Heavy Tobacco Research Articles

The Impact of Donor Tobacco and Marijuana Smoking History on Early and Intermediate-Term Lung Transplant Outcomes

Donor tobacco and marijuana smoking are common in the lung donor pool, with both known to adversely affect post-lung transplant (LTx) outcomes. The intermediate survival outcomes and extent of the interactions of these smoking histories has not been described. DonateLife records and clinical databases were combined, with univariate and multivariate analyses undertaken to clarify the relation between donor tobacco and/or marijuana history and LTx outcomes. Between 2014-2018, 304 LTx were performed from 296 donors, including: A) 140 (46%) donor never smokers; B) 114 (38%) tobacco-light smokers (=<20 pk years) ± marijuana-light smoker (=intermittent use < 5yrs); C) 16 (5.3%) tobacco-heavy smokers (>20pk years) ± marijuana-light smokers; D) 20 (6.6%) marijuana-heavy smokers (= daily use or >5 yrs) + tobacco-light or heavy smokers (n=6 light marijuana only & n= 8 no data resulted not included) (Table 1). Donor smoking type, history and extent varied with donor age & gender. Smoking category adversely impacted 24hrPF ratio. Never smoker A) vs Combination D) were the only categories to show 3yr survival rate difference [P=0.02 by Log-rank (Figure 2), Hazard Ratio: 3.00 (95%CI: 1.17-7.69), P=0.02 by Cox Regression, adjusted for LTx type, diagnosis, and extended donor]. A donor smoking history generally has only a small effect on early and later outcomes. Despite a significantly younger donor age, a combined heavy marijuana and tobacco usage history may have long term consequences that need to be balanced against the risk of no-transplant for an individual waiting list potential recipient.

The risk of bronchial asthma exacerbations among smokers with asthma-chronic obstructive pulmonary disease overlap after inpatient treatment

To assess the risk of exacerbations of bronchial asthma (BA) in smoking patients with the asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) after inpatient treatment. 36 smokers with ACO (main group) and 36 non-smoking patients (control group) with severe or moderate exacerbation of bronchial asthma were examined. Assessment of the severity of exacerbation of BA before treatment, levels of control and risk of exacerbations of BA after treatment was determined according to the Federal clinical guidelines for the diagnosis and treatment of BA (2016). Spirometry, monitoring of blood oxygenation using transcutaneous spectral pulse oximetry and enzyme immunoassay for determination of matrix metalloproteinases 9 were performed. Smoking experience, smoking index and pack/years index were taken into account in patients with ACO. The carboxyhaemoglobin level was analyzed by the carbon monoxide fraction in the exhaled air. For the first time in patients with the ACO, the ability of heavy tobacco smoking and associated decrease in blood oxygenation to potentiate the negative impact of other predictors on the risk of exacerbations of the underlying disease was revealed. In smoking patients with the ACO, for the first time, a direct association of higher levels of matrix metalloproteinases 9 (measured before inpatient treatment) with such a predictor of the risk of further exacerbations of the disease as more frequent detection of symptoms of uncontrolled BA was revealed. In non-smoking patients with BA, a direct relationship between increased sputum secretion and eosinophilia of blood and/or sputum (a predictor of exacerbation of BA) and the relative duration of episodes of decreased blood oxygenation was established. It was found that intensive and prolonged smoking increases the duration and reduces the effectiveness of inpatient treatment of patients with ACO, contributing to the preservation of air traps and low (forced expiratory volume in 1 second 60%) ventilation capacity of the lungs with the persistence of moderately reduced blood oxygenation; the risk of further exacerbations of BA in this phenotype of patients is significantly higher than in non-smoking patients with BA without combination with COPD.

