigarette smokers compared with nonsmokers.

The use of nicotine replacement therapy during hospitalization

Recent findings suggest that smokers who are hospitalized experience significant craving for cigarettes. Thus, nicotine replacement therapy (NRT) may be a particularly important tool for use during hospitalization. The goal of this study is to evaluate the utilization of the transdermal nicotine patch and/or nicotine gum by hospitalized smokers.The data represented in this article are from 580 smokers who participated in a study of a motivational intervention for smoking cessation that was delivered during hospitalization. The primary outcome for this analysis was use of NRT during hospitalization. The results revealed that, among the entire sample, only 7.1% of the overall sample used NRT during hospitalization; 6% of the hospitalized smokers used the transdermal nicotine patch, and 1.1% used nicotine gum. Use of NRT was significantly greater among patients who reported that they were doing anything to help themselves quit smoking at the time of admission (OR=4.1), those who were seriously planning to quit smoking within the next 30 days (OR=2.36), those who were nicotine dependent (OR=2.81), and those for whom a physician had ever offered to prescribe NRT (OR=1.9).The finding that there is a very low rate of NRT use during hospitalization provides important information to hospital-based care providers and smoking cessation intervention planners. Barriers to NRT use among hospitalized patients should be identified, and strategies designed to maximize use when appropriate. TheAHCPR Guideline on Smoking Cessation recommends routine use of NRT in health care settings. Further research is needed to determine why NRT use was so low. In addition, these data suggest that efforts to increase NRT use during hospitalization are needed.

Low correlation between household carbon monoxide and particulate matter concentrations from biomass-related pollution in three resource-poor settings.

Household air pollution from the burning of biomass fuels is recognized as the third greatest contributor to the global burden of disease. Incomplete combustion of biomass fuels releases a complex mixture of carbon monoxide (CO), particulate matter (PM) and other toxins into the household environment. Some investigators have used indoor CO concentrations as a reliable surrogate of indoor PM concentrations; however, the assumption that indoor CO concentration is a reasonable proxy of indoor PM concentration has been a subject of controversy. We sought to describe the relationship between indoor PM2.5 and CO concentrations in 128 households across three resource-poor settings in Peru, Nepal, and Kenya. We simultaneously collected minute-to-minute PM2.5 and CO concentrations within a meter of the open-fire stove for approximately 24h using the EasyLog-USB-CO data logger (Lascar Electronics, Erie, PA) and the personal DataRAM-1000AN (Thermo Fisher Scientific Inc., Waltham, MA), respectively. We also collected information regarding household construction characteristics, and cooking practices of the primary cook. Average 24h indoor PM2.5 and CO concentrations ranged between 615 and 1440 μg/m(3), and between 9.1 and 35.1 ppm, respectively. Minute-to-minute indoor PM2.5 concentrations were in a safe range (<25 μg/m(3)) between 17% and 65% of the time, and exceeded 1000 μg/m(3) between 8% and 21% of the time, whereas indoor CO concentrations were in a safe range (<7 ppm) between 46% and 79% of the time and exceeded 50 ppm between 4%, and 20% of the time. Overall correlations between indoor PM2.5 and CO concentrations were low to moderate (Spearman ρ between 0.59 and 0.83). There was also poor agreement and evidence of proportional bias between observed indoor PM2.5 concentrations vs. those estimated based on indoor CO concentrations, with greater discordance at lower concentrations. Our analysis does not support the notion that indoor CO concentration is a surrogate marker for indoor PM2.5 concentration across all settings. Both are important markers of household air pollution with different health and environmental implications and should therefore be independently measured.

Feasibility intervention trial of two types of improved cookstoves in three resource-limited settings: study protocol for a randomized controlled trial

BackgroundExposure to biomass fuel smoke is one of the leading risk factors for disease burden worldwide. International campaigns are currently promoting the widespread adoption of improved cookstoves in resource-limited settings, yet little is known about the cultural and social barriers to successful improved cookstove adoption and how these barriers affect environmental exposures and health outcomes.DesignWe plan to conduct a one-year crossover, feasibility intervention trial in three resource-limited settings (Kenya, Nepal and Peru). We will enroll 40 to 46 female primary cooks aged 20 to 49 years in each site (total 120 to 138).MethodsAt baseline, we will collect information on sociodemographic characteristics and cooking practices, and measure respiratory health and blood pressure for all participating women. An initial observational period of four months while households use their traditional, open-fire design cookstoves will take place prior to randomization. All participants will then be randomized to receive one of two types of improved, ventilated cookstoves with a chimney: a commercially-constructed cookstove (Envirofit G3300/G3355) or a locally-constructed cookstove. After four months of observation, participants will crossover and receive the other improved cookstove design and be followed for another four months. During each of the three four-month study periods, we will collect monthly information on self-reported respiratory symptoms, cooking practices, compliance with cookstove use (intervention periods only), and measure peak expiratory flow, forced expiratory volume at 1 second, exhaled carbon monoxide and blood pressure. We will also measure pulmonary function testing in the women participants and 24-hour kitchen particulate matter and carbon monoxide levels at least once per period.DiscussionFindings from this study will help us better understand the behavioral, biological, and environmental changes that occur with a cookstove intervention. If this trial indicates that reducing indoor air pollution is feasible and effective in resource-limited settings like Peru, Kenya and Nepal, trials and programs to modify the open burning of biomass fuels by installation of low-cost ventilated cookstoves could significantly reduce the burden of illness and death worldwide.Trial registrationClinicalTrials.gov NCT01686867

