Emphysema and secondary pneumothorax in young adults smoking cannabis

Background: We observed a remarkable increase in the number of young patients who presented with lung emphysema and secondary spontaneous pneumothorax (SSP) at our institution for over a period of 30 months; most of them have a common history of marijuana abuse. Study design: Retrospective case series. Methods: Seventeen young patients presented with spontaneous pneumothorax with bullous lung emphysema were systematically evaluated over a period of 30 months. All were regular marijuana smokers. Clinical history, chest X-ray, CT-scan, lung function test, and laboratory and histological examinations were assessed. We compared the findings of this group (group I) with the findings of non-marijuana smoking patients (group II) in the same period. The findings of this series were also compared with the findings of 75 patients presented with pneumothorax in a previous period from January 2000 till March 2002 (group III). Results: In group I, there were 17 patients: the median age of the patients was 27 years (range 19–43 years), 16 males and 1 female. All were living in Switzerland. All but one smoked marijuana daily for a mean of 8.8 years and tobacco for 11.8 years. CT-scan showed multiple bullae at the apex or significant bullous emphysema with predominance in the upper lobes only in two patients. Only two patients had reduced forced first second expiratory volume (FEV1) and one reduced vital capacity (VC) below the predicted 50%. This correlated with the subjectively asymptomatic condition of the patients. All but two patients were treated by video-assisted thoracoscopic surgery (VATS) for prevention of relapsing pneumothorax. Histology showed severe lung emphysema, inflammation, and heavily pigmented macrophages. In group II, there were 85 patients: there were 78 males, the median age was 24 years (range 17–40 years), 74 patients smoked tobacco for 13.4 years but no marijuana. CT-scan in 72 patients showed only small bullae at the apex but no significant emphysema; other clinical, laboratory, and histopathological findings showed no significant difference in group I. In group III, there were 75 patients: there were 71 males and 4 females. Mean age was 25 years (range 16–46 years). Six smoked marijuana daily for a mean of 3.2 years, and 62 smoked tobacco for 14 years. CT-scan done in 59 patients showed few small bullae at the apex but no significant lung emphysema. The presence of lung emphysema on CT-scan in group I was significantly different than in groups II and III (p = 0.14). No significant difference was found among all groups in the form of clinical, laboratory, and histopathological findings. Conclusions: In case of emphysema in young individuals, marijuana abuse has to be considered in the differential diagnosis. The period of marijuana smoking seems to play an important role in the development of lung emphysema. This obviously quite frequent condition in young and so far asymptomatic patients will have medical, financial, and ethical impact, as some of these patients may be severely handicapped or even become lung transplant candidates in the future.     

Marijuana use should not preclude consideration for kidney transplantation

Transplant eligibility for tobacco and/or marijuana using candidates varies among transplant centers. This study compared the impact of marijuana use and tobacco use on kidney transplant recipient outcomes. Kidney transplant recipients at a single center from 2001 to 2015 were reviewed for outcomes of all‐cause graft loss, infection, biopsy‐proven acute rejection, and estimated glomerular filtration rate between four groups: marijuana‐only users, marijuana and tobacco users, tobacco‐only users, and nonusers. The cohort (N = 919) included 48 (5.2%) marijuana users, 45 (4.8%) marijuana and tobacco users, 136 (14.7%) tobacco users, and 75% nonusers. Smoking status was not significantly associated with acute rejection, estimated glomerular filtration rate or pneumonia within one‐year post‐transplant in an adjusted model. Compared to nonuse, marijuana and tobacco use and tobacco‐only use was significantly associated with increased risk of graft loss (aHR 1.68, P = .034 and 1.52, P = .006, respectively). Patients with isolated marijuana use had similar overall graft survival compared to nonusers (aHR 1.00, P = .994). Marijuana use should not be an absolute contraindication to kidney transplant.     

