Effects on Abstinence of Nicotine Patch Treatment Before Quitting Smoking: Parallel, Two Arm, Pragmatic Randomised Trial

The preloading investigators. BMJ. 2018 Jun 13;361:k2164. [CrossRef] [PubMed]

The authors examined the effectiveness of a nicotine patch worn for four weeks before a quit attempt in a randomized controlled open label trial. There were 1792 adults who were daily smokers with tobacco dependence. 899 were allocated to the preloading arm and 893 to the control arm. Biochemically validated abstinence at six months was achieved by 157/899 (17.5%) participants in the preloading arm and 129/893 (14.4%) in the control arm: difference 3.0% (95% confidence interval −0.4% to 6.4%), odds ratio 1.25 (95% confidence interval 0.97 to 1.62, P=0.08). There was an imbalance between arms in the frequency of varenicline use as post-cessation treatment, and planned adjustment for this gave an odds ratio for the effect of preloading of 1.34 (95% confidence interval 1.03 to 1.73), P=0.03). The authors conclude that although evidence was insufficient to confidently show that nicotine preloading increases subsequent smoking abstinence, a beneficial effect seems to have been masked by a concurrent reduction in the use of varenicline in people using nicotine preloading.  

Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set Process Measures

Gray B, Vandergrift J, Landon B, Reschovsky J, Lipner R. Ann Intern Med. 2018. June 11, 2018. [Epub ahead of print] [CrossRef]

The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. The authors evaluated whether MOC status is associated with performance of 1260 general internists who were initially certified in 1991 and provided care for 85,931 Medicare patients between 2009 and 2012. Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing and low-density lipoprotein (LDL) cholesterol measurement, measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were higher in patients of physicians who maintained certification. Only in biennial eye examinations was there no significant difference between physicians who maintained certification and those who did not. The authors conclude that maintaining certification was positively associated with physician performance scores on a set of process measures. 

Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set Process Measures

Gray B, Vandergrift J, Landon B, Reschovsky J, Lipner R. Ann Intern Med. 2018. June 11, 2018. [Epub ahead of print] [CrossRef]

The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. The authors evaluated whether MOC status is associated with performance of 1260 general internists who were initially certified in 1991 and provided care for 85,931 Medicare patients between 2009 and 2012. Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing and low-density lipoprotein (LDL) cholesterol measurement, measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were higher in patients of physicians who maintained certification. Only in biennial eye examinations was there no significant difference between physicians who maintained certification and those who did not. The authors conclude that maintaining certification was positively associated with physician performance scores on a set of process measures.

Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial

Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, Ong MK, Atkins D, Schectman G, Asch SM. Ann Intern Med. 2018 Jun 5. [Epub ahead of print] [CrossRef] [PubMed]

The authors assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs in patients at high risk for hospitalization. Locally tailored intensive management programs were created providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. From the pre- to post-randomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). However, outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. After adjustment for patient demographic factors and health conditions diagnosed during the year before randomization, total healthcare costs for patients in the intervention group were $471 higher than in the control group. Limitations of the study were that sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment and it is unclear whether all costs were assessed, such as personnel costs. The authors conclude that high-risk patients with access to an intensive management program received more outpatient care but may actually modestly increase costs.  

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial

Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. JAMA Intern Med. 2018 Jun 4 [Epub ahead of print] [CrossRef] [PubMed]

Most of us have assumed that greater supervision of residents would lead to improved outcomes. However, little research has evaluated the role of attending physician supervision on patient safety. The authors conducted a randomized clinical trial of 22 attending physicians each providing 2 different levels of supervision, either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). The authors conclude that increased direct attending physician supervision did not significantly reduce the medical error rate. They suggested that residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy when designing morning work rounds,

Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer

Sparano JA, Gray RJ, Makower DF, et al. N Engl J Med. N Engl J Med. 2018; June 3. [CrossRef]