The impact of financial toxicity in gastrointestinal cancer patients

BackgroundBiopsychosocial distress screening is a critical component of comprehensive cancer care. Financial issues are a common source of distress in this patient population. This study uses a biopsychosocial distress screening tool to determine the factors associated with financial toxicity and the impact of these stressors on gastrointestinal cancer patients. MethodsA 48-question, proprietary distress screening tool was administered to patients with gastrointestinal malignancies from 2009 to 2015. This validated, electronically-administered tool is given to all new patients. Responses were recorded on a 5-point Likert scale from 1 (not a problem) to 5 (very severe problem), with responses rated at ≥3 indicative of distress. Univariate and multivariate logistic regressions were used to analyze the data. ResultsMost of the 1,027 patients had colorectal (50%) or hepatobiliary (31%) malignancies. Additionally, 34% of all patients expressed a high level of financial toxicity. Age greater than 65 (odds ratio: 0.63, 95% confidence interval: 0.47–0.86, P < .01), college education (odds ratio: 0.53, 95% confidence interval: 0.38–0.73, P < .0001), being partnered (odds ratio: 0.61, 95% confidence interval: 0.44–0.84, P < .01), and annual income greater than $40,000 (odds ratio: 0.27, 95% confidence interval: 0.19–0.38, P < .0001) were all protective against financial toxicity on univariate analysis. Also, heavy tobacco use was associated significantly with increased distress on univariate analysis (odds ratio: 2.79, 95% confidence interval: 1.38–5.78, P < .01). With the exception of partnered status (odds ratio: 1.18, 95% confidence interval: 0.76–1.85, P = .46), all these variables retained their significant association with financial toxicity in the multivariate model. ConclusionFinancial toxicity impacts a large number of cancer patients. Further study of at-risk populations may identify patients who would benefit from pre-emptive education and counseling interventions as part of their routine cancer care.

Oral HPV16 Prevalence in Oral Potentially Malignant Disorders and Oral Cavity Cancers.

The role of human papillomavirus type 16 (HPV16) in oral potentially malignant disorders (OPMD) and oral cavity carcinoma (OC) is still under debate. We investigated HPV16 prevalence in unstimulated saliva, oral rinse samples, oral swabs and tumour biopsies collected from OPMD (n = 83) and OC (n = 106) patients. HPV16 genotype, viral load, physical status (episomal vs. integrated) and tumour p16INK4a expression were determined. Oral HPV16 prevalence was higher in OC than in OPMD, but this difference was not statistically significant (7.5% (8/106) versus 3.6% (3/83), odds ratio (OR): 2.18, 95% confidence interval (CI): 0.56, 8.48, p = 0.26). There was a significant association (p < 0.05) between oral HPV16 infection and heavy tobacco consumption. Real-time PCR results indicated that no integration events occurred in either OPMD or OC cases based on the HPV16 E2/E6 ratio. HPV16 positive OPMD and OC patients had similar HPV16 E2 and E6 viral loads. The inter-rater agreement between tumour p16INK4a expression and oral HPV16 infection was considered as fair (k = 0.361) for OC. Our data suggest that the involvement of HPV16 in oral carcinogenesis is limited.

ACANTHOLYTIC SQUAMOUS CELL CARCINOMA OF THE ORAL CAVITY

Acantholytic squamous cell carcinoma (AcSCC) is a rare variant of poorly differentiated oral SCC of aggressive behavior that contains marked acantholysis, resulting in an adenoid appearance. A 58-year-old man presented an extensive painful and necrotic mass affecting the lower lip mucosa and skin, which appeared ulcerated and hardened for the last 5 months. The patient's cervical lymph nodes were palpable, and previous heavy tobacco use was reported. Intraoral examination showed an 8 × 6 cm ulcerated mass affecting lower anterior alveolar ridge with extension to the floor of the mouth and anterior mandible, which was completely destroyed in the image of panoramic radiograph. An incisional biopsy was performed, and microscopically, infiltrative malignant nests containing many acantholytic and dyskeratotic squamous cells were observed. The final diagnosis was of AcSCC, and the patient was referred for treatment. Oral AcSCC may appear as an exuberant infiltrative mass causing extensive bone destruction.

