Product Use-associated Lung Injury Research Articles

Clinical manifestations of EVALI in adolescents and the impact of e-cigarettes on the respiratory disease

In recent years there has been a significant increase in the popularity of electronic cigarettes among adolescents and young adults worldwide. E-cigarettes have reached the market without the extensive preclinical toxicology testing or long-term safety studies required for conventional therapeutics and medical devices. Their effectiveness as a smoking cessation intervention, their impact at the population level and whether they are less harmful than combustible tobacco products are highly controversial. Studies show measurable adverse biological effects on organ and cell health in humans, animals and in vitro. E-cigarette use also increases the risk of respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma. There is a serious risk of complications associated with e-cigarette use, such as EVALI (E-cigarette or Vaping Product Use-Associated Lung Injury) - serious lung damage associated with, especially for adolescents. This paper reviews the effects of e-cigarettes on respiratory health.

The Evolution of a Pediatric Public Health Crisis: E-cigarette or Vaping-Associated Lung Injury.

E-cigarettes and vaping products were first introduced in the United States around 2007, and quickly grew in popularity. By 2014, e-cigarettes had become the most commonly used tobacco product among youth in the United States. An e-cigarette, or vaping, product use-associated lung injury (EVALI) outbreak was identified by the Centers for Disease Control and Prevention (CDC) in 2019, with many cases in the adolescent population. The CDC opened a national database of cases and launched a multistate investigation; reported cases reached a peak in September 2019. The CDC investigation found that a vaping liquid additive, vitamin E acetate, was strongly linked to the EVALI outbreak but determined that the decline in cases was likely multifactorial. Due to decreased cases and the identification of a potential cause of the outbreak, the CDC stopped collecting data on EVALI cases as of February 2020. However, e-cigarettes and vaping products have continued to be the most popular tobacco product among youth, though state and national regulations on these products have increased since 2016. While pediatric case series and studies have shown differences in clinical presentation and medical histories between pediatric and adult EVALI cases, the fact that cases are no longer tracked at a national level limits necessary information for pediatric clinicians and researchers. We describe the available literature on the diagnosis, pathophysiology, treatment, and outcomes of EVALI in the pediatric population, and provide clinical and public health recommendations to facilitate prevention and management of EVALI specific to pediatrics.

How is nicotine vaping product (e-cigarette) use monitored in primary care electronic health records in the United Kingdom? An exploratory analysis of Clinical Practice Research Datalink (CPRD)

BackgroundElectronic health records (EHRs) could identify long-term health effects of nicotine vaping. We characterised the extent to which vaping is recorded in primary care EHRs in the UK, on a population level.MethodsWe performed descriptive analysis of Clinical Practice Research Datalink (CPRD), primary care electronic health records of 25% of the UK population (~ 16 million patients). Patients aged ≥ 18 years whose vaping status was recorded using medical codes between 2006 and 2022 were identified. We reported the frequency of vaping codes; their distribution by patient age, gender, and ethnicity; trends in vaping recording over time (including interrupted time series analyses); and transitions in patient smoking status.ResultsSeven medical codes indicated current or former vaping, from 150,114 patients. When their vaping status was first recorded, mean patient age was 50.2 years (standard deviation: 15.0), 52.4% were female, and 82.1% were White. Of those recorded as currently vaping, almost all (98.9%) had records of their prior smoking status: 55.0% had been smoking, 38.3% had stopped smoking, 5.6% had never smoked. Of those who were smoking prior to being recorded as vaping, more than a year after the vaping record, over a third (34.2%) were still smoking, under a quarter (23.7%) quit smoking, 1.7% received a ‘never smoked’ status, and there was no smoking status for 40.4%. The ‘e-cigarette or vaping product use-associated lung injury’ (EVALI) outbreak was significantly associated with a declining trend in new records of current vaping between September 2019 and March 2020; and an immediate significant increase in new records of former vaping, followed by a declining trend.ConclusionsFew patients are being asked about vaping. Most who vape had smoked, and many quit smoking after starting vaping. To enable electronic health records to provide stronger evidence on health effects, we recommend improved completeness, accuracy and consistency.

Cannabis Vape Product Sales in California Following CDC's Initial Advisory About Lung Injuries.