There is uncertainty about the benefit of chemotherapy in most breast cancer. The authors performed a prospective trial involving 10,273 women with hormone-receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, axillary node–negative breast cancer. Of the 9719 eligible patients with follow-up information, 6711 (69%) had an indeterminate risk for recurrence and were randomly assigned to receive either chemoendocrine therapy or endocrine therapy alone. Endocrine therapy was noninferior to chemoendocrine therapy in the analysis of invasive disease–free survival (hazard ratio for invasive disease recurrence, second primary cancer, or death [endocrine vs. chemoendocrine therapy], 1.08; 95% confidence interval, 0.94 to 1.24; P=0.26). At 9 years, the two treatment groups had similar rates of invasive disease–free survival (83.3% in the endocrine-therapy group and 84.3% in the chemoendocrine-therapy group), freedom from disease recurrence at a distant site (94.5% and 95.0%) or at a distant or local–regional site (92.2% and 92.9%), and overall survival (93.9% and 93.8%). However, there was some benefit of chemotherapy found in women 50 years of age or younger. The authors conclude that addition of chemotherapy had no advantage for most women with hormone-receptor–positive, HER2-negative, axillary node–negative breast cancer, although some benefit of chemotherapy was found in some women 50 years of age or younger.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients with Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial

Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. JAMA. 2018 May 16. [CrossRef] [PubMed]

The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. However, the effect of routine bougie use on first-attempt intubation success is unclear. In a single center study, the authors compared first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet in the emergency department. Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. The authors point out that these findings should be considered provisional until the generalizability is assessed in other institutions and settings.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing

Hadland SE, Cerdá M, Li Y, Krieger MS, Marshall BDL. JAMA Int Med 2018; May 14. [Epub ahead of print] [CrossRef]

Pharmaceutical industry marketing to physicians is widespread, but it is unclear whether marketing of opioids influences prescribing. The authors studied the extent to which pharmaceutical industry marketing of opioid products to physicians during 2014 was associated with opioid prescribing during 2015 using the Open Payments Database and Medicare Part D Opioid Prescriber Summary File. In 2015, 369,139 physicians prescribed opioids under Medicare Part D and met study inclusion criteria. In 2014, 25,767 (7.0%) of these physicians received 105,368 non-research opioid-related payments totaling $9,071,976. Only 436 (1.7%) physicians received $1000 or more in total. Marketing included speaking fees and/or honoraria ($6,156,757; n = 3115), meals ($1,814,340; n = 97,020), travel ($730,824; n = 1862), consulting fees ($290,395; n = 360), and education ($79,660; n = 3011). In multivariable modeling, receipt of any opioid related payments from industry in 2014 was associated with 9.3% (95% CI, 8.7%-9.9%)more opioid claims in 2015 compared with physicians who received no such payments. Each meal received in 2014 was associated with an increasing number of opioid claims in 2015. In multivariable modeling, each additional meal was associated with an increase of 0.7% (95% CI, 0.6%-0.8%) in opioid claims. The authors point out that their findings establish an association, not cause and effect. Amidst national efforts to curb the overprescribing of opioids, the authors suggest that manufacturers should consider a voluntary decrease or complete cessation of marketing to physicians and governments should consider legal limits on the number and amount of payments.

Low-Dose CT for the Diagnosis of Pneumonia in Elderly Patients: A Prospective, Interventional Cohort Study

Prendki V, Scheffler M, Huttner B, et al. Eur Respir J. 2018 Apr 12. pii: 1702375. [CrossRef] [PubMed]

The diagnosis of pneumonia can be challenging. The authors prospectively assessed whether a low-dose computed tomography (LDCT) modified the probability of diagnosing pneumonia in 200 elderly patients suspected of having pneumonia. The treating clinician assessed the probability of pneumonia before and after the LDCT by using a Likert scale. After LDCT, the estimated probability of pneumonia changed in 90 (45%) patients: 60 (30%) were downgraded, 30 (15%) upgraded. The authors conclude that LDCT modified the estimated probability of pneumonia in a substantial proportion of patients.

Nivolumab plus Ipilimumab in Lung Cancer with a High Tumor Mutational Burden

Hellmann MD, Ciuleanu TE, Pluzanski A, et al. N Engl J Med. 2018 Apr 16 [Epub ahead of print]. [CrossRef] [PubMed]

