Manish Joshi

Marijuana and lung diseases.

Purpose of review Cannabis sativa (marijuana) is used throughout the world, and its use is increasing. In much of the world, marijuana is illicit. While inhalation of smoke generated by igniting dried components of the plant is the most common way marijuana is used, there is concern over potential adverse lung effects. The purpose of this review is to highlight recent studies that explore the impact upon the respiratory system of inhaling marijuana smoke. Recent findings Smoking marijuana is associated with chronic bronchitis symptoms and large airway inflammation. Occasional use of marijuana with low cumulative use is not a risk factor for the development of chronic obstructive pulmonary disease. The heavy use of marijuana alone may lead to airflow obstruction. The immuno-histopathologic and epidemiologic evidence in marijuana users suggests biological plausibility of marijuana smoking as a risk for the development of lung cancer; at present, it has been difficult to conclusively link marijuana smoking and cancer development. Summary There is unequivocal evidence that habitual or regular marijuana smoking is not harmless. A caution against regular heavy marijuana usage is prudent. The medicinal use of marijuana is likely not harmful to lungs in low cumulative doses, but the dose limit needs to be defined. Recreational use is not the same as medicinal use and should be discouraged.

IFN-γ Release Assay Conversions and Reversions. Challenges with Serial Testing in U.S. Health Care Workers

RATIONALE IFN-γ release assays (IGRAs) including the QuantiFERON-TB gold in-tube test (QFT-GIT) are increasingly used in place of the tuberculin skin test (TST) in surveillance programs for Mycobacterium tuberculosis infection in the United States. However, data on conversions, reversions, and predictive value of QFT in such programs for health care workers (HCWs) are limited. OBJECTIVES The purpose of this study is to assess long-term reproducibility and conversion and reversion rates of QFT-GIT among HCWs who underwent serial testing at a tertiary care center in the United States. METHODS Retrospective chart review of HCWs at the Central Arkansas Veterans Healthcare System (CAVHS) who underwent serial testing with QFT-GIT as a part of their employee screening between November 1, 2008 and January 31, 2011. MEASUREMENTS AND MAIN RESULTS A total of 2,303 HCWs had at least 2 QFT-GITs 1 year apart. The initial QFT-GIT was positive for 69 and 2 were indeterminate. Of these 69 HCWs, 31 (45%) reverted on repeat testing, and 25 of 31 (80.6%) HCWs who reverted had a negative look-back TST. Of the 2,232 HCWs with an initial negative QFT-GIT, 71 (3.2%) converted on repeat testing. A third QFT-GIT assay was performed in 41 of the 71 converters and 90% (37 of 41) reverted back to negative. Only two HCWs had TST and QFT-GIT conversion. CONCLUSIONS Poor IGRA reproducibility and a low predictive value of QFT-GIT conversions indicate that QFT-GIT with current interpretation criteria should not be used for serial screening of U.S. HCWs. Negative TSTs have higher reproducibility than QFT-GIT for serial testing of HCWs in low tuberculosis incidence settings.

Use of Interferon-Gamma Release Assays in a Health Care Worker Screening Program: Experience from a Tertiary Care Centre in the United States

BACKGROUND Interferon-gamma release assays including the QuantiFERON-TB Gold In-Tube test (QFT-GIT [Cellestis Ltd, Australia]) may be used in place of the tuberculin skin test (TST) in surveillance programs for Mycobacterium tuberculosis infection control. However, data on performance and practicality of the QFT-GIT in such programs for health care workers (HCWs) are limited. OBJECTIVES To assess the performance, practicality and reversion rate of the QFT-GIT among HCWs at a tertiary health care institution in the United States. METHODS Retrospective chart review of HCWs at Central Arkansas Veterans Healthcare System (Arkansas, USA) who underwent QFT-GIT testing as a part of their employee screening between November 1, 2008 and October 31, 2009. RESULTS QFT-GIT was used to screen 3290 HCWs. The initial QFT-GIT was interpreted as positive for 129 (3.9%) HCWs, negative for 3155 (95.9%) and indeterminate for six (0.2%). Testing with QFT-GIT was repeated in 45 HCWs who had positive results on the initial test. The QFT-GIT reverted to negative in 18 (40.0%) HCWs, all of whom had negative TST status and initial interferon-gamma values of 0.35 IU⁄mL to 2.0 IU⁄mL. CONCLUSION The QFT-GIT test is feasible in large health care setting as an alternative to TST for M tuberculosis infection screening in HCWs but is not free from challenges. The major concerns are the high number of positive test results and high reversion rates on repeat testing, illustrating poor short-term reproducibility of positive QFT-GIT test results. These results suggest adopting a borderline zone between interferon-gamma values of 0.35 IU⁄mL to 2.0 IU⁄mL, and cautious clinical interpretation of values in this range.

