JOHNS HOPKINS MEDICINE RESEARCHERS SHOW HOW AIR POLLUTION MAY CONTRIBUTE TO LOSS OF SMELL
Media Contact: Waun'Shae Blount, wblount1@jhmi.edu
The loss of smell, a condition known as anosmia, can severely impact a person's quality of life, making it extremely difficult to taste foods, detect airborne hazards in the environment and carry out other functions dependent on the sense. Those with anosmia may experience weight concerns, decreased social interaction, depression and general anxiety. In some cases, loss of smell has been linked to death in older adults. Now, Johns Hopkins Medicine researchers have studied one of the known causes of anosmia -- long-term exposure to air pollution -- to better understand how it can rob someone of the ability to smell and taste.
The findings appeared May 27, 2021, in JAMA Network Open.
"We included participants from a variety of areas in our study; however, most lived in urban areas where pollution levels are highest," says lead author Murugappan "Murray" Ramanathan, M.D., rhinologist and associate professor of otolaryngology-head and neck surgery at the Johns Hopkins University School of Medicine. "We wanted to assess how their exposure to PM2.5 air pollution -- inhalable, particulate matter less than 2.5 micrometers in size or about 30 times smaller than the diameter of a human hair -- might cause them to lose their sense of smell."
According to the U.S. Environmental Protection Agency (EPA), PM2.5 (the PM stands for "particulate matter") is the term for a mixture of solid particles and liquid droplets found in the air. Depending on location, PM2.5 can consist of many materials, incuding dust, dirt, soot, smoke, organic compounds and metals. It has been linked to cardiovascular disease, lung cancer, decline in cognitive thinking ability, chronic obstructive pulmonary disease, asthma and premature death. Previous research has associated PM2.5 as a likely culprit in loss of smell -- a connection that Ramanathan and his team decided to explore in greater detail.
In their study, the researchers looked at 2,690 people, age 18 and older, who were evaluated by otolaryngologists between January 2013 and December 2016. Of these, 538 were diagnosed with anosmia, with an average age of 54 and with men making up the majority (339 or 63%).
Air pollution data for the study came from the EPA's Air Quality System. The researchers fed the data into a complex computer model -- incorporating meteorological and satellite-based environmental measurements, land-use information and simulations of airborne chemical movement -- to estimate the PM2.5 pollution levels within the participants' residential ZIP codes. The model was created by Zhenyu Zhang, a Johns Hopkins Medicine otolaryngology postdoctoral fellow.
The researchers found long-term airborne exposure to PM2.5 increases the risk of losing one's smell by nearly twice (a 1.6- to 1.7-fold increase). They believe this may occur because the location of the olfactory nerve -- which contains the sensory nerve fibers relating to the sense of smell -- places it directly in the path of inhaled PM2.5 materials.
"Based on this result, we feel that long-term exposure to high levels of PM2.5 represents a common risk factor for the loss of sense of smell, especially in vulnerable populations such as older people -- but also one that is potentially modifiable if sources of PM2.5 components can be better controlled," says Ramanathan.
Next, the researchers plan to study socioeconomic factors among patients with anosmia to determine if they impact the chances of exposure to PM2.5 air pollution. They also hope to evaluate other air pollution components that may contribute to loss of smell, such as ozone.
Ramanathan is available for interviews.
SIMPLE PROTOCOL CAN IMPROVE USE OF PROVEN MEDICINAL TREATMENT FOR OPIOID DEPENDENCE
Media Contact: Michel Morris, melben1@jhmi.edu
Unintentional overdoses are the leading cause of death for Americans under 50, with many people knowing at least one person who has struggled with drug dependence. In a recent study, Johns Hopkins Medicine researchers found that effective treatments for opioid addiction are underutilized and offer a potential solution to the problem -- increasing access to medical help through a quality improvement project.
The study, published May 18, 2021, in the Journal of Hospital Medicine, details how a team led by Ashish Thakrar, an addiction medicine fellow at the Johns Hopkins University School of Medicine, propose a simple, yet effective awareness and educational program. The protocol increases the use of evidence-based medication -- that is, therapeutic drugs shown by scientific evidence to be useful at treating opioid dependence. There are currently only three evidence-based medications to treat opioid dependence, and Thakrar says they are all underutilized. Thakrar's team focused on increasing the use of one of these drugs -- buprenorphine -- in patients admitted to The Johns Hopkins Hospital, many with substance use-related issues.
Buprenorphine is a drug approved by the U.S. Food and Drug Administration to treat opioid dependence. Experts say that buprenorphine -- which also is an opioid -- can be prescribed alone or as part of a comprehensive treatment plan that includes counseling and other behavioral therapies to provide patients with a whole-person approach.
