2 Minute Medicine Rewind March 9, 2020

Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products – California, 2019

1. Study findings suggest that use of THC-containing products and vitamin E acetate to be associated with outbreak of use-associated lung injury in California

Evidence Level: 3 (Average):

Despite e-cigarette, or vaping usage increasing in popularity in North America in the past decade, the contents of the products remain largely unregulated nationwide. With early cases of severe lung injury without evidence of infection reported in August 2019 as being potentially related to vape usage, health concerns for a behavior once thought to be a safer alternative to conventional smoking also began to grow. To better characterize the demographics, clinical characteristics, and associations with vaping, this study examined 160 case reports of suspected e-cigarette, or vaping, product use-associated lung injury (EVALI) that were reported to the California Department of Public Health (CDPH). Specifically, epidemiologic, laboratory, and interview data were used to assess frequency and type of vaping product usage, and its associations with clinical data, level of care, and hospital outcomes. Among 160 EVALI cases, there were 71 (46%) cases requiring ICU admission, 46 (29%) requiring mechanical ventilation, and 4 in-hospital deaths. Of these cases, 71 (83%) cases involved vaping THC containing products, 36 (43%) CBD-containing products, and 39 (47%) nicotine-containing products. Majority of patients (63 [73%]) reported daily vaping usage with 30 (35%) reporting vaping more than 5 times a day. From 24 patients, 87 vaping products were additionally tested, of which 49 (56%) contained THC, and 41 (84%) contained Vitamin E or Vitamin E acetate. Symptoms reported often included cough, shortness of breath, fevers, and chills, with nearly all patients meeting at least 2 systemic inflammatory response syndrome criteria at presentation. Although causality cannot be determined from this investigation, the study suggests a clear association between vaping and acute lung injury, and given the severity of many of these cases reported, cessation of usage continues to be advised.

Effect of a Workplace-Based Multicomponent Intervention on Hypertension Control

1. Workplace wellness programs and health promotion may be an effective addition to standardized management of hypertension to improve health outcomes of employees.

Evidence Rating: 1 (Excellent)

Globally, it is estimated that roughly a quarter of the World’s population has hypertension. Despite appropriate blood pressure (BP) control being a priority given its proven effect ability to reduce stroke and cardiovascular disease risk, a substantial proportion of affected individuals struggle to meet target pressures on conventional management.  In this cluster randomized clinical trial consisting of 4166 participants, researchers sought to investigate whether or not integration of a workplace health promotion strategy across 60 workplaces would be an effective addictive to standardized management to reach target pressures. Health promotion included factors such as CVD health education, healthy diet promotion, tobacco cessation, exercise promotion, physical environment promotion, stress management, and health screening. Of the 3178 participants assigned to the intervention group, only 19.5% had adequate BP control, versus 20.1% in the control group, After 24 months of intervention, the intervention group had significantly higher rates of BP control (66.2% vs. 44%; odds ratio, 1.77; 95% CI, 1.58 – 2.00; P <.001), with an average systolic pressure decrease of 5.8mmHg and diastolic pressure decrease of 3.6mmHg. Additionally, the intervention group benefited from other factors as well, such as greater rates of reduction in drinking, perceived stress, and excessive use of salt in diet. These findings continue to reinforce the importance of lifestyle modifications on overall health outcomes and hypertension management, and provide strong evidence for the workplace as a target for intervention.

Glycaemic status during pregnancy and longitudinal measures of fetal growth in a multi-racial US population: a prospective cohort study

1. Study findings suggest gestational diabetes is associated with larger fetal size starting at week 20, and that efforts to mitigate associated fetal growth should start between 24-28 gestational weeks.