Factors Associated With Isolated Right Heart Failure in Women: A Pilot Study From Western Kenya☆

Background Small observational studies have found that isolated right heart failure (IRHF) is prevalent among women of sub-Saharan Africa. Further, several risk factors for the development of IRHF have been identified. However, no similar studies have been conducted in Kenya. Objective We hypothesized that specific environmental exposures and comorbidities were associated with IRHF in women of western Kenya. Methods We conducted a case-control study at a referral hospital in western Kenya. Cases were defined as women at least 35 years old with IRHF. Control subjects were similarly aged volunteers without IRHF. Exclusion criteria in both groups included history of tobacco use, tuberculosis, or thromboembolic disease. Participants underwent echocardiography, spirometry, 6-min walk test, rest/exercise oximetry, respiratory health interviews, and human immunodeficiency virus (HIV) testing. Home visits were performed to evaluate kitchen ventilation, fuel use, and cook smoke exposure time, all surrogate measures of indoor air pollution (IAP). A total of 31 cases and 65 control subjects were enrolled. Surrogate measures of indoor air pollution were not associated with IRHF. However, lower forced expiratory volume at 1 s percent predicted (adjusted odds ratio [AOR]: 2.02, 95% confidence interval [CI]: 1.27 to 3.20; p = 0.004), HIV positivity (AOR: 40.4, 95% CI: 3.7 to 441; p < 0.01), and self-report of exposure to occupational dust (AOR: 3.9, 95% CI: 1.14 to 14.2; p = 0.04) were associated with IRHF. In an analysis of subgroups of participants with and without these factors, lower kitchen ventilation was significantly associated with IRHF among participants without airflow limitation (AOR: 2.63 per 0.10 unit lower ventilation, 95% CI: 1.06 to 6.49; p = 0.04), without HIV (AOR: 2.55, 95% CI: 1.21 to 5.37; p = 0.02), and without occupational dust exposure (AOR: 2.37, 95% CI: 1.01 to 5.56; p = 0.05). Conclusions In this pilot study among women of western Kenya, lower kitchen ventilation, airflow limitation, HIV, and occupational dust exposure were associated with IRHF, overall or in participant subgroups. Direct or indirect causality requires further study.

The East African Training Initiative. A Model Training Program in Pulmonary and Critical Care Medicine for Low-Income Countries

Despite an extensive burden of lung disease in East Africa, there are remarkably few pulmonary physicians in the region and no pulmonary subspecialty training programs. We developed a unique training program for pulmonary medicine in Ethiopia. The East African Training Initiative (EATI) is a 2-year fellowship program at Tikur Anbessa (Black Lion) Specialized Teaching Hospital, the largest public hospital in Ethiopia and the teaching hospital for the Addis Ababa University School of Medicine. The first year is devoted to clinical care and procedural skills. Lectures, conferences, daily inpatient and outpatient rounds, and procedure supervision by visiting faculty provide the clinical knowledge foundation. In the second year, training in clinical research is added to ongoing clinical training. Before graduation, fellows must pass rigorous written and oral examinations and achieve high marks on faculty evaluations. Funding derives from several sources. Ethiopian trainees are paid by the Ethiopian Ministry of Health and the Addis Ababa University School of Medicine. The World Lung Foundation and the Swiss Lung Foundation supply travel and housing costs for visiting faculty, who receive no other stipend. The first two trainees graduated in January 2015, and a second class of three fellows completed training in January 2016. All five presented research abstracts at the annual meetings of the International Union Against Tuberculosis and Lung Disease in 2014 and 2015. The EATI has successfully provided pulmonary medicine training in Ethiopia and has capacity for local leadership. We believe that EATI could be a model for other resource-limited countries.