SPONTANEOUS REMISSION OF PULMONARY LANGERHANS CELL HISTIOCYTOSIS DESPITE PERSISTENT CIGARETTE AND CANNABIS USE

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pulmonary Langerhans Cell Histiocytosis (PLCH) is a rare tobacco-associated interstitial lung disease causing cysts (1). PLCH is defined by the peribronchiolar accumulation of Langerhan cells, a dendritic cell found in respiratory epithelium (2). Constitutively activated Langerhans cells lead to increased and dysregulated inflammation resulting in the characteristic appearance of (peribronchiolar) nodules progressing to cyst formation (2). Pathologic diagnosis is often confirmed by the presence of S100 protein, CD1a positive, or CD207 (langerin) (3). When Langerhan Cell Histiocytosis is confined to the lungs, 90% of cases are related to tobacco exposure (2). Continued exposure to tobacco will often result in worsening disease. We present an unusual case of spontaneous remission of PLCH while persistent exposure to cannabis and tobacco. CASE PRESENTATION: A forty-four-year-old female current tobacco smoker 30 pack years, cannabis user presented to our hospital with nausea, dyspnea, and weight loss. Her medical history was significant for heavy tobacco and cannabis use. Initial exam revealed bilateral rhonchi though she was breathing comfortably on room air. Computer tomography (CT) of the chest revealed bilateral pulmonary nodules, some with cavitiation, and involvement predominantly in the upper lobes (Figure 1). Transthoracic biopsy (Figure 1) showed eosinophils, fibrosis, and tobacco-pigmented macrophages. Immunohistochemically stains focally positive for S-100 and HLA-DR-CD1a, confirming the diagnosis of PLCH. The patient was counseled on cessation of tobacco and cannabis inhalation, but did not follow up as an outpatient. On subsequent admission for gastrointestinal issues, CT scan demonstrated resolution of most of the nodules with residual small cysts despite persistent use of tobacco and cannabis. DISCUSSION: This case of spontaneous remission without cessation of tobacco or cannabis, represents an unusual trajectory in the disease course of PLCH. Treatments of PLCH centers around avoidance of toxin inhalation (tobacco and cannabis) and supportive care for pulmonary complications (1). The cytotoxic medication Cladribine (purine antagonist) has been used effectively in severe cases. Recently recognized, PLCH has been associated with up to 50% CD1a positive cells with mitogen kinase BRAFV600E mutations, which may lend itself to future targeted therapy. The spontaneous remission presented may support limited therapeutic intervention for PLCH, though randomized control trials are lacking. ten months after her initial diagnosis the pulmonary department continues to follow and support this patient and emphasize tobacco cessation. CONCLUSIONS: Pulmonary Langerhan Cell Histiocytosis is a rare interstitial lung disease linked to tobacco that follows a variable disease trajectory and requires an individualized approach in the absence of high quality clinical trials. Reference #1: Gupta N, Vassallo R, Wikenheiser-Brokamp KA, McCormack FX. Diffuse Cystic Lung Disease. Part I. American journal of respiratory and critical care medicine. 2015;191(12):1354-66. Reference #2: Richards JC, Lynch DA, Chung JH. Cystic and nodular lung disease. Clinics in chest medicine. 2015;36(2):299-312, ix. Reference #3: Roden AC, Yi ES. Pulmonary Langerhans Cell Histiocytosis: An Update From the Pathologists' Perspective. Archives of pathology & laboratory medicine. 2016;140(3):230-40. DISCLOSURES: No relevant relationships by Elliott Bondi, source=Web Response No relevant relationships by Joshua Davidson, source=Web Response No relevant relationships by Volha Liaukovich, source=Web Response No relevant relationships by Edith Okoye, source=Web Response No relevant relationships by Edith Okoye, source=Web Response No relevant relationships by Erum Zahid, source=Web Response

The effects of marijuana smoking on lung function in older people.

Previous studies have associated marijuana exposure with increased respiratory symptoms and chronic bronchitis among long-term cannabis smokers. The long-term effects of smoked marijuana on lung function remain unclear. We determined the association of marijuana smoking with the risk of spirometrically defined chronic obstructive pulmonary disease (COPD) (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio <0.7) in 5291 population-based individuals and the rate of decline in FEV1 in a subset of 1285 males and females, aged ≥40 years, who self-reported use (or non-use) of marijuana and tobacco cigarettes and performed spirometry before and after inhaled bronchodilator on multiple occasions. Analysis for the decline in FEV1 was performed using random mixed effects regression models adjusted for age, sex and body mass index. Heavy tobacco smoking and marijunana smoking was defined as >20 pack-years and >20 joint-years, respectively. ∼20% of participants had been or were current marijuana smokers with most having smoked tobacco cigarettes in addition (83%). Among heavy marijuana users, the risk of COPD was significantly increased (adjusted OR 2.45, 95% CI 1.55-3.88). Compared to never-smokers of marijuana and tobacco, heavy marijuana smokers and heavy tobacco smokers experienced a faster decline in FEV1 by 29.5 mL·year-1 (p=0.0007) and 21.1 mL·year-1 (p<0.0001), respectively. Those who smoked both substances experienced a decline of 32.31 mL·year-1 (p<0.0001). Heavy marijuana smoking increases the risk of COPD and accelerates FEV1 decline in concomitant tobacco smokers beyond that observed with tobacco alone.

Prevalence and analysis of tobacco use disorder in patients diagnosed with lung cancer.

