Multiple Pharmacotherapy Adaptations for Smoking Cessation Based on Treatment Response in Black Adults Who Smoke: A Randomized Clinical Trial

Importance

Adapting to different smoking cessation medications when an individual has not stopped smoking has shown promise, but efficacy has not been tested in racial and ethnic minority individuals who smoke and tend to have less success in quitting and bear a disproportionate share of tobacco-related morbidity and mortality.

Objective

To evaluate efficacy of multiple smoking cessation pharmacotherapy adaptations based on treatment response in Black adults who smoke daily.

Design, Setting, and Participants

This randomized clinical trial of adapted therapy (ADT) or enhanced usual care (UC) included non-Hispanic Black adults who smoke and was conducted from May 2019 to January 2022 at a federally qualified health center in Kansas City, Missouri. Data analysis took place from March 2022 to January 2023.

Interventions

Both groups received 18 weeks of pharmacotherapy with long-term follow-up through week 26. The ADT group consisted of 196 individuals who received a nicotine patch (NP) and up to 2 pharmacotherapy adaptations, with a first switch to varenicline at week 2 and, if needed, a second switch to bupropion plus NP (bupropion + NP) based on carbon monoxide (CO)-verified smoking status (CO ≥6 ppm) at week 6. The UC group consisted of 196 individuals who received NP throughout the duration of treatment.

Main Outcomes and Measures

Anabasine-verified and anatabine-verified point-prevalence abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points). The χ2 test was used to compare verified abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points) between ADT and UC. A post hoc sensitivity analysis of smoking abstinence at week 12 was performed with multiple imputation using a monotone logistic regression with treatment and gender as covariates to impute the missing data.

Results

Among 392 participants who were enrolled (mean [SD] age, 53 [11.6] years; 224 [57%] female; 186 [47%] ≤ 100% federal poverty level; mean [SD] 13 [12.4] cigarettes per day), 324 (83%) completed the trial. Overall, 196 individuals were randomized to each study group. Using intent-to-treat and imputing missing data as participants who smoke, verified 7-day abstinence was not significantly different by treatment group at 12 weeks (ADT: 34 of 196 [17.4%]; UC: 23 of 196 [11.7%]; odds ratio [OR], 1.58; 95% CI, 0.89-2.80; P = .12), 18 weeks (ADT: 32 of 196 [16.3%]; UC: 31 of 196 [15.8%]; OR, 1.04; 95% CI, 0.61-1.78; P = .89), and 26 weeks (ADT: 24 of 196 [12.2%]; UC: 26 of 196 [13.3%]; OR, 0.91; 95% CI, 0.50-1.65; P = .76). Of the ADT participants who received pharmacotherapy adaptations (135/188 [71.8%]), 11 of 135 (8.1%) were abstinent at week 12. Controlling for treatment, individuals who responded to treatment and had CO-verified abstinence at week 2 had 4.6 times greater odds of being abstinent at week 12 (37 of 129 [28.7%] abstinence) than those who did not respond to treatment (19 of 245 [7.8%] abstinence; OR; 4.6; 95% CI, 2.5-8.6; P < .001).

Conclusions and Relevance

In this randomized clinical trial of adapted vs standard of care pharmacotherapy, adaptation to varenicline and/or bupropion + NP after failure of NP monotherapy did not significantly improve abstinence rates for Black adults who smoke relative to those who continued treatment with NP. Those who achieved abstinence in the first 2 weeks of the study were significantly more likely to achieve later abstinence, highlighting early treatment response as an important area for preemptive intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03897439.

Renin-Angiotensin Blockade Reduces Readmission for Acute Chest Syndrome in Sickle Cell Disease

Rationale

Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). Current treatment is supportive-supplemental oxygen, transfusions, and antibiotics. Prevention of ACS may reduce morbidity and mortality in patients with SCD.

Acute chest syndrome appears similar to pulmonary fat embolism (PFE), a complication of severe skeletal trauma or orthopedic procedures from pulmonary micro-vessel blockage by bone marrow fat. Vascular obstruction and bone marrow necrosis occur in PFE and ACS. 