"Changing practice is hard," Thakrar says. "There are dozens of well-conducted prospective and retrospective studies showing that buprenorphine works. It reduces mortality by 50%, reduces the rate at which patients use opioids, improves the patient's quality of life and helps retain patients in other kinds of medical and dependence care."
Before the project was implemented for the study, Thakrar says only 10% of eligible patients received approved medications for treating opioid dependence. After the project, discharge prescriptions more than doubled to 24%. Thakrar says the increase was due to the use of a one-page, easy-to-use protocol posted in common areas of the hospital; the presentation of the protocol at a conference with a successful patient case study; and the establishment of a novel, resident-led buprenorphine bridge team.
The bridge team consists of a group of residents and attendees who are legally permitted to prescribe buprenorphine prescriptions. This facilitates the use of the drug for treating opioid dependence -- because while any provider can administer it within a hospital, prescriptions require a special waiver from the federal Drug Enforcement Administration.
As part of the quality improvement project tested during the study, 140 internal medicine residents and 16 combined medicine-pediatrics residents received one hour of formal education about opioid use disorder. Additionally, 28 residents who were specializing in urban health primary care spent one month in a clinical rotation focused on dependence medicine. During that rotation, they completed the eight-hour training required to receive the DEA waiver. The training included guidance on selecting patients, shared decision-making around treatment, avoiding precipitated withdrawal, dosing buprenorphine and establishing follow-up.
After learning and implementing the protocol, the majority of residents reported feeling more comfortable and more knowledgeable using the buprenorphine treatment.
"Providers want to give good care to patients with opioid dependence, and are eager for tools that can help them do so," says Thakrar. "Many of the limitations for providing the best care are structural and logistical, so we need multidisciplinary approaches that include nurses and social workers. Collaboration is key."
Thakrar says the buprenorphine bridge team continues to be active at The Johns Hopkins Hospital. Since the team was established in 2019, the hospital also has started a full dependence medicine consult service.
"I hope that other hospitals can see that there are protocols that can improve the quality of care," Thakrar says. "Small changes can make a big difference for patients with opioid dependence."
Thakrar is available for interviews.
STUDY SHOWS HOSTILE WORK ENVIRONMENTS ARE GLOBAL HEARTACHE FOR CARDIOLOGISTS
Media Contact: Brian Waters, bwaters3@jhmi.edu
In a global survey of nearly 6,000 cardiologists conducted by Johns Hopkins Medicine and the American College of Cardiology, researchers found that as many as 44% of those polled report experiencing a hostile work environment (HWE) at some point in their careers. Based on this finding and others reported in a recent study assessing the survey responses, the researchers suggest that HWE -- characterized by emotional harassment, discrimination, sexual harassment or any combination of the three -- has an adverse effect on professional and patient interactions and relationships, raises concerns about the well-being of those impacted and may threaten the quality of patient care provided.
The study was published May 10, 2021, in the Journal of the American College of Cardiology.
"Unfortunately, we discovered that the problem of HWE is very widespread, with nearly half of the world's cardiologists experiencing some form of it at one time or another," says lead study author Garima Sharma, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine. "We found HWE in cardiology prevalent across regions, races and ethnicities, and both sexes and all gender identifications."
The 50-item survey in the study was given between September and October 2019 to 5,931 cardiologists in Africa, Asia, the Caribbean, Europe, the Middle East, Oceania, and North, Central and South America. Participants were queried about their demographics, practice environment, academic rank and experiences with discrimination and harassment. Seventy-seven percent of the respondents were men, 54% were white (followed by 17% Asians, 17% Hispanics and 3% Blacks), 73% were age 54 or older and 75% were married.
Cardiologists from the European Union made up the biggest block of respondents (32%), followed by cardiologists from South America (18%); the Middle East, Eastern Europe and Asia (all 9%); Africa (8%); North America (7%); Central America (6%) and Oceania (2%).
"Based on the responses from the survey, we found incidences of HWE were most commonly reported by women [68%], Blacks [53%] and North Americans [54%]," says Roger Blumenthal, M.D., director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and professor of medicine at the Johns Hopkins University School of Medicine. "Gender was the most frequent cause of discrimination [44%], followed by age [37%], race [24%], religion [15%] and sexual orientation [5%]."
Seventy-five percent of survey respondents said HWE adversely affected professional activities with colleagues, while 53% reported a negative impact on relationships with their patients.
Looking at each subset of HWE studied, Sharma says that emotional harassment was experienced by nearly one-third of cardiologists, 30% reported at least one form of discrimination, and women endured more incidences of sexual harassment -- with 44% stating they had experienced multiple types.