IntroductionTobacco use disorder (TUD), previously known as nicotine dependence, was associated with increased risk of lung cancer. However, little is known about the prevalence of TUD and symptom manifestation in smokers with lung cancer.ObjectivesThe aim of the present study was to investigate the prevalence of TUD using DSM-5 diagnostic criteria in patients diagnosed with lung cancer and analyze their tobacco use characteristics.MethodsA total of 200 histologically confirmed lung cancer patients who used tobacco within the prior 12-month period at the time of diagnosis were recruited for this study. Participants were assessed using interviewer-administered questionnaires to determine TUD symptoms and smoking-related behaviors, and self-administered Fagerstrom Test for Nicotine Dependence (FTND) was also administered.ResultsThe prevalence of DSM-5 TUD was 92.0% (n = 184). Of a total of 200 subjects, 23 (11.5%), 35 (17.5%), and 126 (63.0%) were classified into mild, moderate, and severe TUD categories, respectively. A total of 19 (81.3%) moderate TUD and 98 (77.8%) severe TUD patients had attempted smoking cessation. Of these subjects, 21 (21.4%) severe TUD and 12 (63.2%) moderate TUD patients tried more than three times. The number of satisfied criteria under DSM-5 TUD was positively correlated with FTND score, cumulative lifetime smoking amount, and daily smoking levels.ConclusionsSmokers diagnosed with lung cancer showed a high prevalence of DSM-5 TUD. Their heavy and consistent tobacco use suggests reduced motivation to abstain from smoking.

High wattage e-cigarette vaping induces arterial hypoxemia and tissue hypoxia in tobacco smokers suffering from coronary artery disease: A RCT

Background Whereas high wattage electronic cigarettes (e-cigarettes) vaping (V) is increasingly popular, its health effects are largely unknown. We tested the hypothesis that pure propylene glycol/glycerol e-liquid vehicles V decreases arterial oxygen partial pressure in heavy tobacco smokers suspected of coronary artery disease. Methods After their coronary angiogram, twenty tobacco smokers participated in an open-label randomized parallel study; serial intra-arterial blood samples were performed before and after 1-gram propylene glycol/glycerol e-cigarette V at 60 Watts (N = 10) or sham-vaping (SV) (N = 10). Peripheral pulse oximetry, transcutaneous gas tension and microcirculatory blood flow were also assessed throughout the experimental sessions. Results Eighty % of the patients were hypertensive and 60% had a left ventricular ejection fraction – Δ-arterial oxygen partial pressure (SV: + 5.4 ± 3.3 mmHg vs. V: − 5.4 ± 1.9 mmHg; P = 0.012) (difference between groups; 10.8 [95%CI, 8.4–13.2]mmHg); – Δ-arterial oxygen saturation (SV: + 0.9 ± 0.6% vs. V: − 0.8 ± 0.3%; P = 0.023); – Δ-oxyhemoglobin fraction (SV: + 1 ± 0.5% vs. V: − 0.6 ± 0.3%; P = 0.028); – Δ-peripheral oxygen saturation (SV: + 1.3 ± 0.4% vs. V: − 1.3 ± 0.5%; P – Δ-transcutaneous oxygen partial pressure (SV: + 6 ± 3.4 mmHg vs. V: − 1.2 ± 2.1 mmHg; P = 0.041). The decrease in Δ-peripheral oxygen saturation (SV: + 0.7 ± 0.6% vs. V: − 0.7 ± 0.5%; P = 0.036) persisted up to 20 minutes after V compared to SV. Conclusions Acute high wattage e-cigarette V in smokers with heart disease induces arterial hypoxemia with subsequent tissue hypoxia. The latter could be related to ventilation/perfusion mismatches.

Aneurysmal Subarachnoid Hemorrhage Associated with Small Aneurysms in Smokers and Women: A Retrospective Analysis

BackgroundPrevious studies have shown low rupture rates for small aneurysms (<10 mm), suggesting that the risk of treatment could exceed the benefits. However, evidence has changed, showing crescent rates of aneurysmal subarachnoid hemorrhage (aSAH) associated with small aneurysms. We report trends in size, localization, clinical characteristics, and outcomes of intracranial aneurysms (IAs).MethodsIn this retrospective study, a total of 200 clinical histories of patients diagnosed with IAs over an 8-year period were analyzed. Variables considered included age, sex, tobacco consumption, morphological characteristics of the aneurysm, complications, vasospasm, and mortality. Qualitative variables were assessed by measurements of absolute and relative frequency. Smoking behavior, aneurysm size, and aneurysm rupture (AR) were compared using 1-way analysis of variance. Categorical variables were analyzed using Pearson's χ2 test.ResultsThe average age at presentation was 58 years. The average size of ruptured aneurysms in the general group was 2.5–7.5 mm, and AR was most common in women (76%) and in patients age 50–60 years (33%). The rate of vasospasm was 19%, and mortality was 37%. Smokers composed 32% of the cohort. Heavy smokers had a 57% rate of aSAH, with an average size of rupture of 5 mm. The most common location of aneurysms and AR was the AComA (33%).ConclusionsOur results suggest increasing AR rates in aneurysms smaller than 10 mm. This trend is seen especially in individuals with heavy tobacco consumption and in women of perimenopausal age. Our findings show a tendency of AR in accordance with previous results and are expected to serve as basis for further research on aneurysm management.