Introduction: The 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) is believed to have been caused by vitamin E acetate, an additive used in some cannabis vaporizer products. Previous studies have primarily focused on changes in sales of electronic nicotine delivery systems following the initial advisory issued by the Centers for Disease Control (CDC) on August 17, 2019. The present study is intended to examine variation by age groups in sales of regulated cannabis vape products in the state of California before, during, and after the outbreak. Methods: Weekly sales revenue of cannabis vape products (from January 1, 2018, to December 31, 2020) was obtained from a sample of recreational cannabis retailers licensed in California. An interrupted time series analysis, using AutoRegressive, Integrated, Moving Average methods, was employed to estimate changes in the sales and market share of cannabis vape products in the weeks following the CDC advisory. Results: The total volume of regulated cannabis vape product sales increased substantially over the 3-year study period (2018-2020). Sales and market share of cannabis vape products, however, declined in both young and older adults immediately following the advisory, rebounding to pre-EVALI levels only for the young adults. For sales, the potential EVALI effect following the CDC's advisory equates to an 8.0% and 2.2% decline below expected levels in the older and young adults, respectively. Conclusions: The differential age effect on sales may reflect concerns regarding health effects of cannabis vaping products and greater awareness of the outbreak among older adults. Findings highlight the importance of informing consumers about health risks associated with using cannabis vape products acquired from regulated versus illicit sources.

High-performance liquid chromatography-tandem mass spectrometry method formeasuring cotinine andtrans-3'-hydroxycotinine inbronchoalveolar lavage fluid ofpatients with e-cigarette, or vaping, product use-associated lung injury.

In 2019, nearly 3000 U.S. residents developed severe lung injury associated with recent use of e-cigarette or vaping products. The Centers for Disease Control and Prevention responded to the outbreak, which was formally defined as e-cigarette, or vaping, product use-associated lung injury (EVALI). Centers for Disease Control and Prevention Laboratory rapidly developed assays to analyze potentially harmful and addictive substances in bronchoalveolar lavage (BAL) fluid collected from EVALI case patients. This report describes the development and validation of a high-throughput isotope-dilution high performance liquid chromatography-tandem mass spectrometry method for measuring two nicotine biomarkers, cotinine (COT) and trans-3'-hydroxycotinine (HCT), in bronchoalveolar lavage fluid samples. COT and HCT are the major metabolites of nicotine, the addictive alkaloid presents in tobacco products. This method had good specificity and sensitivity. The limit of detection is 0.033 and 0.0165 ng/mL for COT and HCT, respectively, using only 200 µL of sample volume. The within-run and between-run precision were 2-10%. The overall accuracy, calculated from recovery in three different sample matrices spiked at three concentrations, was 94.8% and 93.6% for COT and HCT, respectively. This novel HPLC-MS-MS method was utilized to characterize recent tobacco exposure in EVALI case patients. This method is useful for characterizing tobacco exposure that may be related to acute and chronic lung injury.

Vaping lung damage (review)

The review presents data from meta-analyses and original studies on the study of the vapers disease electronic cigarette or vaping product use-associated lung injury (EVALI) a new nosological form in patients with acute and subacute respiratory diseases caused by the consumption of electronic nicotine delivery vehicles, or vaping. The number of users are growing in around the world, especially among young people. According to a 2022 meta-analysis, the global prevalence of vaping use was 23%, including 16% in women and 22% in men. Prevalence of electronic nicotine delivery systems among cigarette smokers reached 43%, while on different continents, except for Asia, during the life it was approximately the same: in America 24%, Europe 26%, Asia 16%, Oceania 25%. Vaping rates among children aged 15 to 17 are almost four times (21.3%) higher than those aged 1214 (5.4%). Two-thirds (66.1%) of children aged 12 to 17 using electronic nicotine delivery devices were also smokers, while they started with vapes. Nicotine cartridges used by 89.3% of teen vapers aged 15 to 19 years. Vaping lung diseases have been reported since invention e-cigarettes, but the number of cases increased sharply at the end of September 2019, and by February In 2020, the number of hospitalized patients in the United States reached 2807, with 68 confirmed deaths. Most of the cases are male adolescents and men aged 1334 years. The review discusses the etiology, clinical picture, imaging findings, pathological EVALI features. When examining patients with EVALI, computed tomography revealed images characteristic of acute lung injury and pneumonia, as well as those resembling non-fibrous hypersensitivity pneumonitis, acute eosinophilic pneumonia. The article discusses the main differences between these diseases and the computed tomography picture of COVID-19. Before EVALI, vaping was associated with a wide range of pulmonary manifestations, including lipoid pneumonia, acute respiratory distress syndrome and diffuse alveolar hemorrhage. Although the overall prevalence of EVALI has declined sharply compared to with a peak in September 2019, other chemicals may appear that cause various pulmonary diseases associated with vaping. EVALI is a new nosological form in patients with acute and subacute respiratory diseases caused by lung damage due to the use of electronic means delivery of nicotine. The appearance of radiographic images in EVALI is diverse: from bilateral opacities in the lungs to reveal centrilobular nodules resembling non-fibrous hypersensitivity pneumonitis. When interpreting acute lung injury in young people, the possibility of EVALI should be considered.

