Air pollution increases lung cancer risk in non-smokers

Morning MEDtalks with Dr KK Aggarwal

New Delhi, September 29, 2018 :

Lp(a) can be reduced: Treatment with a proprietary antisense agent was associated with significant reductions in levels of lipoprotein(a) in a phase 2 study of patients with established coronary or peripheral vascular disease and elevated Lp(a). The observed reductions in Lp(a) occurred at all tested dosage levels of the drug, called AKCEA-APO(a)-LRx (Akcea/Ionis), formerly ISIS 681257, and at several dosing frequencies that included once-monthly in the placebo-controlled study.

Air pollution increases lung cancer risk in non-smokers. We always wonder how come the incidence of lung cancer is increasing in our country in non-smokers in both men and women. The factor may be high indoor and outdoor air pollution. Among never smokers women are far more susceptible than men to develop lung cancer when exposed to air pollution as per Renell Myers, MD, University of British Columbia, Vancouver, Canada.

23% of lung cancer deaths worldwide are caused by indoor and outdoor air pollution. In 2013 WHO listed particulate matter of a concentration of 2.5 ug/m3 (PM2.5) as an environmental carcinogen.

The study included 681 lung cancer patients, 35% of whom had never smoked. The remaining 65% either had a history of smoking or were current smokers. A significant association was found between lung cancer in never-smoking females and air pollution. No association was seen between exposure to air pollution and lung cancer in never-smoking men. Median exposure to air pollution among all cancer patients was 7.1 PM2.5 ug/m3. However, among ever-smokers, 6.1% had a PM2.5 > 10 ug/m3, whereas more than twice that proportion, 15.1%, of never-smokers had exposure levels exceeding PM2.5 > 10 ug/m3.

Among never-smokers with lung cancer whose level of air pollution exposure was at the highest threshold, almost three quarters were women, and 83% were of Asian descent.

Atrial fibrillation clinical practice guidelines 2018 from the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (Medscape)

Opportunistic point-of-care screening should be conducted in people aged 65 years or older.

Pacemakers and defibrillators should be investigated regularly for atrial high-rate episodes (AHREs) and should be confirmed by atrial electrocardiogram (EGM) to be AF.

A 12-lead electrocardiogram (ECG) is recommended for all patients with AF.

A transthoracic echo should be performed in all patients with newly diagnosed AF.

A thyroid stimulating hormone (TSH) test should be undertaken in patients with newly diagnosed AF but should be delayed in acutely ill patients.

In overweight and obese individuals with AF, intensive management of weight (to a target of ≥10% body weight loss, aiming for a BMI below 27) and concomitant management of associated cardiovascular risk factors to target levels should be performed.

Beta adrenoceptor antagonists or non-dihydropyridine calcium channel antagonists are recommended for acute control of the ventricular rate in hemodynamically stable patients, but caution is needed if given intravenously.

Amiodarone is recommended for acute control of the ventricular rate in highly symptomatic AF patients or those with known left ventricular systolic dysfunction who are not unstable enough to require immediate electrical cardioversion.

Beta adrenoceptor antagonists, digoxin and non-dihydropyridine calcium channel antagonists should be the first-line agents for long-term ventricular rate control.

When digoxin is used, serum concentration should be monitored, with the goal of maintaining levels <1.2 ng/mL.

Calcium channel antagonists should be avoided in patients with left ventricular systolic dysfunction (ejection fraction <40%).

Amiodarone should not be administered as a first-line agent for chronic rate control because of its toxicity profile.

Membrane-active antiarrhythmic agents (e.g., sotalol or flecainide) should not be used in patients managed with a rate-control strategy.

If pharmacologic rate control fails, catheter ablation of AV node should be considered after a permanent pacing device has been implanted.

Electrical cardioversion should be done urgently in hemodynamically unstable patients with AF.

Catheter ablation should be considered for symptomatic paroxysmal or persistent AF refractory or intolerant to at least one Class I or III antiarrhythmic medication.

The CHA2DS2-VA score—the sexless CHA2DS2-VASc score—is recommended for predicting stroke risk in AF.

Oral anticoagulation therapy to prevent stroke and systemic embolism is recommended in patients with non-valvular AF (N-VAF), whose CHA2DS2-VA score is ≥2, unless there are contraindications to anticoagulation.

Oral anticoagulation therapy to prevent thromboembolism and systemic embolism is not recommended in patients with N-VAF whose CHA2DS2-VA score is 0.

When oral anticoagulation is initiated in a patient with N-VAF, a non-vitamin K oral anticoagulant (NOAC)—apixaban, dabigatran, or rivaroxaban—is recommended in preference to warfarin.

Warfarin is recommended and NOACs should not be used in patients with valvular AF (mechanical heart valves or moderate to severe mitral stenosis).

Antiplatelet therapy is not recommended for stroke prevention in N-VAF patients, regardless of stroke risk.

Where dual antiplatelet therapy is required in combination with OAC, low-dose aspirin (100 mg) and clopidogrel (75 mg) are recommended. Ticagrelor and prasugrel are not recommended in this situation.

Warfarin or acitrom should be used if an AF patient with severe CKD requires anticoagulant therapy.

Anticoagulation is recommended at the time of electrical or pharmacologic cardioversion and for at least 4 weeks post procedure.

CCI probe finds unfair practices by three drug companies. A preliminary investigation by the Competition Commission of India has found that three pharmaceutical companies and a few regional chemist bodies used unfair trade practices to distribute drugs. Torrent Pharmaceuticals, Intas Pharmaceuticals and Macleod Pharmaceuticals are accused of violating the Competition Act of 2002 by being part of a ploy by some regional trade bodies to appoint their favoured ones as stockists. The competition regulator has started hearing the matter and a verdict is likely to be out soon. If found guilty, the companies could face hefty penalties. During the preliminary probe, the commission found that these trade associations issued no-objection certificates for the appointment of stockists in their regions to a few entities they favoured. Pharma companies are also a part of this unfair practice as they appoint stockists and this amounts to stifling the competition in the market by controlling supply of drugs.

Antibiotics may be a feasible alternative to surgery for patients with uncomplicated acute appendicitis as per a 5-year follow-up data from a randomized trial published online in JAMA.

Although appendectomy has been the mainstay of treatment for acute appendicitis for many years, recent advances in diagnostic imaging and antibiotic therapies have allowed clinicians to consider antibiotic treatment as a viable alternative strategy in some cases. In the trial, 73% of all patients with acute uncomplicated appendicitis who received antibiotics alone did not need surgery at 1-year follow-up.

The randomized Appendicitis Acuta trial was conducted at 6 hospitals in Finland and enrolled 530 adults (329 men; 201 women) with uncomplicated acute appendicitis. Of those, 273 underwent appendectomy (median age, 35 years) and 257 initially received antibiotic treatment (median age, 33 years).

With 5 years of follow-up, 3 patients had died: 2 in the appendectomy group and 1 in the antibiotics group. However, none of the deaths was considered related to the trial. Among the 257 patients who initially received antibiotics, 100 underwent appendectomy during follow-up. Of those, 70 experienced their recurrent appendicitis within 1 year of the first episode and 30 patients required an appendectomy at between 1 and 5 years. The cumulative incidence of recurrent appendicitis among patients who initially received antibiotics alone was 34.0% at 3 years, 37.1% at 4 years, and 39.1% at 5 years.