MON-392 Bilateral Pheocromocytoma With A Ret Proto-oncogene Mutation

Introduction: Pheochromocytoma is a rare neoplasm, occurring in less than 0.2% percent of patients with hypertension. We present a case of bilateral pheochromocytoma with a RET proto-oncogene mutation. Clinical case: 47 year old male with history of multiple hypertensive crises, 10 kg weight loss in a 3 month period and atrial fibrillation with rapid ventricular rate; heavy tobacco use; and family history of cerebrovascular disease. He presents to the emergency department with fever, right flank ecchymosis, abdominal pain, and blood pressure of 210/110 mmHg (n <120/90 mmHg); thyroid and pulmonary examination were normal. Abdominal CT scan revealed bilateral growth of adrenal glands, which prompted his hospital admission. Total plasma catecholamines were 12159 pg/ml (n <504 pg/ml), predominately epinephrine; 24 hour urine catecholamines measured 1254 µg (n <100 µg), and 24 hour urine metanephrines measured 22485 µg (n <900 µg). Abdominal MRI showed bilateral adrenal tumors; right adrenal gland measuring 3.5 x 4 cm and left adrenal gland 6 x 5 cm; heterogeneous, with cystic features and hyperintensity on T2 weighted images. Patient underwent bilateral adrenalectomy. The pathology report showed bilateral pheochromocytoma without capsular or vascular invasion. Peripheral leukocyte DNA analysis showed a RET proto-oncogene TGC-TAC mutation in codon 634 of exon 11. Postoperative testing showed normal catecholamine and metanephrine levels. Patient presented complete clinical remission. Conclusion: There are several familial disorders associated with adrenal pheochromocytoma, all of which have autosomal dominant inheritance: von Hippel-Lindau syndrome, multiple endocrine neoplasia type 2 and, less commonly, neurofibromatosis type 1. Multiple endocrine neoplasia type 2 is associated with mutations in the RET proto-oncogene. If a patient presents with bilateral adrenal pheochromocytoma but without a history of medullary thyroid cancer or goiter, tests for mutations in the following genes should be ordered sequentially: VHL, RET, SDHx, TMEM127, and MAX. This particular case presented with bilateral pheochromocytoma and a RET proto-oncogene mutation, but no other neoplasms. The definite treatment is laparoscopic adrenalectomy by an experienced endocrine surgeon with preoperative alpha-adrenergic blockade. Because of the identification of the RET proto-oncogene mutation a prophylactic thyroidectomy is recommended.

Neurobiological Determinants of Tobacco Smoking in Schizophrenia.

Purpose of review: To provide an overview of the underlying neurobiology of tobacco smoking in schizophrenia, and implications for treatment of this comorbidity.Recent findings: Explanations for heavy tobacco smoking in schizophrenia include pro-cognitive effects of nicotine, and remediation of the underlying pathophysiology of schizophrenia. Nicotine may ameliorate neurochemical deficits through nicotine acetylcholine receptors (nAChRs) located on the dopamine, glutamate, and GABA neurons. Neurophysiological indices including electroencephalography, electromyography, and smooth pursuit eye movement (SPEM) paradigms may be biomarkers for underlying neuronal imbalances that contribute to the specific risk of tobacco smoking initiation, maintenance, and difficulty quitting within schizophrenia. Moreover, several social factors including socioeconomic factors and permissive smoking culture in mental health facilities, may contribute to the smoking behaviors (initiation, maintenance, and inability to quit smoking) within this disorder.Summary: Tobacco smoking may alleviate specific symptoms associated with schizophrenia. Understanding the neurobiological underpinnings and psychosocial determinants of this comorbidity may better explain these potential beneficial effects, while also providing important insights into effective treatments for smoking cessation.