Nivolumab, a PD-1 inhibitor, plus ipilimumab, an activator of cytotoxic T cells, have shown promise for the treatment of non-small-cell lung cancer (NSCLC) in a phase 1 trial.  In this open-label, multipart, phase 3 trial, the authors examined progression-free survival with nivolumab plus ipilimumab versus chemotherapy among patients with a high tumor mutational burden (≥10 mutations per megabase). Patients with stage IV or recurrent NSCLC that was not previously treated with chemotherapy were randomly assigned, in a 1:1:1 ratio, to receive nivolumab plus ipilimumab, nivolumab monotherapy, or chemotherapy. Progression-free survival among patients with a high tumor mutational burden was significantly longer with nivolumab plus ipilimumab than with chemotherapy. The 1-year progression-free survival rate was 42.6% with nivolumab plus ipilimumab versus 13.2% with chemotherapy, and the median progression-free survival was 7.2 months (95% confidence interval [CI], 5.5 to 13.2) versus 5.5 months (95% CI, 4.4 to 5.8) (hazard ratio for disease progression or death, 0.58; 97.5% CI, 0.41 to 0.81; P<0.001). The objective response rate was 45.3% with nivolumab plus ipilimumab and 26.9% with chemotherapy. The benefit of nivolumab plus ipilimumab over chemotherapy was broadly consistent within subgroups, including patients with a PD-L1 expression level of at least 1% and those with a level of less than 1%. The rate of grade 3 or 4 treatment-related adverse events was 31.2% with nivolumab plus ipilimumab and 36.1% with chemotherapy. The results validate the benefit of nivolumab plus ipilimumab in NSCLC and the role of tumor mutational burden as a biomarker for patient selection.

Four-gene Pan-African Blood Signature Predicts Progression to Tuberculosis

Suliman S, Thompson E, Sutherland J, et al. Am J Respir Crit Care Med. 2018 Apr 6. [Epub ahead of print] [CrossRef] [PubMed]

Contacts of tuberculosis (TB) patients constitute an important target population for preventative measures as they are at high risk of infection with Mycobacterium tuberculosis but only 5-10% progress to develop TB during their lifetime. progression to disease. In a case-control study HIV-negative African cohort of exposed household contacts, the authors employed RNA sequencing, polymerase chain reaction (PCR) and the Pair Ratio algorithm in a training/test set approach. Overall, 79 progressors, who developed tuberculosis between 3 and 24 months following exposure, and 328 matched non-progressors, who remained healthy during 24 months of follow-up, were investigated. A four-transcript signature (RISK4), derived from samples in a South African and Gambian training set, predicted progression up to two years before onset of disease in blinded test set samples from South Africa, The Gambia and Ethiopia with little population-associated variability and also validated on an external cohort of South African adolescents with latent Mycobacterium tuberculosis infection. By contrast, published diagnostic or prognostic tuberculosis signatures predicted on samples from some but not all 3 countries, indicating site-specific variability. Post-hoc meta-analysis identified a single gene pair, C1QC/TRAV27, that would consistently predict TB progression in household contacts from multiple African sites but not in infected adolescents without known recent exposure events.  This simple whole blood-based PCR test predicts tuberculosis in household contacts from diverse African populations, with potential for implementation in national TB contact investigation programs.

A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era

Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF. Fam Med. 2018 Feb;50(2):91-9. [CrossRef] [PubMed]

Electronic health records (EHRs) have lengthened the time required to care for patients in primary care clinics with EHRs. The authors directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time. The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. The authors conclude that primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.

Impact of Temporary Methotrexate Discontinuation for 2 Weeks on Immunogenicity of Seasonal Influenza Vaccination in Patients with Rheumatoid Arthritis: A Randomised Clinical Trial

Park JK, Lee YJ, Shin K, Ha YJ, et al.  Ann Rheum Dis. 2018 Mar 23. pii: annrheumdis-2018-213222. [CrossRef]  [PubMed]

Rheumatoid arthritis (RA) is a common disease and methotrexate (MTX) is often used to treat RA. The present study examined whether a 2-week methotrexate (MTX) discontinuation after vaccination improves the efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis (RA). In this prospective randomized parallel-group multicenter study, patients with RA on stable dose of MTX were randomized to continue MTX or to hold MTX for 2 weeks after seasonal influenza vaccination. The primary outcome was frequency of satisfactory vaccine response defined as greater than or equal to fourfold increase of hemagglutination inhibition antibody titer at 4 weeks after vaccination against ≥2 of four vaccine strains. The intention-to-treat population included 156 patients in the MTX-continue group and 160 patients in the MTX-hold group. More patients in MTX-hold group achieved satisfactory vaccine response than the MTX-continue group (75.5% vs 54.5%, p<0.001). Although it is late in influenza season in the US, this study suggests that a temporary MTX discontinuation for 2 weeks after vaccination improves the immunogenicity of seasonal influenza vaccination in patients with RA without increasing RA disease activity.