E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Continues: An Opportunity for Pharmacist Intervention.

Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) was first identified and reported in 2019, but media coverage and reporting of cases drastically decreased when the COVID-19 pandemic started in early 2020. The syndrome has continued to occur since that time and it is critical that pharmacists are aware of how EVALI presents, and when it should be considered as a potential diagnosis. Inpatient and outpatient pharmacists play a vital role in the treatment of EVALI, and should be knowledgeable of the utility of corticosteroids, even though data are extremely limited. Pharmacists should understand the importance of collecting detailed and accurate information about vaping from patient interviews. Pharmacists also play a leading role in cessation counseling and treatment, selecting medications that can be used to treat nicotine addiction from vaping, and assisting with transitions of care and follow-up.

Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association.

Vaping and electronic cigarette (e-cigarette) use have grown exponentially in the past decade, particularly among youth and young adults. Cigarette smoking is a risk factor for both cardiovascular and pulmonary disease. Because of their more limited ingredients and the absence of combustion, e-cigarettes and vaping products are often touted as safer alternative and potential tobacco-cessation products. The outbreak of e-cigarette or vaping product use-associated lung injury in the United States in 2019, which led to >2800 hospitalizations, highlighted the risks of e-cigarettes and vaping products. Currently, all e-cigarettes are regulated as tobacco products and thus do not undergo the premarket animal and human safety studies required of a drug product or medical device. Because youth prevalence of e-cigarette and vaping product use was as high as 27.5% in high school students in 2019 in the United States, it is critical to assess the short-term and long-term health effects of these products, as well as the development of interventional and public health efforts to reduce youth use. The objectives of this scientific statement are (1) to describe and discuss e-cigarettes and vaping products use patterns among youth and adults; (2) to identify harmful and potentially harmful constituents in vaping aerosols; (3) to critically assess the molecular, animal, and clinical evidence on the acute and chronic cardiovascular and pulmonary risks of e-cigarette and vaping products use; (4) to describe the current evidence of e-cigarettes and vaping products as potential tobacco-cessation products; and (5) to summarize current public health and regulatory efforts of e-cigarettes and vaping products. It is timely, therefore, to review the short-term and especially the long-term implications of e-cigarettes and vaping products on cardiopulmonary health. Early molecular and clinical evidence suggests various acute physiological effects from electronic nicotine delivery systems, particularly those containing nicotine. Additional clinical and animal-exposure model research is critically needed as the use of these products continues to grow.

Alveolar macrophages from EVALI patients and e-cigarette users: a story of shifting phenotype

Exposure to e-cigarette vapors alters important biologic processes including phagocytosis, lipid metabolism, and cytokine activity in the airways and alveolar spaces. Little is known about the biologic mechanisms underpinning the conversion to e-cigarette, or vaping, product use-associated lung injury (EVALI) from normal e-cigarette use in otherwise healthy individuals. We compared cell populations and inflammatory immune populations from bronchoalveolar lavage fluid in individuals with EVALI to e-cigarette users without respiratory disease and healthy controls and found that e-cigarette users with EVALI demonstrate a neutrophilic inflammation with alveolar macrophages skewed towards inflammatory (M1) phenotype and cytokine profile. Comparatively, e-cigarette users without EVALI demonstrate lower inflammatory cytokine production and express features associated with a reparative (M2) phenotype. These data indicate macrophage-specific changes are occurring in e-cigarette users who develop EVALI.