Predictors of tobacco and alcohol co-use from ages 15 to 32: The Amsterdam Growth and Health Longitudinal Study.

Tobacco and alcohol are often used in tandem over time, but specific predictors of course and patterns of course over time need explication. We examined differences in alcohol and tobacco course among an adolescent population as they transitioned into young adulthood across a 17-year period. Data came from participants (n = 303 for ages 15-21, n = 196 for ages 21 to 32; 52% female and 54% female, respectively) enrolled in the Amsterdam Growth and Health Longitudinal Study, an epidemiologic investigation examining disease across the life span. We utilized parallel latent growth modeling to assess the impact of sex, personality traits, cholesterol, blood pressure, and body mass index (BMI), on initial status and linear change over time in course of tobacco and alcohol. Females reported less alcohol use at adolescent baseline (β = -21.79), less increase during adolescence (β = -7.92, p < .05), slower decrease during young adulthood (β = 4.67, p < .05), and more rapid decline in tobacco use during young adulthood (β = -70.85, p < .05), relative to males. Alcohol and tobacco use baseline status' and change over time were all significantly associated with one another during both adolescence and young adulthood (p < .05; aside from alcohol baseline and slope during young adulthood). Effects of BMI, cholesterol, blood pressure, and personality traits were also observed on tobacco and alcohol course. In light of the strong, but sex dependent relationship between alcohol and tobacco course, particularly from ages 15 to 21, prevention efforts to curb heavy alcohol and tobacco use should consider targeting course taking into account biological sex and other notable covariates. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Early carcinoma tongue: evaluation using ultrasonography and its comparison with final histopathological findings

Background: Squamous cell carcinoma of the tongue is a common malignancy associated with risk factors like excessive alcohol consumption, heavy tobacco smoking and human papilloma virus. Magnetic resonance imaging (MRI) scan is considered to be the gold standard in investigating these tumors. However, MRI equipment is expensive to buy and is not readily available in some centers. Computed tomography scan has also been used in imaging these patients, but this modality carries a radiation burden. Patient’s five-year survival is dependent on early diagnosis. It is, therefore, important to diagnose early and image accurately to ensure good outcomes. This study was focused on evaluating the role of Ultrasonography in assessing early tongue cancer and its comparison with postoperative histopathological findings. The objectives of this study are to evaluate the role of sonography in assessing early tongue cancer depth of invasion and compared it with postoperative histopathological findings.Methods: A prospective study was performed on 100 cases of early tongue cancer. sonography of the tongue was performed, BY 7.5 MHz - 12 MHz Probe. Ultrasonography findings compared with post-operative histopathological findings sensitivity and specificity calculated.Results: All patients underwent sonography of tongue with 7.5 MHz probe to know the depth of tumor and these findings were compared with depth demonstrated on final histopathological reports. Sensitivity and specificity of USG for depth of tumor were very high (HPR findings were taken as standard results). On USG, tumor thickness i.e. 2 mm, 2-4 mm and &gt;4 mm were observed in 22, 55 and 23 patients. On HPR, tumor thickness i.e. 2 mm, 2-4 mm and &gt;4 mm were observed in 20, 60 and 20 patients. Sensitivity and septicity both above 90%.Conclusions: Ultrasonography proved a reliable diagnostic tool with sensitivity and specificity more than 90%, for knowing the pre-operative depth of tumor but further larger randomized studies required to confirm the recommendations.

An improved model of ethanol and nicotine co-use in female P rats: Effects of naltrexone, varenicline, and the selective nicotinic α6β2* antagonist r-bPiDI

Background Although pharmacotherapies are available for alcohol (EtOH) or tobacco use disorders individually, it may be possible to develop a single pharmacotherapy to treat heavy drinking tobacco smokers by capitalizing on the commonalities in their mechanisms of action.Methods Female alcohol-preferring (P) rats were trained for EtOH drinking and nicotine self-administration in two phases: (1) EtOH alone (0 vs. 15% EtOH, 2-bottle choice) and (2) concomitant access, during which EtOH access continued with access to nicotine (0.03 mg/kg/infusion, i.v.) using a 2-lever choice procedure (active vs. inactive lever) in which the fixed ratio (FR) requirement was gradually increased to FR30. When stable co-use was obtained, rats were pretreated with varying doses of naltrexone, varenicline, or r-bPiDI, an α6β2* subtype-selective nicotinic acetylcholine receptor antagonist shown previously to reduce nicotine self-administration.Results While EtOH intake was initially suppressed in phase 2 (co-use), pharmacologically relevant intake for both substances was achieved by raising the “price” of nicotine to FR30. In phase 2, naltrexone decreased EtOH and water consumption but not nicotine intake; in contrast, naltrexone in phase 1 (EtOH only) did not significantly alter EtOH intake. Varenicline and r-bPiDI in phase 2 both decreased nicotine self-administration and inactive lever pressing, but neither altered EtOH or water consumption.Conclusions These results indicate that increasing the “price” of nicotine increases EtOH intake during co-use. Additionally, the efficacy of naltrexone, varenicline, and r-bPiDI was specific to either EtOH or nicotine, with no efficacy for co-use. Nevertheless, future studies on combining these treatments may reveal synergistic efficacy.