Quantifying Population-Level Health Benefits and Harms of E-Cigarette Use in the United States

Soneji SS, Sung HY, Primack BA, Pierce JP, Sargent JD. PLoS One. 2018 Mar 14;13(3):e0193328. [CrossRef] [PubMed]

Electronic cigarettes (e-cigarettes) may help cigarette smokers quit smoking, yet they may also facilitate cigarette smoking for never-smokers. The authors quantified the balance of health benefits and harms associated with e-cigarette use at the population level using a Monte Carlo stochastic simulation model. Model parameters drawn from census counts, national health and tobacco use surveys, and published literature were used to calculate the expected years of life gained or lost from the impact of e-cigarette use on smoking cessation and transition to long-term cigarette smoking among never smokers.  The model estimated that 2,070 additional current cigarette smoking adults would quit smoking and remain continually abstinent from smoking for ≥7 years. However, the model also estimated 168,000 additional never-cigarette smoking adolescents would initiate cigarette smoking and eventually become daily cigarette smokers. Overall, the model estimated that e-cigarette use would lead to 1,510,000 years of life lost. The authors conclude that effective national, state, and local efforts are needed to reduce e-cigarette use among youth and young adults if e-cigarettes are to confer a net population-level benefit in the future.

Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial

Krebs EE, Gravely A, Nugent S, et al. JAMA. 2018 Mar 6;319(9):872-82. [CrossRef] [PubMed]

Opioids are usually considered more efficacious than nonopioids for acute pain. Based on this, opioids have been assumed to be better pain relievers than nonopioids for chronic pain. The authors challenged that assumption in 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis. Patients were randomized to either opioids (immediate-release morphine, oxycodone, or hydrocodone/acetaminophen) or non-opioids (acetaminophen or a nonsteroidal anti-inflammatory). Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). Groups did not significantly differ on pain-related function over but pain intensity was significantly better in the nonopioid group. These results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Adolescent Exposure to Toxic Volatile Organic Chemicals from E-Cigarettes

Rubinstein ML, Delucchi K, Benowitz NL, et al. Pediatrics. 2018;141(4):e20173557. [CrossRef]

The authors sought to identify the presence of chemical toxicants contained in cigarette smoke in adolescent e-cigarette users. E-cigarette users and dual users (use of cigarettes in the past 30 days in addition to e-cigarettes) were compared to never-using controls. Urine excretion of metabolites of benzene, ethylene oxide, acrylonitrile, acrolein, and acrylamide was significantly higher in dual users versus e-cigarette–only users (all P < .05). Excretion of metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide, and crotonaldehyde were significantly higher in e-cigarette–only users compared with controls (all P < .05). E-cigarette vapor may be less hazardous than tobacco smoke, but e-cigarette vapor contains many of the volatile carcinogens found in cigarette smoke. The authors encourage warnings about the potential risk from toxic exposure to carcinogenic compounds generated by these products.

Electronic Cigarette Use and Progression from Experimentation to Established Smoking

Chaffee BW, Watkins SL, Glantz SA. Pediatrics. 2018;141(4):e20173594. [CrossRef]

In previous studies of youth who have never smoked cigarettes, those who tried electronic cigarettes (e-cigarettes) were more likely to initiate conventional cigarette smoking compared with e-cigarette never users. The authors evaluated associations between e-cigarette use and progression to established smoking among adolescents who had already tried cigarettes. Participants (age 12–17 years) in the nationally representative Population Assessment of Tobacco and Health survey who had smoked a cigarette (≥1 puff) but not yet smoked 100 cigarettes (N = 1295), were examined for 3 outcomes at 1-year follow-up as a function of baseline e-cigarette use:

1. Having smoked ≥100 cigarettes (established smoking);
2. Smoking during the past 30 days;
3. Both having smoked ≥100 cigarettes and past 30-day smoking (current established smoking).

Survey-weighted multivariable logistic regression models were fitted to obtain odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for smoking risk factors. Versus e-cigarette never use, having ever used e-cigarettes was positively associated with progression to established cigarette smoking (19.3% vs 9.7%), past 30-day smoking (38.8% vs 26.6%), and current established smoking (15.6% vs 7.1%). Among adolescent cigarette experimenters, using e-cigarettes was positively and independently associated with progression to current established smoking, suggesting that e-cigarettes do not divert from, and may encourage, cigarette smoking in this population.