Symptom burden in chronic obstructive pulmonary disease and cancer.

Purpose of review Chronic obstructive pulmonary disease (COPD) is a crippling disease with a high worldwide prevalence. The purpose of this review is to highlight recent studies which define the global impact of COPD on quality of life. There are direct implications for care. Recent findings Dyspnea is a dominant and defining symptom for patients with COPD, but the overall degree of impairment suffered by patients with COPD extends far beyond shortness of breath. A series of recent studies gives us insight into both the physical and the psychosocial burdens of the disease and their negative net effects upon quality of life. The suffering of patients with COPD is similar to that of patients with cancer, and palliative measures have been shown to be an important component of comprehensive care. Summary The symptom burden in patients with severe COPD is high and is comparable to that of patients with cancer. Ironically, patients with COPD could be said to suffer more than those with cancer; the symptom burden is similar, but patients with COPD tend to live longer. The literature is replete with evidence that a palliative care approach to patients with cancer increases the quality of life (and perhaps even the quality of death). The same palliative care approach can and should be used for patients with COPD. There are now objective data to support the benefits of such an approach.

Delay in diagnosis of chronic obstructive pulmonary disease: reasons and solutions.

Purpose of review Chronic obstructive pulmonary disease (COPD) is a crippling disease with a high worldwide prevalence. It is the fifth-leading cause of death worldwide and estimated to become the third-leading cause of death by 2030. This review highlights recent studies that discuss reasons for and possible solutions to the delay in diagnosis of COPD. Recent findings Delay in COPD diagnosis is multifactorial and can be grouped into healthcare provider-related factors, patient-related factors, and heterogeneity in the disease itself. The current literature strongly supports the lack of awareness and knowledge about COPD among healthcare providers as an important factor in misdiagnosis and/or delays in diagnosis. Ironically, COPD is both underdiagnosed and overdiagnosed. Summary Achieving the goal of early diagnosis in COPD needs a major overhaul and culture change in primary care settings. Respiratory symptoms in a smoker 40 years or above should trigger automatic health alert and spirometry indications. Awareness of tobacco-related injury is the first building block in prevention and cure.

How to reduce hospital readmissions in chronic obstructive pulmonary disease

Purpose of review This article examines factors associated with readmission for chronic obstructive pulmonary disease and interventions that may decrease readmissions. Recent findings The literature on this topic is relatively sparse. Drug therapy revolves around appropriate use of bronchodilators, antibiotics, and steroids. Patient education and participation and a multidisciplinary approach to the transition out of hospital can lead to decreased rehospitalizations. Patients who cannot participate in self-care may do better in skilled nursing facilities. Summary We must optimize in-hospital care and see that patients receive a continuum of care upon discharge. We must also recognize that some patients have received optimal care and yet continue to suffer with end-stage disease on an ongoing basis; palliative medications such as long-acting narcotics and end-of-life discussions need to be considered in patients unable to survive for long outside of hospital.

The Impact of Vaccination on Influenza-Related Respiratory Failure and Mortality in Hospitalized Elderly Patients Over the 2013-2014 Season

Background : Seasonal Influenza (“the flu”) is a respiratory illness caused by influenza viruses. Yearly influenza vaccination is considered to be protective against illness and/or severity of illness and is recommended by CDC for all individuals > 6 months of age. However, the effectiveness of influenza vaccine in older individuals has come under question. Objectives : To describe the clinical characteristics and treatment outcomes of patients admitted to an academic tertiary care Veterans Administration hospital with influenza during the 2013-2014 influenza season and determine the impact, if any, of prior influenza vaccination upon patient outcomes. Methods : Medical electronic records were searched for all patients admitted to the Little Rock Veterans Administration Hospital with proven influenza during the 2013-2014 influenza season. Cohorts of vaccinated and non-vaccinated patients were then compared to determine the impact of prior influenza vaccination upon respiratory-failure and mortality. Results : Seventy patients met selection criteria. Mean age was 66 years. Sixty-four (91%) patients had at least one underlying co-morbid condition; these conditions included COPD, congestive heart failure, diabetes, and cancer. 60/70 (85%) tested positive for Influenza A, and 43 tested positive for H1N1. Oseltamivir was initiated in 55 (78%) patients. Forty-four percent of the patients had been vaccinated. When separated by vaccination status, those who had been vaccinated had higher rates of ICU admission, need for mechanical or non-invasive ventilation, and mortality. All but mortality reached statistical significance. Conclusion : The data suggest that there was no protective effect from prior vaccination in preventing hospital admission, respiratory failure, and mortality in this population of older men admitted to the hospital with influenza.