Outcomes of lung transplantation from donors with a history of substance abuse

ObjectiveThe study objective was to determine whether donor substance abuse (opioid overdose death, opioid use, cigarette or marijuana smoking) impacts lung acceptance and recipient outcomes.MethodsDonor offers to a single center from 2013 to 2019 were reviewed to determine if lung acceptance rates and recipient outcomes were affected by donor substance abuse.ResultsThere were 3515 donor offers over the study period. A total of 154 offers (4.4%) were opioid use and 117 (3.3%) were opioid overdose deaths. A total of 1744 donors (65.0%) smoked cigarettes and 69 donors (2.6%) smoked marijuana. Of smokers, 601 (35.0%) had less than 20 pack-year history and 1117 (65.0%) had more than 20 pack-year history. Substance abuse donors were younger (51.5 vs 55.2 P < .001), more often male (65.6 vs 54.8%, P < .001), more often White (86.2 vs 68.7%, P < .001), and had hepatitis C (8.3 vs 0.8%, P < .001). Donor acceptance was significantly associated with brain dead donors (odds ratio, 1.56, P < .001), donor smoking history (odds ratio, 0.56, P < .001), hepatitis C (odds ratio, 0.35, P < .001), younger age (odds ratio, 0.98, P < .001), male gender (odds ratio, 0.74, P = .004), and any substance abuse history (odds ratio, 0.50, P < .001), but not opioid use, opioid overdose death, or marijuana use. Recipient survival was equivalent when using lungs from donors who had opioid overdose death, who smoked marijuana, or who smoked cigarettes for less than 20 patient-years or more than 20 patient-years, and significantly longer in recipients of opioid use lungs. There was no significant difference in time to chronic lung allograft dysfunction for recipients who received lungs from opioid overdose death or with a history of opioid use, marijuana smoking, or cigarette smoking.ConclusionsDonor acceptance was impacted by cigarette smoking but not opioid use, opioid overdose death, or marijuana use. Graft outcomes and recipient survival were similar for recipients of lungs from donors who abused substances.     

Incident testicular cancer in relation to using marijuana and smoking tobacco: A systematic review and meta-analysis of epidemiologic studies

BackgroundRecent epidemiologic studies identified credible associations between marijuana smoking and risk of nonseminomatous testicular germ cell tumors (TGCTs), but did not distinguish exposure to cannabinoid compounds from exposure to other constituents of smoke.MethodsWe implemented a systematic review of scholarly literature followed by random effects meta-analysis to quantitatively synthesize published data relating incident TGCT to each of 2 exposure histories: ever using marijuana, and ever smoking tobacco.ResultsWe identified four epidemiologic studies of marijuana use and 12 of tobacco smoking. Summary data concur with earlier reports of a specific association of marijuana use with nonseminoma, summary odds ratio [sOR] = 1.71 (95% confidence interval [CI] 1.12–2.60), and identify a positive association, sOR = 1.18 (95% CI 1.05–1.33), between tobacco smoking and all TGCT.ConclusionsAvailable data accord with positive associations between incident TGCT and each exposure, implicating both cannabinoid compounds and other constituents of smoke. Etiologic interpretation awaits epidemiologic studies that assess associations between tobacco smoking and nonseminomatous TGCT, investigating not only these exposures but also both co-use of tobacco and marijuana and smoke-free sources of cannabinoids, while adequately evaluating potential confounding among all of these exposures.     

Marijuana Use in Potential Liver Transplant Candidates

Concern exists that liver transplant center substance abuse policies may have an inappropriate and disproportionate impact on marijuana users. Our hypothesis is that patients with chronic liver disease who were marijuana users will have inferior survival. This is a retrospective (1999–2007) cohort study. The primary outcome measure is time-dependent, adjusted patient survival from the time of liver transplant evaluation. The primary exposure variable is a positive cannabinoid toxicology screen during the liver transplant evaluation period. Overall, 155 patients qualified as marijuana users while 1334 patients were marijuana non-users. Marijuana users were significantly (p < 0.05) younger (48.3 vs. 52.1), more likely to be male (78.1% vs. 63.0%), have hepatitis C (63.9% vs. 40.6%) and were less likely to receive a transplant (21.8% vs. 14.8%). Marijuana users were more likely to use tobacco, narcotics, benzodiazepines, amphetamines, cocaine or barbiturates (p < 0.05). Unadjusted survival rates were similar between cohorts. Upon multivariate analysis, MELD score, hepatitis C and transplantation were significantly associated with survival, while marijuana use was not (HR 1.09, 95% CI 0.78–1.54). We conclude that patients who did and did not use marijuana had similar survival rates. Current substance abuse policies do not seen to systematically expose marijuana users to additional risk of mortality.     