Pulmonary fat embolism rat models have shown that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) mitigate damage in PFE. These medications could work similarly in ACS. We hypothesize that time to readmission after one hospitalization for ACS will be reduced in patients taking ACEI or ARB compared to patients who are not.

Methods

This is a retrospective cohort study. Inclusion criteria are adults (18 to 100 years) with sickle cell anaemia (HbSS), hemoglobin SC (HbSC) disease, sickle cell thalassemia (HbSβThal), hospitalized with ACS over 16 years (January 1, 2000, to March 31, 2016); patients who take and don’t take ACEI or ARB. Children (<18 years old), elderly adults (>100 years old), pregnant patients, and patients with sickle cell trait were excluded.

Data was collected from the Health Facts database, which contains de-identified information from the electronic medical records of hospitals in which Cerner© has a data use agreement.

Kaplan-Meier estimates explored a time-to-event model of ACS readmission. Multivariable analysis (age, gender, smoking history) was conducted using Cox proportional hazards regression. Results were reported around a 95% confidence interval.

Results

There were 6972 patients in total. Of which, 9.6% (n = 667) reported taking ACEI or ARB. Results for the covariates were: average age of 38 years old; 63% female (n = 4366/6969); 16% smokers (n = 1132).

Readmission rates were higher for patients not taking ACEI/ARB than those who did: 0.44 (95% CI 0.43, 0.46) versus 0.28 (95% CI 0.24, 0.31) at one year, and 0.56 (95% CI 0.55, 0.58) versus 0.33 (95% CI 0.29, 0.37) at two years. Age had the strongest effect on readmission rates for patients taking ACEI/ARB (adjusted hazards ratio 0.78 [95% CI 0.68, 0.91]).

Conclusion

Patients with SCD who reported taking ACEI or ARB had lower readmission rates for ACS; age was the strongest covariate. Our results may have a significant impact on the prevention of ACS. Prospective studies comparing ACEI or ARB therapy versus placebo are needed to confirm this preventative effect.

Organizing Pneumonia Secondary to Pulmonary Actinomycosis: A Case Report and Literature Review

Pulmonary actinomycosis is a common clinical infection caused by Actinomyces species. Although its treatment is very effective with Intravenous (IV) antibiotics, its diagnosis is challenging and easily missed. Organizing Pneumonia (OP) can be cryptogenic or secondary to different clinical diseases. Herein, we discuss a case of acute hypoxemic respiratory failure that was found to be due to OP, secondary to pulmonary actinomycosis, with a brief review of the literature. A 64-year-old male presented with acute hypoxemic respiratory failure two days after undergoing elective right total hip arthroplasty. Chest imaging with CT scan showed symmetric bilateral ground-glass opacities most pronounced within the upper lung lobes. The patient was treated initially with IV diuresis, steroids, and broad-spectrum antibiotics. However, his clinical status continued to worsen and his chest imaging showed worsening lung opacities. Video-assisted thoracoscopic lung biopsy (VATS) was done, and pathology results showed features of organizing pneumonia. Tissue culture confirmed Actinomyces species. The patient had clinical improvement after treatment with IV methylprednisolone and IV penicillin G.

Pulmonary actinomycosis is very rarely associated with OP but this bacterial infection should always be in the differential diagnosis when OP is confirmed as the treatment is effective with IV antibiotics.

Gastroesophageal Reflux Disease-Associated Chronic Cough: A Population-Based Analysis of Patient Presentations in the United States

Gastroesophageal reflux disease is an extremely prevalent illness in the United States; however, clinicians report that its association with chronic cough is often overlooked and undiagnosed. We used the CERNER Health Facts^® database to analyze the statistical prevalence. Our findings indicate that there is a minority of patients who are untreated for this common complaint. We propose considering this on the differential diagnosis and following current treatment guidelines with proton pump inhibitors to effectively treat this complaint.