Evidence Rating: 1 (Excellent)

Maternal glucose concentrations have been found to be positively associated with birth weight, with mothers with gestational diabetes more likely to give birth to children who are large-for-gestational age and at increased risk for later development of obesity and diabetes. Prior literature has largely focused on late pregnancy however, and no studies to date have attempted to precisely identify the gestational week when fetal growth begins to differ by maternal glycemic status. In this prospective cohort study, 2458 pregnant women were enrolled from 2009 to 2013 in the NICHD Fetal Growth Studies-Singletons study to address this gap. Specifically, women were enrolled at gestational weeks 8-13 and assigned to ultrasonogram schedules that would capture weekly fetal growth. Of the 2458 participants, 105 (4.4%) had gestational diabetes, 118 (4.8%) had impaired glucose tolerance, and 2020 (82.2%) had normal glucose tolerance. Compared to the NGT cohort, fetal weight of mothers with gestational diabetes was larger at starting from week 20 and statistically significant at weeks 28-40 (at week 37: 3061g [95% CI 2967-2962] vs. 2943g [2924-2962]). Maternal glucose concentrations at weeks 10-14 were additionally significantly associated with a larger estimated fetal weight from week 27 through term. Overall, this study is the first to propose a set week by which estimated fetal weight begins to differ between mothers with gestational diabetes from control. If these estimates are indeed accurate, this further suggests an importance of monitoring glycemic status to abate fetal growth prior to 24-28 weeks of gestation.

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

1. Cessation of opioid treatment was associated a period of increased risk of overdose or suicide, with a positive association between risk and length of treatment prior to stopping

Evidence Rating: 2 (Good)

In the past decade, significant efforts have been taken in North America to mitigate opioid prescription as a means to combat the opioid crisis and mitigate opioid use disorders and opioid related deaths. One of the safety concerns in question revolves around the cessation of treatment, as stopping opioid treatment was been found to be associated with suicidal thoughts, self-harm, and increased risk of hospitalization for an opioid-related event. To further characterize post-cessation risk, researchers conducted a retrospective study of 1,394,102 patients in the Veterans Health Administration with an outpatient opioid prescription, with the main outcome measures being suicide, overdose, and interaction with time of length of treatment. Of all patients examined, 799,668 (57.4%) had stopped opioid treatment, with variable rates of cessation depending on length of treatment. Stopping treatment was associated with an increased risk of overdose or suicide, with increased risk associated with longer duration of treatment. Hazard ratios for patients who stopped opioid treatment were 1.67 (for patients on treatment for 30 days or less), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Other independent factors associated with greater risk of suicide or overdose included not being married, male sex, medical comorbidities, and prior diagnoses of mental health or substance use disorders. Rates were most pronounced immediately after treatment cessation, with decrease in incidence over three to 12 months. Data from this investigation reiterates the importance of placing patient safety at the forefront when prescribing opioids, and identifies several factors that clinicians should take into consideration to attenuate the risk of adverse outcomes when discontinuing the medication.

Associations of habitual fish oil supplementation with cardiovascular outcomes and all cause mortality: evidence from a large population based cohort study

1. Regular consumption of fish oil appears to be associated with decreased all-cause and cardiovascular disease risk

2. Consumption of fish oil was associated with decreased incidence of cardiovascular events with effects being most pronounced in patients with hypertension.

Evidence Rating: 2 (Good)

Lifestyle modification and dietary supplementation have long been recognized as potential avenues of additional therapeutic options to manage and prevent cardiovascular disease (CVD).  Fish oil and omega 3 fatty acid supplementation have previously been recognized as products that could potentially prevent CVD and have widespread usage globally despite follow-up investigations providing inconclusive results. To better characterize its suitability for usage in the general population, researchers conducted a large-scale cohort study consisting of 427,678 participants aged 40 to 69 in the UK investigating the associations between fish oil supplementation with all-cause mortality, CVD mortality, and CVD events, consisting of strokes and myocardial infarction. Median follow up times were 9 years for mortality outcomes and 8.1 years for CVD events. Compared to controls, the cohort of 133,438 participants self-reporting habitual use of fish oil supplements had lower hazard ratios for all-cause mortality (0.87; 95% CI 0.83 – 0.90), CVD mortality (0.84; 95% CI, 0.78 – 0.91), and CVD events (0.93; 95% CI, 0.90 – 0.96). The effect of CVD event mitigation was most pronounced with patients with hypertension. Results were independent of possible confounding risk factors such as sex, BMI, physical activity, and diet. Findings from the study provide further evidence to suggest a role for fish oil supplementation in providing a marginal benefit for CVD management and the prevention of mortality from all causes and CVD.

Image: PD

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