Lung function in primary Sjögren''s syndrome: a cross sectional and longitudinal study.

Clinical and radiological assessment of 100 patients (97 female) with primary Sjögren''s syndrome was performed within six months of diagnosis in conjunction with spirometry and measurement of transfer factor for carbon monoxide (TLCO). This was repeated in an unselected subgroup of 30 patients after a mean interval of four years. On initial assessment, 43 patients had symptoms of lung disease and 10 had related physical signs; the chest radiograph was abnormal in five. There was a significant reduction (more than 2 standardised residuals) in forced expiratory volume in one second (FEV1), vital capacity (VC), and TLCO in 14, 12, and 10 patients, 24 patients overall having a significant reduction in one or more of these measures. There was a strong relation between reduction in lung function and both pulmonary symptoms and a lip biopsy specimen positive for Sjögren''s syndrome. Lung function at the initial assessment in the 30 patients who were restudied was almost identical to that of the group as a whole. Seventeen now had symptoms and nine had related physical signs. The chest radiograph was abnormal in four patients. More patients had a significant reduction in FEV1, VC, and TLCO. Lung disease is sometimes an early feature of primary Sjögren''s syndrome and may progress over a relatively short period.     

Open lung biopsy in neonatal and paediatric patients referred for extracorporeal membrane oxygenation (ECMO)

BACKGROUND: This study was undertaken to determine the usefulness, safety, and most appropriate timing of open lung biopsy in infants and children considered for and on extracorporeal membrane oxygenation (ECMO) for respiratory failure. METHODS: A retrospective review of children referred for consideration of and placed on ECMO in our institution in the period 1996-2002. RESULTS: 506 patients were referred, 15 (3%) of whom underwent antemortem open lung biopsy (eight neonatal, four paediatric, and three cardiac patients). In the neonatal group open lung biopsy contributed to clinical decision making in all patients. Four neonates had a fatal lung dysplasia (three alveolar capillary dysplasia and one surfactant protein B deficiency) and treatment was withdrawn. Of the other four neonates, two had pulmonary hypoplasia, one had pulmonary lymphangiectasia, and one had meconium aspiration with mild barotrauma. Treatment was continued in these four patients and two survived. In the paediatric group the biopsies were of clinical relevance in two infants with pertussis who had lung infarction on biopsy in whom treatment was withdrawn. In the other two paediatric patients the biopsies were equivocal, treatment was continued, but both patients died. In the cardiac group, who presented perioperatively with pulmonary hypertension, the biopsies excluded a fatal lung dysplasia and severe pulmonary vascular disease but all three infants died. One patient had non-fatal bleeding complications. CONCLUSION: Open lung biopsy is clinically most useful when performed to diagnose fatal lung dysplasias in neonates and to confirm the presence of viable lung tissue in patients with acute lung injury due to pertussis infection.     

Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes

OBJECTIVES Opportunities to treat multifocal lung cancers, mostly adenocarcinoma, are increasing due to the development of imaging technologies. The optimal therapy modality to treat multifocally growing lung cancers remains obscure. To determine the features of multifocal lung cancers, we retrospectively reviewed patients with multiple lung lesions. METHODS Clinical, pathological and genetic characteristics of 31 patients with multifocal lesions were compared with those of patients who had had radical lung resection for solitary lung cancer. Gene mutation analyses for EGFR, KRAS and P53 were performed on three tumours of each of the patients who had four or more lesions. RESULTS Of the 31 patients, 17 had double tumours, 4 had triple tumours and 10 had 4 or more lesions. Patients with four or more lesions were significantly more likely to be females and never smokers. All of the histologically confirmed tumours of the cases with four or more lesions were adenocarcinoma in situ or lepidic predominant adenocarcinoma. The number of lesions in the right upper lobes when compared with the right lower lobes was significantly higher in patients with four or more lesions than in patients with double or triple lesions (P?=?0.013). Five of the 12 tumours were positive for the EGFR mutation L858R in exon 21. No KRAS mutation was found. CONCLUSIONS Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes. Genetic analysis suggested that the specific EGFR mutation L858R in exon 21 might be the main factor contributing to lung carcinogenesis in multiple lung cancers. Further investigation of the right upper lobe in those patients compared with the lower lobes might provide more insights into lung carcinogenesis.     