The Use of Direct Oral Anticoagulants in the Management of Venous Thromboembolism in Patients With Obesity

Introduction

The use of direct oral anticoagulants (DOACs) has gained significant traction given the lack of therapeutic monitoring and the need for anticoagulant bridging. There is a paucity of data on their effectiveness in obese patients with venous thromboembolism (VTE). Preliminary subgroup and pharmacokinetic analyses suggest reduced efficacy in those with a bodyweight >120 kg or body mass index (BMI) ≥40 kg per m² and it is currently not recommended that these agents be used as first-line agents. We aimed to assess the rate of VTE recurrence in obese patients diagnosed with VTE and treated with DOAC therapy.

Methods

We utilized the Health Facts Center National Data Warehouse (Cerner) to perform a retrospective analysis of patients with VTE (acute deep venous thrombosis (DVT) or pulmonary embolism) that presented to the hospital between 2010 and 2016 and were managed with DOACs. The cohort of patients diagnosed with DVT or PE were identified using International Classification of Disease (ICD-9-CM, ICD-10-CM). Patients were divided into two groups based on their weight: 1) weight <120 kg or 2) weight>120 kg. Six-month VTE recurrence rates were recorded. Summary and univariate statistics were performed.

Results

A total of 18,147 patients with a mean (±SD) age of 62 (17) years were included; 48% (n=8732) were male. A total of 2,419 (13%) patients weighed >120 kg while the rest (N=15,728, 87%) weighed <120 kg. There were significantly more female patients weighing<120 kg (54% vs 42%, p<0.0001); otherwise, there was no significant difference in age or tobacco use between both groups (p>0.05). There was no significant difference in six-month readmission rates for VTE recurrence in patients that weighed <120 kg (34%) in comparison with patients >120 kg (36%) (p=0.08).

Conclusion

Our study suggests that the use of DOACs in obese patients is equally efficacious with similar VTE recurrence rates in comparison with non-obese patients. This study paves the way for prospective multi-institutional randomized control trials to further reinforce the safe use of such agents in this patient population.

Fluid flow and particle transport in mechanically ventilated airways. Part I. Fluid flow structures

A large eddy simulation-based computational study of fluid flow and particle transport in upper tracheobronchial airways is carried out to investigate the effect of ventilation parameters on pulmonary fluid flow. Respiratory waveforms commonly used by commercial mechanical ventilators are used to study the effect of ventilation parameters and ventilation circuit on pulmonary fluid dynamics. A companion paper (Alzahrany et al. in Med Biol Eng Comput, 2014) reports our findings on the effect of the ventilation parameters and circuit on particle transport and aerosolized drug delivery. The endotracheal tube (ETT) was found to be an important geometric feature and resulted in a fluid jet that caused an increase in turbulence and created a recirculation zone with high wall shear stress in the main bronchi. Stronger turbulence was found in lower airways than would be found under normal breathing conditions due to the presence of the jet caused by the ETT. The pressure-controlled sinusoidal waveform induced the lowest wall shear stress on the airways wall.

Fluid flow and particle transport in mechanically ventilated airways. Part II: particle transport

The flow mechanisms that play a role on aerosol deposition were identified and presented in a companion paper (Timothy et al. in Med Biol Eng Comput. doi: 10.1007/s11517-015-1407-3 , 2015). In the current paper, the effects of invasive conventional mechanical ventilation waveforms and endotracheal tube (ETT) on the aerosol transport were investigated. In addition to the enhanced deposition seen at the carinas of the airway bifurcations, enhanced deposition was also seen in the right main bronchus due to impaction and turbulent dispersion resulting from the fluid structures created by jet caused by the ETT. The orientation of the ETT toward right bronchus resulted in a substantial deposition inside right lung compared to left lung. The deposition inside right lung was ~12-fold higher than left lung for all considered cases, except for the case of using pressure-controlled sinusoidal waveform where a reduction of this ratio by ~50 % was found. The total deposition during pressure constant, volume ramp, and ascending ramp waveforms was similar and ~1.44 times higher than deposition fraction when using pressure sinusoidal waveform. Varying respiratory waveform demonstrated a significant role on the deposition enhancement factors and give evidence of drug aerosol concentrations in key deposition sites, which may be significant for drugs with negative side effects in high concentrations. These observations are thought to be important for ventilation treatment strategy.