"These data come at a crucial time when harassment and the culture of discrimination in medicine are being openly challenged," the study states. "These findings support the need to improve the culture within medicine greatly and raise a call to action to address harassment and discrimination."
Sharma and Blumenthal are available for interviews.
TO CULTURE OR NOT TO CULTURE: NEW TOOL HELPS DECIDE -- AND LOWER ANTIBIOTIC USE IN THE PICU
Media Contact: Michael E. Newman, mnewma25@jhmi.edu
The dictionary defines stewardship as "the job of properly and responsibly taking care of things so that they can be used effectively." Nowhere is that concept -- and the responsibility attached to it -- taken more seriously than in a pediatric intensive care unit (PICU), especially when it involves stewarding the appropriate use of antibiotics. Now, Johns Hopkins Medicine researchers hope to make that high-value health care task simpler and more effective with a new bedside tool that helps clinicians better determine when to test for bacteria in endotracheal tubes being used for critically ill pediatric patients.
The findings were reported in the May 2021 issue of the journal Pediatrics.
To diagnose potentially serious bacterial respiratory infections in a PICU patient receiving invasive mechanical ventilation with an endotracheal tube, physicians and nurses often obtain secretions from inside the tube (known as an endotracheal aspirate) and culture it in the laboratory. The problem with these endotracheal aspirate cultures (EACs) is they may lead to a case of mistaken identity that could do the patient more harm than good, says study lead author Anna Sick-Samuels, M.D., M.P.H., a pediatric infectious disease specialist at Johns Hopkins Children's Center and assistant professor of pediatrics at the Johns Hopkins University School of Medicine.
"The human respiratory tract is far from a sterile environment, so bacteria cultured from aspirated samples may just be part of the body's normal microflora and not be causing an infection that needs antibiotics," says Sick-Samuels. "However, the detection of any bacteria in these cultures is often misinterpreted as a sign of a ventilator-associated infection, which then may result in unnecessary -- and potentially harmful -- antibiotic treatment."
To address the problem, Sick-Samuels and her colleagues developed a clinical decision support algorithm for use in the PICU. The algorithm is a simple flow chart of progressively more definitive, "yes or no" criteria by which clinicians can make an informed, rather than speculative, decision about whether or not an EAC is needed.
"The algorithm standardizes the thought process and makes the clinician carefully consider whether or not to call for an EAC, which in turn, prevents a 'knee-jerk' response to bacteria and the inappropriate use of antibiotics," says Sick-Samuels. "It also helps reduce the problem of clinicians ordering repeated EACs from the same patient, even though the same bacteria typically grow again in repeated cultures."
For a PICU patient with a tracheostomy (a surgically created airway directly into the trachea) or an endotracheal tube in place for more than 48 hours, Sick-Samuels explains that the algorithm asks clinicians to consider obtaining an EAC only if:
- The patient has an increased quantity of secretions in the tracheostomy or endotracheal tube over time.
- There is at least one additional supporting sign of infection, such as fever greater than 38 degrees Celsius (100.4 degrees Fahrenheit), an increase in white blood cell counts or a chest X-ray that indicates a developing pneumonia.
- The patient has not had another EAC within the past 3 days.
To test the effectiveness of their algorithm, Sick-Samuels and her research team put it to work as part of a 12-month quality improvement program at the Children's Center PICU. In the year before the tool was implemented, the researchers documented 557 EACs obtained over 5,092 days of patients on mechanical ventilation (tracheostomy or endotracheal tube). This was equivalent to 10.9 EACs for every 100 ventilator-days.
In the year after the algorithm became part of the regular clinical practice at the Children's Center PICU, the number of EACs dropped to 234 over 3,654 ventilator-days, or 6.5 per 100 ventilator-days -- a 40% reduction. The researchers say the use of the algorithm and the resulting sustained decline in EACs did not change the number of deaths, readmissions or lengths of stay for patients in the PICU. They also estimate that the direct cost savings from obtaining fewer EACs would be approximately $26,000 per year.
What makes this stewardship different from other programs seeking to prevent the inappropriate use or overuse of antibiotics, says Sick-Samuels, is that the "decision tree" process goes to work earlier in the thought process before antibiotics might be started.
"The algorithm makes the early decision for or against microbiological testing the pivotal point, not the choice of whether or not to prescribe antibiotics," she says. "At JHCC, it really did make our staff more mindful and aware of their actions, and it led to a shift in practice that was sustained even through the COVID-19 pandemic."
Next, the researchers plan to introduce diagnostic stewardship of EACs at 15 pediatric centers across the United States, validate its effectiveness and show that the stewardship program can be adapted for use in other PICUs. They also hope their efforts will serve as a model for EAC decision-making tools that can be used in other clinical settings.
Sick-Samuels is available for interviews.
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Journal
JAMA Network Open