Bisher AKIL, MD

Archive for November 22nd, 2019|Daily archive page

Will This Make Me an Addict?

In General Health, Uncategorized on November 22, 2019 at 4:24 pm

The risk of addiction after a short course of opioids for acute pain is poorly understood. To quantify the risk of ongoing opioid use after a single prescription in the emergency department (ED), researchers prospectively enrolled adult opioid-naive patients with new-onset acute pain who were prescribed an opioid and discharged from the ED. Follow-up was performed at 6 months via telephone call, chart review, and review of a statewide prescription database. Among 484 patients enrolled at two EDs, average age was 46 years and the median pain duration was 2 days. Most patients (88%) were low risk for opioid misuse based on the Opioid Risk Tool. Oxycodone-acetaminophen was the most common opioid prescription (77%). Overall, 102 patients (21%) filled at least one additional opioid prescription within 6 months (the primary outcome). “Persistent opioid use,” defined as at least six prescriptions during the 6-month follow up, occurred in five patients (1%). Of patients with persistent opioid use, prescription frequency decreased over the 6-month follow up period.

Citation:  Friedman BW et al. Opioid use during the six months after an emergency department visit for acute pain: A prospective cohort study. Ann Emerg Med 2019 Nov 1; [e-pub]. (


Summary appeared in NEJM- Journal Watch

Comments: This question comes up quite often; patients may even endure pain for fear of  potential addiction; here is a good, but not great, answer; still 1% met the authors’ definition of persistent opioid use. Patients’ awareness and physician watchful attention are needed to make this practice lower- BA

Hold the Popcorn!

In General Health, Kids & teens on November 22, 2019 at 4:07 pm

Although electronic cigarettes (e-cigarettes) were initially marketed as a potential smoking-cessation aid and a safer alternative to smoking, the long-term health effect of e-cigarette use (“vaping”) is unknown. Vaping e-liquids expose the user to several potentially harmful chemicals, including diacetyl, a flavoring compound known to cause bronchiolitis obliterans (inflammatory obstruction of the lung’s tiniest airways, called bronchioles. The bronchioles become damaged and inflamed by chemical particles or respiratory infections) with inhalational exposure (“popcorn worker’s lung”- described from a number of workers in factories making microwave popcorn developed “popcorn lung” after inhaling the flavoring chemical diacetyl, which is also used in e-liquids ). Here is a case reported by Canadian physicians,  of a 17-year-old male youth who presented with intractable cough, progressive dyspnea (difficult or labored breathing)  and malaise after vaping flavored e-liquids and tetrahydrocannabinol(one of at least 113 cannabinoids identified in cannabis. THC is the principal psychoactive constituent of cannabis) intensively.  He required intubation (a procedure by which a tube is inserted through the mouth down into the trachea – the large airway from the mouth to the lungs), invasive mechanical ventilation and venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypercapnia (a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous product of the body’s metabolism and is normally expelled through the lungs). The patient’s condition improved with high dose corticosteroids. He was weaned off ECMO and mechanical ventilation, and discharged home after 47 days in hospital. Several months after hospital discharge, his exercise tolerance remained limited and pulmonary function tests showed persistent, fixed airflow obstruction with gas trapping. The patient’s clinical picture was suggestive of possible bronchiolitis thought to be secondary to inhalation of flavoring agents in the e-liquids, although the exact mechanism of injury and causative agent are unknown. They concluded that this  case of severe acute bronchiolitis, causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction in a previously healthy Canadian youth, may represent vaping-associated bronchiolitis obliterans. This novel pattern of pulmonary disease associated with vaping appears distinct from the type of alveolar injury predominantly reported in the recent outbreak of cases of vaping associated pulmonary illness in the United States, underscoring the need for further research into all potentially toxic components of e-liquids and tighter regulation of e-cigarettes.

Source:  Simon T. Landman, Inderdeep Dhaliwal, Constance A. Mackenzie, Tereza Martinu, Andrew Steele and Karen J. Bosma CMAJ November 20, 2019 cmaj.191402; DOI:

Summary reported in NEJM_ Journal Watch

Comments:  Yet another one!_BA

Descovy vs. Truvada: tit for tat?

In HIV on November 22, 2019 at 3:38 pm

Current antiretroviral therapy (ART) treatment guidelines and practice have resulted in a pronounced shift from use of tenofovir disoproxil fumarate (TDF – Truvada®) to tenofovir alafenamide (TAF – Descovy®), which is associated with less bone and renal toxicity. Recently, concerns have been raised about increased cholesterol and body weight linked to TAF relative to TDF. In this study, investigators examined changes in cholesterol, body weight, body-mass index (BMI), and American College of Cardiology atherosclerotic cardiovascular disease (ASCVD) risk score in ART-experienced persons living with HIV who switched from TDF to TAF at an academic-based HIV clinic. Before the switch, participants had been on an effective TDF-containing regimen, defined as on TDF >1 year with at least two consecutive HIV RNA levels <200 copies/mL and no levels >200 copies/mL in the previous year.

A total of 110 patients (58% African American; 73% male; mean age, 50; median baseline body weight, 185 pounds; median BMI, 28 kg/m2) met study criteria. During the year after the switch, significant increases were observed in average total cholesterol (by 12.5 mg/dL), LDL cholesterol (by 8.2 mg/dL), HDL cholesterol (by 3 mg/dL), weight (by 3 pounds), BMI (by 0.5 kg/m2), and ASCVD risk score (by 0.4 points). In regression models, switching from TDF to TAF was associated with a 0.45 kg/m2 BMI increase and a 13% increase in ASCVD risk score.

Source: Schafer JJ et al. Changes in body mass index and atherosclerotic disease risk score after switching from tenofovir disoproxil fumarate to tenofovir alafenamide. Open Forum Infect Dis 2019 Oct 4; 6:ofz414. (

Summary appeared in NEJM Journal Watch – 20191120

Comments: This is a retrospective and small study, with caveats – the majority are African American, male, older, high BMI, only one year follow up- yet the results showing a concerning trend and should be verified by larger and more inclusive study- of note, this is from people with HIV infection, and it may or may not apply for those taking Pre-exposure prophylaxis (PreP). BA