ACUTE EPIGLOTTITIS IN A NONAGENARIAN

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Notes from the Field. Training Pulmonary Specialists in a Low-Income Country

In this month’s issue of AnnalsATS, our colleagues Jeremiah Chakaya, Jane Carter, and Phil Hopewell (pp. 486–490) nicely describe the rationale behind current efforts to promote international engagement in the development of training programs in pulmonary medicine in lowand middleincome countries (1). The burden of lung disease in these settings is enormous and is likely to grow as the drivers of those diseases continue unchecked (2). At the same time, the overall number of physicians in many of these countries is very low, and the number of specialists is even lower. Among all the low-income countries in the world, these issues are most acute in subSaharan Africa, a region that contains many of the world’s poorest countries, many of which have very few or essentially no specialists (3). The survey reported by Obaseki and colleagues in this issue (pp. 591–598) describing availability of trained respiratory specialists, equipment, and services needed to provide basic and routine pulmonary care in Nigeria highlights this acute need (4). Nigeria, officially classified by the World Bank as a lower-middle-income country, is far from Africa’s poorest nation, but it is the most populous, and its needs are tremendous. Obaseki and colleagues clearly describe those needs. We have worked over the past several years in Tikur Anbessa (Black Lion) Hospital in Addis Ababa, Ethiopia, leading a program funded by the World Lung Foundation and the Swiss Lung Foundation to develop a pulmonary medicine fellowship program to train a cadre of qualified pulmonary physicians. Tikur Anbessa is the largest public hospital in Addis. We have recently graduated our first two fellows, and six more are in training. We briefly highlight several aspects of our experience here to amplify the points made in the papers by Chakaya and Obaseki and colleagues. A full description of the development of our program and its subsequent successes and occasional frustrations is beyond the scope of this editorial but will be forthcoming soon in a fuller manuscript. Ethiopia has the second highest population in Africa, with some 94 million people, yet it has fewer physicians than most other countries in the region and certainly has among the lowest number of physicians in the world. Data from the World Bank indicate there are fewer than 0.1 physicians of any kind (general doctors or specialists) per 1,000 persons in Ethiopia (5). This compares with 0.2/1,000 in neighboring Kenya, 0.3/1,000 in Botswana, 0.8/1,000 in South Africa, 2.8/1,000 in Egypt, 3.4/1,000 in France and 4.2/1,000 in Norway. When our program in Addis began, there was one very senior pulmonologist in the entire country, as far as we could determine, and he was in private practice. What could the effect possibly be of adding eight or so pulmonologists to a country of 94 million people? We have been acutely aware of this question throughout our experience. To address it at least in part, we have encouraged our trainees to think about lung diseases not only in a medical context but also in a public health context. We have endeavored to teach them to think about the epidemiology of lung disease in Addis and Ethiopia in general, as well as to think about population-based approaches to the burden of respiratory illness. Accordingly, our trainees have engaged in research projects to describe the nature and extent of common conditions such as asthma, chronic obstructive pulmonary disease, and lung cancer, and they have developed continuing education programs directed at generalists. In addition, our pulmonary fellows are expected to play a large teaching role for the many medical students now enrolled in some 20 new medical schools around the country. In these ways, we hope the effect of training a relatively small number of subspecialists can add greatly to the knowledge base of physicians and public health officials in the country, and thus multiply the effect of our program. We have been constantly challenged in our program by the lack of resources that most of us take for granted in our dayto-day lives as pulmonary physicians. Pulmonary function testing equipment, arterial blood gas analyzers, mechanical ventilators, and bronchoscopes are all in very short (or nonexistent) supply. Maintenance and upkeep of equipment is a very significant challenge. Access to webbased educational resources is often limited by balky and slow Internet connections and frequent interruptions in electricity. We have chosen in general to try to provide equipment we felt was absolutely necessary for education and training (it is difficult to learn about gas exchange without access to blood gas interpretation, for example), but we have not been in a position, nor do we think it wise, to be suppliers of large amounts of expensive

Creating a specialist physician workforce in low-resource settings: reflections and lessons learnt from the East African Training Initiative

Many African countries have extremely low ratios of physicians to population, and there are very, very few specialists. This leaves most patients without access to specialised care, and importantly also leaves many countries with insufficient expertise to properly evaluate the burden of illness and the needs of the population overall. The challenges to training a specialised physician workforce in resource-limited settings are many, and they go far beyond the (relatively simple) task of transmission of clinical skills. We initiated a capacity-building programme to train pulmonary physicians in Ethiopia, a country of 105 million persons with a high burden of lung disease that had no prior existing training programme in pulmonary medicine. Using volunteer faculty from the USA and Europe, we have provided high-quality training and established a cohort of pulmonary specialists there. We have identified several components of training that go beyond clinical skills development but which we feel are crucial to sustainability. These components include the delineation of viable career pathways that allow professional growth for subspecialist physicians and that support the permanent establishment of a local faculty; the development of important non-clinical skills, including leadership and pedagogical techniques; training in clinical research methodologies; and the development of mechanisms to amplify the impact of a still relatively small number of specialised physicians to address the needs of the population generally. Our programme, the East African Training Initiative, has successfully addressed many of these challenges and we hope that it can be replicated elsewhere.