A case of DIPNECH presenting as usual interstitial pneumonia

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disease that is classically described as presenting with cough, dyspnea, and wheezing in non-smoker middle aged females. Pulmonary function tests commonly demonstrate an obstructive pattern and CT of chest usually reveals diffuse air trapping with mosaic pattern. We present a case of patient with DIPNECH manifesting with restrictive pattern and as usual interstitial pneumonia on imaging.

Seeing what we hear: an eye to help the ear

Lung auscultation dates back to the time of Hippocrates but became widespread with the invention of the stethoscope by René Laënnec in 1816. During the 20th century, technological advances in radiology, ultrasonography and magnetic resonance imaging shifted interest from lung auscultation to imaging studies, which can detect lung disease with an accuracy never previously imagined. However, modern computer-assisted programs offer an opportunity both for precise recording and for analysis of lung sounds, prompting the correlation of acoustic indices with measures of lung mechanics. This innovative though rarely used approach has improved our knowledge of acoustic characteristics and increased the clinical usefulness of auscultation. In this issue of Respirology, Bhattacharyya et al. have described a novel computer-assisted instrument for the interpretation of breath sounds. The authors record breath sounds and then apply mathematical analyses that appear to be complex and are not part of the regular ‘vocabulary’ of physicians. In this case, we may not understand the trees, but we can see the forest. The authors recorded sounds from the anterior tracheal position, subtracted the impact of heartbeat upon the sound profile and then, by combining analysis of skewness, lacunarity and sample entropy within those sound signals, were able to separate normal patients from patients with diffuse interstitial lung disease. An ultimate simplification of their findings would be that irregularly irregular anatomic structures produce irregularly irregular sound patterns. The statistics of the paper are striking; using their pictoral representation of the analysed sound patterns, even lay persons could separate normal from abnormal with 100% accuracy. This is extremely rare in medicine. It generally occurs when the question being asked is too simple. Such is likely in this case. Auscultatory diagnosis, to be of value, needs to identify focal areas of abnormality and a variety of abnormal sounds. Limiting the choices to normal and diffuse fibrotic lung disease would probably allow a lay person to separate normal from abnormal with 100% accuracy using a stethoscope. No computer needed. Given the above, why the excitement? Why should the paper even be published, let alone be the topic of an editorial? The answer lies in the word ‘novel.’ The study is novel in more than one way. It is novel in the aspects of sound that were chosen for analysis. It is novel (at least for us as physicians) in its visual representation of sound. The struggle to convert sound into images could be considered as herculean as the struggle to convert language into a written form, and the authors have presented an interpretable pictoral display of their data. Exciting examples that are different but similarly novel come to mind. In the early 2000s, an Israeli group developed a ‘vibration response imaging device’. Cups laid over the back of a patient measured the vibrations produced by air movement, allowing visual displays that corresponded with physiology. This technique was brilliant, novel and a teaching tool for physiologic function and dysfunction but has not to date penetrated clinical medicine. Another example of a novel approach is the diagnosis of lung disease patterns using ultrasound. The lung cannot be directly imaged by ultrasound because of the presence of air. In the late 1990s, Lichtenstein et al. made the brilliant observation that images formerly considered to be useless artefact actually represented the impact of specific lung disease patterns upon the ultrasound image. This approach, the harnessing of ‘artefact’, has some similarities to Bhattacharya et al.’s use of skewness, lacunarity and sample entropy. Unlike vibration response imaging, the use of ultrasound to study lungs has become a routine part of clinical medicine. The method used by Bhattacharya et al. may not become integrated into pulmonary medicine or may find its way into another area. Perhaps by interrogating a blood vessel for skewness, lacunarity and sample entropy, one could assess the burden of atherosclerotic vascular disease. One cannot at present predict. Perhaps the technique described by Bhattacharya et al. will be refined and actually make it into clinical practice. Perhaps the key concepts will be found to be of value in another area of medicine. Perhaps they will simply teach us a little bit about skewness, lacunarity and sample entropy, about the inner architecture of the sounds we listen to every day. Regardless, we thank them for looking at our world with different eyes.

A 62-Year-Old Man With Hypotension, Hyperkalemia, and Hyponatremia

A 62-year-old man with a history of antiphospholipid syndrome (APS) and recurrent lower extremity DVT on long-term warfarin therapy presented to the outpatient endoscopy suite for an esophagogastroduodenoscopy. His warfarin was withheld in anticipation of the procedure. The endoscopy was uneventful; however, he was admitted for further workup of hyponatremia, hyperkalemia, and mild elevation in liver function tests. His therapeutic anticoagulation was further withheld in the inpatient setting because of concerns over a drop in his hematocrit level. He subsequently developed diffuse abdominal pain and malaise followed by refractory hypotension and was transferred to the ICU for further management of his shock.