"Better Than Any DARE Program": Qualitative Analysis of Adolescent Reactions to EVALI Television Storylines.

Introduction. Research suggests that awareness of e-cigarette, or vaping, product-use associated lung injury (EVALI) among adolescents is associated with increased harm perception of e-cigarettes. The depiction of EVALI on three primetime medical dramas offers an opportunity to examine the use of these storylines for tobacco prevention education. Methods. We conducted four focus groups with seventh- and eighth-grade students at an urban middle school. Participants viewed three clips of scenes followed by a facilitated discussion as to the influence of the clips on knowledge and perceptions of e-cigarettes and the use of clips for tobacco prevention education. Two research assistants double-coded notes from the focus groups using a qualitative content analysis approach. Results. Our final sample included 78 adolescents; we obtained self-reported demographic information for 75. The majority of participants were 13 to 14 years of age (82.7%) and identified as cisgender female (52.0%) and Black (52.0%). No participants had knowledge of EVALI prior to viewing the clips. Comments made both during and after watching suggest the clips may have reinforced knowledge and perceptions of harm; participants stated that the clips could be a useful intervention tool. Viewing the clips also generated unprompted discussion about flavored products, tobacco advertising, other television programs, and marijuana. Conclusions. Clips featuring the depiction of EVALI on medical dramas may be an effective tool for raising awareness of e-cigarette use-related harms. These results offer a promising first step for future collaborative research between public health, adolescents, and schools to develop tobacco prevention education utilizing these clips.

Is nicotine vaporization a better alternative to traditional cigarette smoking? E-cigarettes harmful effects summary and the management of EVALI based on the latest literature

Introduction: Electronic cigarettes are battery-powered devices that allow users to inhale vapor produced by heating a liquid (e-liquid) containing nicotine and other substances. The first such devices were introduced in China in 2003, and subsequently approved for use in the European Union in 2006 and the United States in 2007. The number of e-cigarette users is constantly growing, with the largest increases observed in the 18-24 age group. Various modifications led to the emergence of a new disease entity in 2019 called EVALI (e-cigarette or vaping product use-associated lung injury).
 Aim of the study: To summarize the current state of knowledge about harmful substances contained in e-cigarettes and to systematize the latest methods of management in cases of suspected EVALI.
 Methods and materials: A literature review was conducted using PubMed, Google Scholar, and ScienceDirect, including publications from the last 8 years, using the following keywords: "E-cigarette," "Electronic cigarette," "EVALI," "THC," "Vitamin E."
 Results: Electronic cigarettes contain a number of substances harmful to health. E-cigarettes have not been approved as nicotine replacement therapy. The presence of vitamin E breakdown products in the respiratory tract of EVALI patients has been confirmed. Vitamin E was primarily used to increase the volume of e-liquids containing THC.
 Conclusions: Electronic cigarettes should not be used due to the numerous harmful substances they contain. When using e-cigarettes, both the devices and the e-liquids should be purchased from reputable sellers approved in the respective country. EVALI is a potentially fatal disease, and prompt diagnosis facilitates treatment