Cigarettes, alcohol and marijuana are related to pyospermia in infertile men

The relationship of current use of cigarettes, marijuana and alcohol to the parameters of seminal fluid analysis, sperm penetration assay and sperm autoimmunity was studied in 164 men from infertile couples. Current cigarette smokers, marijuana users and heavy alcohol users showed greater numbers of leukocytes in the seminal fluid than did nonusers (p less than 0.02, less than 0.007 and less than 0.01, respectively). In addition, cigarette smokers had lower sperm penetration assay scores than nonsmokers (median 2.5 versus 8.0, p = 0.05). Users of cigarettes, marijuana or alcohol showed no decrease in sperm count, motility or percentage of oval sperm, and no difference in prevalence of antisperm antibodies compared to nonusers. After controlling for past sexually transmitted diseases and multiple substance exposures in a multivariate model, use of cigarettes (p = 0.006), marijuana (p = 0.12) or alcohol (p = 0.098) continued to be associated with a trend toward increased number of seminal fluid leukocytes. Cigarette smoking continued to show a significant decrease in sperm penetration assay score (p = 0.03).     

Pregnancy in cystic fibrosis lung transplant recipients: case series and review.

A single centre experience of four pregnancies in four cystic fibrosis (CF) lung transplant recipients is reported. Six more cases were identified from the literature review and combined data analysis on 10 pregnancies in 10 CF lung transplant recipients was performed to determine maternal, foetal and graft outcome. There were nine live births and one therapeutic abortion. Three required caesarean sections. Five babies were premature but all nine children were well at follow-up. Five recipients who had a long, stable interval (i.e. at least three years) between transplant and pregnancy had a favourable outcome. Three recipients developed rejection during the pregnancy and one already had obliterative bronchiolitis before pregnancy. All showed progressive decline in lung function and subsequently died of chronic rejection within 38 months of delivery. Pregnancy in CF lung transplant recipients is feasible but should still be regarded as a risky undertaking.     

Marijuana use does not spuriously elevate serum human chorionic gonadotropin levels

Marijuana use has been reported to spuriously elevate immunoreactive human chorionic gonadotropin (HCG) in the serum of patients with testicular germ cell tumors. To reinvestigate this finding, we measured serum HCG and delta 9-tetrahydrocannabinol (delta 9-THC) levels in 16 men known or suspected to be marijuana users. Eight of the serum samples had measurable levels of delta 9-THC, while eight did not. None contained immunoreactive HCG. The addition of delta 9-THC directly to pooled male serum had no effect on the HCG radioimmunoassay. These results indicate that marijuana does not artificially elevate serum HCG concentrations.     

The changing spectrum of cystic pulmonary lesions requiring surgical resection in infants

Congenital labor emphysema and cystic adenomatoid malformation have been the most common surgically treatable cystic lesions of the lung. With the successful treatment of newborn respiratory distress syndrome, an increased frequency of an acquired form of cystic disease, interstitial pulmonary emphysema, has been observed. Some degree of interstitial pulmonary emphysema is relatively common, and during the years 1980 to 1983 this disease was diagnosed in 372 infants. Seven of these infants, all premature, underwent resection of relatively localized areas of persistent cystic interstitial pulmonary emphysema. Lobectomy or wedge resection was performed in five patients because of their inability to be weaned from the ventilator. A sixth patient with this disease underwent lobectomy for recurrent pneumothoraces. A seventh patient underwent lobectomy because the cystic interstitial pulmonary emphysema produced atelectasis and recurrent infections. All seven patients were extubated by the fourth postoperative day, have been discharged, and are showing respiratory improvement. Within the same period, four infants had congenital lobar emphysema and two had congenital cystic adenomatoid malformation. They were gestational age 36 weeks or older and, although respiratory distress was present to some degree in all six, only one was ventilator dependent at operation. All underwent lobectomy and one infant had a left upper lobe resection and right middle lobectomy on separate occasions for bilateral congenital cystic adenomatoid malformation. All patients with congenital labor emphysema and congenital cystic adenomatoid malformation have been discharged and are doing well. Our results suggest the following conclusions: Persistent interstitial pulmonary emphysema is now the most common indication for pulmonary resection in the newborn period. The anatomic distribution of resected interstitial pulmonary emphysema is similar to that of congenital lobar emphysema. Although only a small fraction (less than 2%) of patients with interstitial pulmonary emphysema require operation, the development of relatively large discrete cystic areas that (1) significantly decrease effective lung volume and produce respirator dependence, (2) produce atelectasis and recurrent infections, or (3) lead to pneumothoraces may make pulmonary resection beneficial. Finally, despite the presence of generalized lung disease in patients with interstitial pulmonary emphysema, these patients can be expected to improve significantly after resection, and the long-term outcome is generally good.     