Reform of primary health care in Pakistan

With a neonatal mortality rate exceeding 45 per 1000 livebirths, a UNICEF report ranked Pakistan as the riskiest place to be born on earth. 1 UNICEFEvery child alive: the urgent need to end newborn deaths. United Nations Children Fund, New York2018 Google Scholar Although the recent Demographic and Health Survey indicates that the situation has improved, the neonatal mortality rate in Pakistan is among the highest in the world. 2 National Institute of Pakistan StudiesPakistan Demographic and Health Survey: key indicators report, 2017–18. National Institute of Pakistan Studies, Islamabad2017 Google Scholar Other health indicators, particularly those pertaining to maternal and child health and nutrition, are worse than other countries in the region with comparable or lower socioeconomic indicators. 3 Akseer N Kamali M Arifeen SE et al. Progress in maternal and child health: how has South Asia fared?. BMJ. 2017; 357: j1608 Crossref PubMed Scopus (39) Google Scholar Pakistan is one of only two countries in the world where polio remains endemic and the country had little success in achieving the Millennium Development Goals (MDGs), especially those related to maternal and child health outcomes. 4 Government of PakistanPakistan Millennium Development Goals report 2013. Planning Commission, Government of Pakistan, Islamabad2013 Google Scholar The Astana Declaration: the future of primary health care?Primary health care is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge. Half the world's population has no access to the most essential health services. Yet 80–90% of people's health needs across their lifetime can be provided within a primary health-care framework—from maternity care and disease prevention through vaccination, to management of chronic conditions and palliative care. As populations age, and multimorbidity becomes the norm, the role of primary health-care workers becomes ever more important. Full-Text PDF Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in HealthIn 2013, the Lancet Commission on Investing in Health published its report, “Global health 2035: a world converging within a generation” (GH2035). The report concluded that a grand convergence in health—a reduction in infectious, child, and maternal mortality to rates seen in the best-performing middle-income countries—is technically and financially feasible for all but the poorest countries by 2035. Mortality from non-communicable diseases could be reduced through inexpensive population-based and clinical interventions, especially fiscal policies such as heavy tobacco taxation. Full-Text PDF Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in EthiopiaWeakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Full-Text PDF

Primary health care for the 21st century, universal health coverage, and the Sustainable Development Goals

Good health and wellbeing are fundamental to the prosperity of societies. By many measures, modern humanity enjoys better health than earlier generations. 1 WHOWorld health statistics 2018: monitoring health for the Sustainable Development Goals. World Health Organization, Geneva2018 Google Scholar But the benefits of modern health care are not accessible to all. Even as the incidence of infectious diseases such as HIV, tuberculosis, and malaria are reduced, many countries struggle to cope with the growing burden of non-communicable diseases, and the complex and growing health needs of ageing populations. 2 WHOTime to deliver: report of the WHO Independent High-level Commission on Noncommunicable Diseases. World Health Organization, Geneva2018 Google Scholar , 3 WHOWorld report on ageing and health. World Health Organization, Geneva2015 Google Scholar The Astana Declaration: the future of primary health care?Primary health care is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge. Half the world's population has no access to the most essential health services. Yet 80–90% of people's health needs across their lifetime can be provided within a primary health-care framework—from maternity care and disease prevention through vaccination, to management of chronic conditions and palliative care. As populations age, and multimorbidity becomes the norm, the role of primary health-care workers becomes ever more important. Full-Text PDF Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in HealthIn 2013, the Lancet Commission on Investing in Health published its report, “Global health 2035: a world converging within a generation” (GH2035). The report concluded that a grand convergence in health—a reduction in infectious, child, and maternal mortality to rates seen in the best-performing middle-income countries—is technically and financially feasible for all but the poorest countries by 2035. Mortality from non-communicable diseases could be reduced through inexpensive population-based and clinical interventions, especially fiscal policies such as heavy tobacco taxation. Full-Text PDF Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in EthiopiaWeakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Full-Text PDF Yelzhan Birtanov: leading Kazakhstan to universal health coverageAlthough only a child at the time, Yelzhan Birtanov, Minister of Healthcare of Kazakhstan, remembers the landmark 1978 Alma-Ata conference. His physician parents were attendees. “I recall doing drawings with the pens that they brought back from the meeting, and looking at a lot of photos of the conference; even as a young child, it was clear that something major was taking place in my country”, he says. Full-Text PDF