The role of coupled resistance-compliance in upper tracheobronchial airways under high frequency oscillatory ventilation

A large eddy simulation (LES) based computational fluid dynamics (CFD) study was conducted to investigate lung lobar ventilation and gas exchange under high frequency oscillatory ventilation conditions. Time-dependent pressure coupled with the airways resistance and compliance (R&C) were imposed as boundary conditions (BCs) in the upper tracheobronchial tree of patient-specific lung geometry. The flow distribution in the left and right lungs demonstrated significant variations compared to the case in which traditional BCs based on mass flow rate fractions was used and is in agreement with the in vivo data available in the literature. The gas transport due to the pendelluft mechanism was captured in the different lung lobes and units. The computed pendelluft elapsed time was consistent with available physiological data. In contrast to in vivo studies, our simulations were able to predict the volume associated with the pendelluft elapsed time at different frequencies. Significant differences in coaxial counter flow and flow structures were observed between different BCs. The consistency of the results with the physiological in vivo data indicates that computations with coupled R&C BCs provide a suitable alternative tool for understanding the gas transport, diagnosing lung pathway disease severity, and optimizing ventilation management techniques.

Flow transport and gas mixing during invasive high frequency oscillatory ventilation

A large Eddy simulation (LES) based computational fluid dynamics study was performed to investigate gas transport and mixing in patient specific human lung models during high frequency oscillatory ventilation. Different pressure-controlled waveforms (sinusoidal, exponential and square) and ventilator frequencies (15, 10 and 6Hz) were used (tidal volume=50mL). The waveforms were created by solving the equation of motion subjected to constant lung wall compliance and flow resistance. Simulations were conducted with and without endotracheal tube to understand the effect of invasive management device. Variation of pressure-controlled waveform and frequency exhibits significant differences on counter flow pattern, which could lead to a significant impact on the gas mixing efficiency. Pendelluft-like flow was present for the sinusoidal waveform at all frequencies but occurred only at early inspiration for the square waveform at highest frequency. The square waveform was most efficient for gas mixing, resulting in the least wall shear stress on the lung epithelium layer thereby reducing the risk of barotrauma to both airways and the alveoli for patients undergoing therapy.

Chronic obstructive pulmonary disease: clinical review and update on consensus guidelines

In the last 2 decades, chronic obstructive pulmonary disease (COPD) has been increasingly recognized as a major public health problem. Since the introduction of the Global Initiative for Chronic Obstructive Lung Disease in 1998, growing interest in the pathogenesis and management of patients with COPD has led to notable improvements in patient care and quality of life. Despite greater awareness of this common preventable disease and major therapeutic advances during this period, the global impact of COPD remains strikingly large. We provide an evidence-based clinical review on COPD, with a focus on internists as the target audience.

A Case of Mycobacterium avium Complex Pulmonary Disease in an Immunocompetent Host

Mycobacterium avium complex is the most common of nontuberculous mycobacterium capable of causing disease in humans. The manifestations can vary from asymptomatic exposure to hypersensitivity pneumonitis to advanced fibrocavitary disease. We describe the case of a 37-year-old male with advanced cavitary disease from Mycobacterium avium complex. The patient had no previous history of pulmonary disease, but did have a history of snorting crushed Lortab (hydrocodone/acetaminophen) tablets and we postulate that possible injury to the lung from talc or other chemicals in the tablets may have predisposed him to develop Mycobacterium avium pulmonary disease.

Use of intrapleural streptokinase in the treatment of thoracic empyema

The incidence of pleural effusions in bacterial pneumonia may exceed 40%, a factor that may be related to increased morbidity and mortality. Options in the treatment of complicated pleural effusions or empyema, when unresponsive to closed tube drainage, include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes, instillation of intrapleural streptokinase, and surgical intervention. The authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema, thus eliminating the necessity for further invasive intervention.

Treatment of pulmonary sporotrichosis with ketoconazole

Antifungal therapy that included ketoconazole failed in a 44-year-old woman with pulmonary sporotrichosis progressing slowly over a seven-year period. On the basis of this case and the modest amount of experience reported in the literature, ketoconazole does not appear to be effective in the treatment of pulmonary sporotrichosis.