Pulmonary sequelae in survivors of congenital diaphragmatic hernia.

Nineteen survivors of congenital diaphragmatic hernia repair were compared with age and sex matched control children six to 11 years after repair. All subjects were examined clinically and underwent lung function testing. The patients also had individual lung volumes assessed radiographically and had radionuclide (krypton-81 m, technetium-99 m macroaggregates) ventilation-perfusion (V/Q) lung scans. Four patients had pectus excavatum and two had mild scoliosis. Spirometric measurements were lower in the patients than in the control subjects but only the differences in peak expiratory flow and flow at 50% of expired vital capacity were significant. The radiographic left lung volumes in patients surviving left diaphragmatic repair were larger than expected at 49.3% (SD 2%), suggesting alveolar overdistension. V/Q scans showed a mismatch in the ipsilateral lung, mean Q (40% (7%] being significantly lower than mean V (47% (6%)). In seven patients who had required ventilation for four days or more perfusion to the ipsilateral lung was significantly lower (34% (6%)) than values for the 12 patients ventilated for less than four days (43% (6%)). Survivors of right diaphragmatic repair had a better outcome in terms of relative radiographic lung volumes and V/Q distribution. More severely affected children are now surviving repair of congenital diaphragmatic herniation, with residual pulmonary abnormalities that could produce functional impairment in adult life.     

Comparison and ranking of cancer mortality rates in the various populations of the RSA in 1970

Age-adjusted mortality rates (MRs) in all four population groups in the RSA (age range 25 - 74 years) for different types of cancer were compared and ranked. Lung and stomach cancer had the highest MRs in white, Indian and coloured males. In white males lung cancer ranked 1st (MR more than twice as high as that for stomach cancer), while in Indian and coloured males stomach cancer ranked 1st and lung cancer 2nd. The MR for lung cancer in coloured males was a little higher than that in white males. In black males oesophageal cancer ranked 1st and liver cancer 2nd. In white females breast cancer ranked 1st and lung cancer 2nd. In coloured females cancer of the cervix ranked 1st followed by cancer of the breast and of the stomach. In black females cancer of the oesophagus and of the liver ranked 2nd and 3rd after cancer of the cervix, and in Indian females the rank order was stomach cancer 1st, breast cancer 2nd, and cervical cancer 3rd. Cancers of the rectum and bladder were low in the rank order in both males and females of all four population groups. The main feature of age-specific MRs for the more common cancers was the fact that MRs for stomach cancer in both coloured males and females were relatively high in the younger age groups. Also, the MRs for cancer of the cervix in coloured and black females were not only higher at all ages (except in the highest age group in blacks) but were particularly high in the younger age groups compared with figures for the other populations.     

Surgery for Mycobacterium avium complex lung disease in the clarithromycin era.