Impaired glucose metabolism – A potential risk factor for idiopathic nodular glomerulosclerosis: A single center study

Nodular glomerulosclerosis is a characteristic histological finding of diabetic nephropathy (DN) with thickened glomerular basement membrane and hyalinized arterioles. Idiopathic nodular glomerulosclerosis (ING), a distinct clinicopathologic entity, is the term used to denote classic DN confirmed by light microscopy, immuno-fluorescence, and electron microscopy but in the absence of diabetes mellitus (DM). ING has been linked to heavy tobacco smoking, chronic hypertension, and obesity. We report the result of a retrospective study identifying seventeen subjects from Thomas Jefferson University (1999–2014) with biopsy-proven nodular glomerulosclerosis but no pre-existing history of DM. The main indications for percutaneous kidney biopsy (PKB) were either reduced renal function or the presence of proteinuria. The subjects’ mean (±SD) age was 60.2 (14.4) years, their highest documented random glucose level was 104.4 (23.5) mg/dL, serum creatinine measured 2.35 (1.03) mg/dL, and body mass index calculated 29.4 (6.2) kg/m2. None of the patients fulfilled criteria for diabetes at the time of PKB. However, review of medical records revealed history of intermittently elevated blood glucose or borderline-high HgbA1c levels. The role of impaired glucose metabolism or insulin resistance, as a possible etiology for ING is potentially underestimated and needs additional studies.

Tetralogy of Fallot, Bicuspid Valves and a Single Origin Coronary: Uncorrected and Asymptomatic

A 79-year-old asymptomatic man was referred to our clinic for routine immigration screening. His past medical history was significant only for remote treated pulmonary tuberculosis and heavy tobacco use. Examination revealed oxygen saturations of 90%, blood pressure of 150/90 mmHg, and a prominent right ventricular heave. There was no digital clubbing. Chest X-ray demonstrated an enlarged cardiothoracic ratio with a prominent right heart border and left hilar enlargement (Figure 1A ). His electrocardiograph (ECG) showed atrial fibrillation, right axis deviation and anterior T-wave inversion consistent with right ventricular strain (Figure 1B).

Brain Structure Alterations in Respect to Tobacco Consumption and Nicotine Dependence: A Comparative Voxel-Based Morphometry Study.

The main purpose of this study is to examine the lifetime tobacco consumption and the degree of nicotine dependence related gray matter (GM) and white matter (WM) volume alterations in young adult-male smokers. Fifty-three long-term male smokers and 53 well-matched male healthy non-smokers participated in the study, and the smokers were respectively categorized into light and heavy tobacco consumption subgroups by pack-years and into moderate and severe nicotine dependence subgroups using the Fagerström Test for Nicotine Dependence (FTND). Voxel-based morphometry analysis was then performed, and ANCOVA analysis combined with subsequent post hoc test were used to explore the between-group brain volume abnormalities related to the smoking amount and nicotine dependence. Light and heavy smokers displayed smaller GM and WM volumes than non-smokers, while heavy smokers were found with more significant brain atrophy than light smokers in GM areas of precuneus, inferior and middle frontal gyrus, superior temporal gyrus, cerebellum anterior lobe and insula, and in WM areas of cerebellum anterior lobe. However, the contrary trend was observed regarding alterations associated with severity of nicotine dependence. Severe nicotine dependence smokers rather demonstrated less atrophy levels compared to moderate nicotine dependence smokers, especially in GM areas of precuneus, superior and middle temporal gyrus, middle occipital gyrus, posterior cingulate and insula, and in WM areas of precuneus, posterior cingulate, cerebellum anterior lobe and midbrain. The results reveal that the nicotine dependence displays a dissimilar effect on the brain volume in comparison to the cigarette consumption. Our study could provide new evidences to understand the adverse effects of smoking on the brain structure, which is helpful for further treatment of smokers.