Association of Cigarette, Cigar, and Pipe Use With Mortality Risk in the US Population

Christensen CH, Rostron B, Cosgrove C, et al. JAMA Intern Med. 2018 Feb 19. [Epub ahead of print] [CrossRef] [PubMed]

The authors investigated the mortality risks associated with current and former use of cigars, pipes, and cigarettes. Participants in The National Longitudinal Mortality Study provided tobacco use information from 1985 and through 2011. The study included 357,420 participants including those who reported exclusively using cigar, pipes, or cigarettes or reported never using any type of tobacco product. All-cause and cause-specific mortality as identified as the primary cause of death were obtained from death certificate information. Exclusive current cigarette smokers (hazard ratio [HR], 1.98; 95% CI, 1.93-2.02) and exclusive current cigar smokers (HR, 1.20; 95% CI, 1.03-1.38) had higher all-cause mortality risks than never tobacco users. Exclusive current cigarette smokers (HR, 4.06; 95% CI, 3.84-4.29), exclusive current cigar smokers (HR, 1.61; 95% CI, 1.11-2.32), and exclusive current pipe smokers (HR, 1.58; 95% CI, 1.05-2.38) had an elevated risk of dying from a tobacco-related cancer (including bladder, esophagus, larynx, lung, oral cavity, and pancreas). This study provides further evidence that exclusive use of cigar, pipes, and cigarettes each confers significant mortality risks. This study provides further evidence that exclusive use of cigar, pipes, and cigarettes each confers significant mortality risks. The study may have important implications for the Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (HR 564, S294) now pending before the US Congress. These bills amend the Federal Food, Drug, and Cosmetic Act to exempt cigars from regulation by the Food and Drug Administration (FDA) and from user fees assessed on tobacco products by the FDA.

Cleaning at Home and at Work in Relation to Lung Function Decline and Airway Obstruction

Svanes Ø, Bertelsen RJ, Lygre SH, et al. Am J Respir Crit Care Med. 2018 Feb 16. [Epub ahead of print] [CrossRef] [PubMed]

A Norwegian study examined the relationship between cleaning tasks and lung function. The rationale is that cleaning implies exposure to chemical agents and as increased risk of asthma and respiratory symptoms among cleaners has been reported. The authors conduced a multi-center study of a population-based cohort at three time points over twenty years. 6230 participants with at least one lung function measurements from 22 study centers were included. As compared to women not engaged in cleaning (FEV1=-18.5 ml/year), FEV1 declined more rapidly in women responsible for cleaning at home (-22.1, p=0.01) and occupational cleaners (-22.4, p=0.03). The same was found for decline in FVC (FVC-=8.8 ml/year; -13.1, p=0.02 and -15.9, p=0.002, respectively). Both cleaning sprays and other cleaning agents were associated with accelerated FEV1 decline (-22.0, p=0.04 and -22.9, p=0.004, respectively). Cleaning was not significantly associated with lung function decline in men or with chronic airway obstruction. Studies have a difficulty controlling for confounders. Although the hypothesis might be true, it may be that cleaning is associated with another activity (e.g., cooking) which might be responsible for the decline in lung function.

Long-term Use of Inhaled Corticosteroids in COPD and the Risk of Fracture

Gonzalez AV, Coulombe J, Ernst P, Suissa S. Chest. 2018;153(2):321-8. [CrossRef] [PubMed]

It is uncertain whether long-term use of inhaled corticosteroids (ICSs), widely used to treat COPD, increases the risk of fracture, particularly in women, in view of the postmenopausal risks. The authors assessed whether long-term ICS use in patients with COPD increased the risk of hip or upper extremity fractures, and examined sex-related differences. A nested case-control analysis was used with each case of fracture was matched with 20 control subjects. In the cohort of 240,110 subjects, 19,396 sustained a fracture during a mean 5.3 years (rate, 15.2 per 1,000 per year). Any use of ICSs was not associated with an increased rate of fracture (RR, 1.00; 95% CI, 0.97-1.03). The fracture rate was increased with > 4 years of ICS use at daily doses > 1,000 mg in fluticasone equivalents (RR, 1.10; 95% CI, 1.02-1.19). This risk increase did not differ between men and women. The authors conclude that long-term ICS use at high doses is associated with a modest increase in the risk of hip and upper extremity fractures in patients with COPD. This dose-duration risk increase does not appear to be higher for women.