Occupational airborne exposure in relation to Chronic Obstructive Pulmonary Disease (COPD) and lung function in individuals without childhood wheezing illness: A 50-year cohort study

Background Evidence from longitudinal population-based studies relating occupational exposure to the full range of different forms of airborne pollutants and lung function and airway obstruction is limited. Objective To relate self-reported COPD and lung function impairment to occupational exposure to different forms of airborne chemical pollutants in individuals who did not have childhood wheeze. Methods A prospective cohort study was randomly selected in 1964 at age 10–15 years and followed up in 1989, 1995, 2001 and 2014 (aged 58–64) by spirometry and respiratory questionnaire. Occupational histories were recorded in 2014 and occupational exposures assigned using an airborne chemical job exposure matrix. The risk of COPD and lung function impairment was analyzed in subjects, who did not have childhood wheeze, using logistic and linear regression and linear mixed effects models. Results 237 subjects without childhood wheeze (mean age 60.6 years, 47% male) were analyzed. There was no association between any respiratory outcomes and exposure to gases, fibers, mists or mineral dusts and no consistent associations with exposure to fumes. Reduced FEV1 was associated with longer duration (years) of exposure to any of the six main pollutant forms - vapors, gases, dusts, fumes, fibers and mists (VGDFFiM) with evidence of a dose-response relationship (p-trend=0.004). Exposure to biological dusts was associated with self-reported COPD and FEV1<Lower Limit of Normal (LLN) (adjusted odds ratio [95%CI] 4.59 [1.15,18.32] and 3.54 [1.21,10.35] respectively), and reduced FEF25–75% (adjusted regression coefficients [95% CIs] −9.11 [−17.38, −0.84] respectively). Exposure to vapors was associated with self-reported COPD and FEV1<LLN (adjOR 6.46 [1.18,35.37] and 4.82 [1.32,17.63]). Longitudinal analysis demonstrated reduced FEV1 and FEF25–75% associated with exposure to biological dusts or vapors. Conclusions People with no history of childhood wheezing who have been occupationally exposed to biological dusts or vapors or had longer duration of lifetime exposure to any VGDFFiM are at a higher risk of reduced lung function at age 58–64 years. Occupational exposure to biological dusts or vapors also increased the risk of self-reported COPD

Protecting the Solid Organ Transplant Recipient: Vaccination

Video/audio recording of Aurora St. Luke\u27s Transplant Grand Rounds on July 22, 2015 presented by Jon Godden, PharmD, BCPS. 54 minutes

Two under the Indian sun

Thomas S. HansenCataloging2009121

Evaluation of the association between thrombotic and bleeding outcomes and bridging anticoagulation strategies in patients with left ventricular assist device

Background: In patients with a left ventricular assist devices (LVAD), long-term anticoagulation with a warfarin regimen is required to prevent thromboembolic events, including device thrombosis. Patients with LVAD frequently experience subtherapeutic international normalized ratio (INR) and/or interruption of anticoagulation. In these cases, bridge therapy should be considered, taking into account the balance between thrombotic and bleeding risk. Bridging strategies include anticoagulation with intravenous heparin and low-molecularweight heparin. Purpose: To assist in the expansion of anticoagulation approaches for the LVAD population. Methods: This is a retrospective, observational, single-center study of patients with LVAD. Patients were identified through the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database. Patients implanted from January 2012 to December 2017 and who survived 30 days posthospitalization were followed until time of explant, transplant, or death. A bridging event is defined as the start of anticoagulation until 30 days post. Primary outcomes include thrombotic events and major bleeding events as reported in the INTERMACS registry. A generalized estimating equations model was used to analyze associations between baseline and temporal predictors of thrombotic and major bleeding events. Results: A total of 156 patients were included. During followup time, 109 major bleeding events occurred, with 30 unique bridging events utilizing enoxaparin and 227 utilizing heparin. We adjusted for baseline predictors associated with major bleeding events. Therapeutic INR per protocol was associated with reduced risk of bleeding (relative risk [RR]: 0.47 [0.26– 0.87]; P=0.02). Compared to no bridging, patients bridged on heparin experienced significantly fewer bleeding events (RR: 0.43 [0.21–0.87]; P=0.02). There was no difference between patients bridged on enoxaparin compared to no bridging (RR: 0.91 [0.34–2.34]; P=0.85). Results on thrombotic events are pending. Conclusion: Compared to patients who were not bridged, patients bridged with enoxaparin had no increase in bleeding events, whereas patients bridged with heparin experienced lower rates of bleeding. Although known bleeding risk factors were adjusted for, these results may be limited by physician discretion of bridging based on individual patient risk. Further data analysis will be conducted to identify independent bleeding and thrombotic risk factors to assist in anticoagulation practices in patients with LVAD

The seven islands [a tale]

Thomas S. HansenCataloging2009121