OBJECTIVE: Since the introduction of clarithromycin, it has been assumed that pulmonary Mycobacterium avium complex (MAC) disease can be treated with medication alone. This study examines whether surgery can still play an important role in the management of MAC lung disease in the current era. METHODS: Between April 1993 and January 2001, 21 patients (11 men and 10 women) underwent a pulmonary resection for MAC infection. The median age of the patients was 56 years (range: 27-67 years). None of the patients were immunocompromised. Regimens employing clarithromycin were initiated preoperatively in all patients. The indications for surgery were failure of drug therapy in 19 patients and discontinuation of chemotherapy because of drug toxicity in two patients. The pulmonary resections (19 right lung, 2 left lung) performed included lobectomy in 16 patients, pneumonectomy in three, bilobectomy in one, and lobectomy plus segmentectomy in one. RESULTS: All of the patients survived the surgery. Six major postoperative complications occurred in six patients (28.6%) and these included two bronchopleural fistulas after right pneumonectomy, two space problems, one prolonged air leak, and one case of interstitial pneumonia. All postoperative complications were manageable, and four of these were treated surgically. All patients had sputum-negative status after their operation. Relapse occurred in two patients (9.5%) at six months and two years postoperative, respectively. The first patient, who originally had a right upper lobectomy, underwent a left upper lobectomy during the follow-up period, attaining sputum conversion. The second patient underwent a right pneumonectomy and then died of respiratory failure four years postoperatively. This one late death was the only fatality. CONCLUSIONS: Although it is associated with relatively high morbidity, surgery provides a high sputum conversion rate for patients whose MAC disease responds poorly to drug therapy. Even in the present clarithromycin era, pulmonary resection remains the treatment of choice when MAC lung disease has not been successfully eradicated by drug treatment alone.     

Intrapulmonary lymph nodes enlarged after lobectomy for lung cancer

A 62-year-old man, who had had a left upper lobectomy for mucoepidermoid lung carcinoma, was admitted again 3 months later because of enlargement of four small nodules in the left lower lobe. A computed tomography–guided needle aspiration biopsy obtained insufficient material for diagnosis, and because pulmonary metastases were suspected, two of the four tumors were extirpated. Intraoperative frozen section found the nodules to be intrapulmonary lymph nodes. Intrapulmonary lymph nodes should be included in the differential diagnosis of coin lesions in the peripheral lung field.     

Surgical treatment of lung cancer with combined resection of the aorta or superior vena cava

Until December 1997, 699 cases of lung cancer were resected in our institute. Four cases of invasion into the aorta and seven cases of invasion into the superior vena cava were also operated and each vessels were reconstructed. Two pneumonectomies and nine lobectomies were performed. Four cases of squamous cell carcinoma, three of adenocarcinoma, three of large cell carcinoma and one of adenosquamous carcinoma were found on pathological examination. Four cases of N0, four of N2 and two of N3 were also detected on pathological lymph node evaluation. One case was stage IV with metastasis of ipsilateral axillar lymph nodes and the others were stage IIIB. With respect to pathological curability, absolutely noncurative operation was performed in all cases involving the aorta and absolutely noncurative in four and relatively curative three in cases involving the superior vena cava. During resection and reconstruction of the aorta, three cases received temporary blood supplying bypass and one case was underwent temporary clamping. Two cases developed bilateral lower extremity paralysis. During resection and reconstruction of the superior vena cava, one case underwent intraluminal temporary blood supplying bypass, two received sideclamping and four were reconstructed with double artificial grafts for bilateral innominate veins. Two cases who underwent resection of the aorta died within one year and one is alive after nine months of operation. Five cases who underwent resection of the superior vena cava died due to cancer. One case of N0 and relatively curative is alive in free of recurrence after seven years and six months of operation and another case who had brain metastasis resected is alive after two years and two months of pulmonary operation. Careful selection should be made for resection of the aorta because the prognosis is usually poor. In the resection of the superior vena cava, good prognosis is expected in some cases (N0, relatively curative) and quality of life is expected to improve with the prevention of the superior vena cava syndrome. Aggressive resection should be considered for lung cancer invasion into the superior vena cava.     

Posttraumatic stress symptom severity predicts marijuana use coping motives among traumatic event-exposed marijuana users

The present study examines the relation between posttraumatic stress symptom severity and motives for marijuana use among 103 (55 women) young adult marijuana users (current) who reported experiencing at least one traumatic event in their lifetime. As expected, after covarying for the theoretically relevant variables of frequency of past 30-day marijuana use, number of cigarettes smoked per day, and volume of alcohol consumed, posttraumatic stress symptom severity was significantly related to marijuana use coping motives, but no other motives for marijuana use. Results are discussed in relation to better understanding the role of coping-motivated marijuana use among young adults experiencing posttraumatic stress.