Chemistry Review of Vaping Products and Respiratory Injury

Background: While the Public Health Agency of Canada notes 19 cases from May 2019 to February 2020 relating to e-cigarette or vaping product use-associated lung injury (EVALI) in Canada, there are likely many more unreported cases, including non-hospitalized and asymptomatic cases. E-cigarette use or vaping exposes users to numerous aerosolized chemical species, some of which have proven to be deleterious to health. These chemical species can include vitamin E acetate (VEA), flavourants, base / solvents (propylene glycol or vegetable glycerin), psychoactive substances, pesticides, endotoxins, metals, and pyrolysis by-products from e-cigarette heating coils. Objectives: We aim to review current findings related to EVALI from the standpoint of known chemical species currently used in vaping products. We specifically examine the toxicological profiles of these chemical species and the mechanisms through which they cause lung injury. Methods: A comprehensive literature search was performed with MEDLINE for EVALI-related human studies that were published between January 1, 2010, and May 15, 2020. This search strategy identified 832 case reports, case series, clinical trials, and in-vitro laboratory studies. From this group, 71 records were examined in greater detail. Results and Conclusions: Although the chemical composition and toxicology of vaping products have largely been characterized, the physiological effects of the chemical interactions between various constituents of vaping products and the generation of new species remain inconclusive. Given the rapid increase in the popularity of vaping and e-cigarettes, there is a need for further research. Developing a comprehensive understanding of the chronic health effects of vaping through randomized controlled trials and physiological studies is prudent and necessary to reduce the long-term impacts on users and the health care system

The Effects of Cognitive Stress on Asthma Exacerbations among University Students

Introduction: Many asthmatics complain of worsening respiratory symptoms during periods of stress.This study evaluated the relationship among asthma symptoms, lung physiology, inflammatory parametersand perceived cognitive stress and quality of life in healthy adult students. This relationship was assessedat two time points: a time of normal activity and at a time of cognitive stress during academic examinations. Methods: Subjects attended the University of Alberta Hospital for a screening visit, which included aclinical exam, spirometry, methacholine challenge, allergen skin tests to assess atopy status and MiniInternational Neuropsychiatric Interview (MINI). Eligible subjects returned for a low stress visit (LSV) atleast 14 days prior to an exam and a high stress visit (HSV) within 24 hours of an exam. Spirometry, andmethacholine challenge were performed during both LSV and HSV along with the collection of urine (testedfor cortisol), and the administration of 4 questionnaires to assess perceived stress and quality of life. Results: Subjects showed no significant change in psychosocial or quality of life questionnaires betweenLSV and HSV. No significant change was noted in lung function or urine cortisol. There was an unexpectedhigh rate of pre-existing psychiatric comorbidities in this population (based on the MINI screen failure rate).Conclusion: We did not find a significant change in quality of life, psychosocial wellbeing or pulmonaryfunction or inflammation, measured by urine cortisol, during a high stress period. The high rate ofcomorbidities would be important to consider as part of evaluation used in clinical asthma studies in the future

Failure of Administrative Data to Guide Asthma Care

Rationale: Asthma is a chronic inflammatory disease of the airways that is very common (7.9% ofCanadians over the age of 12). Despite numerous clinical guidelines, education events and administrativedata reviews, there has been little change to the way asthma is managed in the Canadian health caresystem for nearly 30 years. We evaluated, through the Physician Learning Program (PLP) in Alberta,possible reasons why administrative datasets have not been able to provide meaningful information toadjust health policy. Methods: Provincial data was attained through Alberta Health Service and Alberta Health on pulmonaryfunction testing from 2005-2011 (through the PLP). The number of asthma diagnosis made during the sametime frame were then compared. Results: The preliminary results of the PLP found that spirometry was billed for roughly half as often asthe asthma diagnostic codes were utilized during the same time frame. However, the review also revealedinconsistencies in how administrative data are captured, making it difficult to determine whetherspirometry is being underutilized by physicians in making asthma diagnoses. Conclusions: Inconsistencies in how administrative data are captured in Alberta may be contributingto an incomplete picture of the rates of asthma diagnosis and physiological testing, and may explain, inpart, the limited influence of administrative datasets on guiding meaningful change within the healthcaresystem

The Role of Primary Care in Asthma Control and Severity: Asthma and Primary Care in Alberta

