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.

Anmerkungen zu den (spät)persischen Samaria-Bullen aus dem Wadi ed-Dalije. Hellenisches, Persisches und Lokaltraditionen im Grenzgebiet der Provinz Jehud

The present article deals exemplarily with the remarkable iconographic attestations connected with the Wadi ed-Daliye (WD) findings. The discussed bullae were attached to papyri which provide a clear dating of the hoard between 375-335 BCE. Considering style and convention the preserved motives are to be classified as Persian, Greek or Greco-Persian. A major goal of the following presentation is the contextualization of the very material; this is achieved by taking into account local parallels as well as relevant attestations of the dominant / “imperial” cultures of Persia and Greece. The correlation of motives with the (often more complex, more detailed or more contoured) examples stemming from the “source-cultures” follows a clear agenda: It is methodologically based on the approach that was employed by Silvia Schroer and Othmar Keel throughout the project „Die Ikonographie Palästinas/Israels und der Alte Orient (IPIAO). Eine Religionsgeschichte in Bildern” (2005, 23ff). The WD-findings demand a careful analysis since the influencing cultures behind the imagery are deeply rooted in the field of Greek mythology and iconography. Special attention has to be drawn to the bullae, as far as excavated, from a huge Punic temple archive of Carthago (Berges 1997 and 2002) as well as those from the archive of the satrap seat in Daskyleion in the Northwest of Asia Minor (Kaptan 2002), which are chronologically close (end 5th and 4th century BCE) to the WD-finds. Not each and every single motive and artifact of the WD-corpus comprising more than 120 items can be dealt with in detail throughout the following pages. We refer to the editio princeps by Leith (1990, 1997) respectively to the concerning chapter in Keel’s Corpus volume II (Keel 2010, 340-379). The article gives a brief history of research (2.), some basic remarks on the development of style (3.) and a selection of detail-studies (4.). A crosscheck with other relevant corpora of stamp-seals (5.) as well as a compressed synthesis (6.) are contributions in order to characterize and classify the unique iconographic assemblage. There are rather few references to the late Persian coins from Samaria (Meshorer/Qedar 1999), which have been impressed about contemporaneous with the WD-bullae (372-333 BCE), as there is an article by Patrick Wyssmann in this volume about that specific corpus. Through the perspective of the late Persian iconography, Samaria appears as a dazzling metropolis at the crossroads of Greek and Persian culture, which is far away from a strict and revolutionary religious orthodoxy

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology

Bullous pemphigoid is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or generalized bullous lesions. In up to 20% of affected patients, bullae may be completely absent, and only excoriations, prurigo-like lesions, eczematous lesions, urticated lesions and/or infiltrated plaques are observed. The disease is significantly associated with neurological disorders. The morbidity of bullous pemphigoid and its impact on quality of life are significant. So far, a limited number of national treatment guidelines have been proposed, but no common European consensus has emerged. Our consensus for the treatment of bullous pemphigoid has been developed under the guidance of the European Dermatology Forum in collaboration with the European Academy of Dermatology and Venereology. It summarizes evidence-based and expert-based recommendations.