Changes in E-Cigarette Use Among U.S. Adults, 2019–2021

E-cigarette use increased between 2014 and 2018 among younger U.S. adults who had never smoked combustible cigarettes, potentially increasing nicotine addiction risk and progression to combustible tobacco products. It is unknown how prevalence changed after the E-cigarette, or vaping, product use-associated lung injury epidemic (late 2019) and COVID-19 pandemic (March 2020) by age group and combustible cigarette smoking status. Data from cross-sectional, nationally representative National Health Interview Surveys in 2019, 2020, and 2021 (analyzed in 2022) were used to estimate current E-cigarette use prevalence, adjusted prevalence difference between survey years, and population counts, by age group (younger, 18-29 years, n=11,700; middle age, 30-44 years, n=21,300, 45-59 years, n=21,308; older, ≥60 years, n=36,224) and cigarette smoking status (current, former, and never). E-cigarette use prevalence increased among younger adults between 2019 and 2021 (8.8%-10.2%, adjusted prevalence difference=1.7% points, 95% CI=0.1, 3.3), primarily owing to an increase among those who never smoked cigarettes (4.9%-6.4%, adjusted prevalence difference=1.7% points, 95% CI=0.3, 3.1). People who never smoked cigarettes constituted 53% (2.68 million) of younger adults who used E-cigarettes in 2021, increasing by 0.71 million from 2019. Conversely, among middle age and older adults, the prevalence was similar in 2019 and 2021 irrespective of cigarette smoking status, and those who formerly smoked cigarettes constituted the largest proportion of people who used E-cigarettes in 2021 (age 30-44 years: 51.8%, 1.8 million; age 45-59 years: 51.6%, 0.85 million; age ≥60 years: 47.5%, 0.45 million). Efforts must address the rise in E-cigarette use among younger adults who never smoked cigarettes. At the same time, assistance is needed to help those who switched to E-cigarettes to stop smoking to transition to non-use of all products.

A Large Lung Abscess in an Electronic Cigarette User: To Drain or Not to Drain

A lung abscess is a walled necrotizing infection involving the lung parenchyma, characterized by a cavitary lesion filled with fluid. It is usually caused by microbial infection with aspiration of oropharyngeal contents being the most common mechanism for primary lung abscesses. Secondary lung abscesses occur in the presence of predisposing lung conditions like bronchial obstruction, vascular or septic emboli or impaired host defenses. Lung abscesses caused by electronic cigarette use have gained relevance in the recent years since the outbreak of EVALI, that is, e-cigarette or vaping product use-associated lung injury, in 2019. First-line therapy involves prompt initiation of antibiotics given their success rate in the treatment of lung abscess in the current potent antibiotic era. Percutaneous aspiration and catheter drainage is considered a second line approach due to concerns for potential complications including catheter blockage necessitating repeat procedures, pneumothorax, hemothorax, hemoptysis, need for surgical intervention, infection of pleural space and bronchopleural fistula. We describe a case of a 21-year-old female with a history of electronic cigarette use presenting with a large left upper lobe lung abscess (14.5 x 8.5 x 13.3 cm) treated successfully with broad-spectrum antibiotics alone resulting in clinical and radiologic improvement.

US researchers call for FDA action to avoid another EVALI outbreak.

Researchers are calling for tighter US Food & Drug Administration (FDA) regulation of vaping products to avoid another outbreak of e-cigarette or vaping product use-associated lung injury (EVALI). EVALI hospitalised thousands of Americans starting in 2019, most of them teenagers or young adults, leaving many survivors with damaged lungs and persisting pulmonary dysfunction.

Bronchoalveolar Lavage (BAL) and Pathologic Assessment of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): The EVALI-BAL Study, A Multicenter Cohort.

E-cigarette or vaping-use related acute lung injury (EVALI) is a spectrum of radiographic and histologic patterns consistent with acute to subacute lung injury. However, limited data exist characterizing bronchoalveolar lavage (BAL) findings. The goal of this study is to further define the pathologic findings from BAL and biopsy samples of subjects with EVALI across 7 institutions. A multicentered registry of patients admitted with EVALI who underwent flexible bronchoscopy with BAL+/-transbronchial biopsy from July 2019 to April 2021 was compiled for retrospective evaluation from 7 academic institutions throughout the United States. Radiographic and cytopathologic findings and frequencies were correlated with the substance vaped. Data from 21 subjects (42.9% women) who were predominantly White (76.2%) with a median age of 25 years (range, 16 to 68) with EVALI were included in this study. Sixteen patients (76.2%) reported use of tetrahydrocannabinol; the remainder used nicotine. BAL was performed in 19 of the 21 subjects, and transbronchial lung biopsy was performed in 7 subjects. BAL findings revealed neutrophilic predominance (median, 59.5%, range, 3.1 to 98) in most cases. Ten BAL samples demonstrated pulmonary eosinophilia ranging from 0.2% to 49.1% with one subject suggesting a diagnosis of acute eosinophilic pneumonia associated with the use of e-cigarettes. Lipid-laden macrophages were noted in 10 of 15 reports (66.7%). Transbronchial biopsy most frequently demonstrated patterns of organizing pneumonia (57.1%). EVALI-associated BAL findings typically demonstrate a spectrum of nonspecific inflammatory changes, including neutrophilia, lipid-laden macrophages, and in some cases eosinophilia.