Background: Asthma is a common chronic inflammatory disease of the airways affecting 3 millionCanadians. Primary Care Providers (PCPs) are integral to care coordination, enhanced through thedevelopment of a strong patient-PCP relationship with Continuity of Care (COC). A recent CIHI studynoted that 40% of Albertans do not have a COC model for primary care.Objectives: We aim to evaluate how primary care for adults with asthma impacts different measures ofcontrol.Methods: Prospective population-based recruitment of adults through various community venuesacross Alberta. Those who had self-reported asthma and were willing to participate completed a surveywhich included demographics, comorbidities, medication use (including biologics, allergy medications,steroids), Asthma Control Questionnaire (ACQ-5), Asthma Control Test (ACT), Quality of Life (QoL)measured through the mini-Asthma Quality of Life Questionnaire (mini-AQLQ) and health care utilization(including Emergency Department (ED) visits, hospitalizations and ICU stays for asthma).Results: Of the 1685 individuals approached, 61 (3.6%) reported having asthma, of which 47 lived inAlberta. Most (41, 87%) had a PCP, with 30 (64%) visiting their PCP at least twice a year. Uncontrolledasthma was noted in 21 (45%) with either the ACQ-5 or ACT. The mini-AQLQ indicated 5 (11%) withreduced QoL. Mean lifetime hospitalizations, lifetime Emergency Department (ED) visits, and ICU staysrelated to asthma were 1.52, 4.55 and 0.25 respectively. Further, mean hospitalizations and ED visits inthe past 12 months related to asthma were 0.05 and 0.30 respectively.Conclusions: Asthma control was poor in 21 (45%) surveyed individuals, suggesting sub-optimal asthmamanagement in Alberta. Knowledge of Primary Care Networks (PCNs) was low, while ED and hospitalusage was high

Common bleeding disorders affecting individuals with Hereditary Hemorrhagic Telangiectasia

Purpose: Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder affecting vasculature in different organ systems; seen at a rate of approximately 1:5000 in North America. Complications, with significant increases in health service utilization, arise from bleeding and shunts, and are particularly problematic in the lung and liver. Although these patients tend to chronically bleed from the GI tract and nasal cavities, a single bleed from arterio-venous malformations in the lungs or brain can have serious health implications and may be fatal. Bleeding due to vascular wall fragility in HHT patients can be further complicated with a concomitant bleeding disorder. Methods: The proportion of adult patients seen in the Edmonton HHT center with a concomitant bleeding disorder, as assessed by blood test results for Factor VIII and related factors (Ristocetin Cofactor), Factor IX and Factor XI, was determined in a retrospective, single centre study. Results: Of 77 individuals with HHT, four had below normal values of von Willebrand Factor, Ristocetin Cofactor or Factor VIII. Two patients had laboratory parameters diagnostic of a bleeding disorder, accounting for 2.6% of confirmed HHT subjects. These results indicate that establishing screening for bleeding disorders in HHT centers is important in managing bleeding symptomatology. Conclusions: In individuals with HHT, the presence of a second bleeding disorder can have significant clinical implications on patient management and health care utilizations. This paper highlights areas that need to be reviewed with respect to best practice protocols for the management of HHT patients

Hats off to the CIM Reviewers of 2020

For over 40 years the Journal of Clinical and Investigative Medicine (CIM) has published articles of value to clinician investigators in Canada and elsewhere. We try our best to strive for the highest standards and to remain relevant to our readers, but we cannot achieve these goals without the help of our reviewers, all of whom play a vital role in maintaining the integrity of the scientific process. Without their efforts, academic excellence would falter. So, a massive “thank you” to the more than 80 reviewers who have contributed their talent and time to CIM over the past year (September 1, 2019 to August 31, 2020)

Severe asthma associated with myasthenia gravis

Severe asthma constitutes a subgroup of approximately 10% of all asthma cases. Approximately one-half of these individuals have a refractory form of the disease in which atopy and T-helper cell 2-skewed immunological response may not be as closely linked to the disease as in other phenotypes of asthma. This suggests that not all asthma is explained by a T-helper cell 2-skewed immunological response, and that other immunological mechanisms may be important in this category of nonatopic asthma. The authors present a case involving a 55-year-old Caucasian man with nonatopic, adult-onset asthma, nonsteroidal anti-inflammatory drug sensitivity and idiopathic urticaria. This individual presented two years following his initial asthma diagnosis with diplopia and mild ptosis, and was subsequently diagnosed with seropositive myasthenia gravis