Neighborhood Characteristics and the Burden of E-Cigarette, or Vaping, Product Use-Associated Lung Injury: An Ecological Comparison Study

Purpose: E-cigarette, or vaping, product use-associated lung injury (EVALI) is a severe consequence of vaping first described in 2019. Investigating associations between neighborhood-level characteristics and EVALI cases is an important step in identifying at-risk communities to implement future targeted prevention programs. Methods: We retrospectively identified 41 adolescents <19 years hospitalized for treatment for EVALI at Children's Medical Center Dallas from December 2018 to June 2021. Patient ZIP codes were extracted from the electronic medical record and were compared with Dallas area ZIP codes containing no EVALI cases. Socioeconomic status (SES) characteristics were obtained from the 2019 American Community Survey, and they were mapped for ZIP codes using ESRI ArcMap geospatial processing software. A parallel analysis was conducted utilizing data of adolescents hospitalized with appendicitis. Results: Ninety-five percent of our cohort used tetrahydrocannabinol-containing products, and 66% obtained their vaping products from informal sources. EVALI cases were less likely to reside in higher SES ZIP codes as measured by the proportion of the population with at least a high school education (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.99), access to broadband access (OR: 0.95, 95% CI: 0.91-0.99), and private health insurance (OR: 0.97, 95% CI: 0.95-0.99). Alternatively, they were more likely to reside in lower SES ZIP codes as measured by proportion of the population without any health insurance (OR: 1.07, 95% CI: 1.01-1.12). No neighborhood level low SES characteristics were associated with appendicitis hospitalizations. Conclusions: Although small in magnitude, EVALI cases were associated with lower SES ZIP codes but not with vape shop density.

The implications of Vitamin E acetate in E-cigarette, or vaping, product use-associated lung injury.

In the summer of 2019, a cluster of cases were observed with users of battery-operated or superheating devices presenting with multiple symptoms, such as dyspnea, cough, fever, constitutional symptoms, gastrointestinal upset, and hemoptysis, that is now termed e-cigarette, or vaping, product use-associated lung injury (EVALI). The Centers for Disease Control and Prevention reported 2807 cases within the USA leading to at least 68 deaths as of February 18, 2020. The heterogeneous presentations of EVALI make diagnosis and treatment difficult; however, treatment focused on identifying and removal of the noxious substance and providing supportive care. Vitamin E acetate (VEA) is a likely cause of this lung injury, and others have reported other components to play a possible role, such as nicotine and vegetable glycerin/propylene glycol. EVALI is usually observed in adolescents, with a history of vaping product usage within 90 days typically containing tetrahydrocannabinol, and presenting on chest radiograph with pulmonary infiltrates or computed tomography scan with ground-glass opacities. Diagnosis requires a high degree of suspicion to diagnose and exclusion of other possible causes of lung disease. Here, we review the current literature to detail the major factors contributing to EVALI and primarily discuss the potential role of VEA in EVALI. We will also briefly discuss other constituents other than just VEA, as a small number of EVALI cases are reported without the detection of VEA, but with the same clinical diagnosis.

Ecigarette or Vaping Product Use Associated Lung Injury (EVALI) Reports to NPDS Implicated New Marijuana Substances

Context: Beginning Aug-2019, the Centers for Disease Control and Prevention (CDC) initiated investigation of e-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). We examined all National Poison Data System (NPDS) EVALI cases through 31-Mar-2020 for substances, treatments, clinical effects, and medical outcome. We also examined all NPDS eCig exposures for earlier reports of EVALI. Methods: We extracted all exposures coded to EVALI product code 7322608 (E-Cigarette Associated Pulmonary Illness) and all single substance exposures to any of 6 NPDS eCig generic codes (GCs). We examined substance, patient characteristics, and exposure details on the severity of EVALI via multivariate analyses. We developed an EVALI clinical score (ECS) based on the EVALI clinical effects (CEs) and treatments weighted by the % of cases for each finding. We used ECS to search for EVALI candidate cases from 2001 to 31-Mar-2020. Descriptive statistics and change over time via linear and quadratic regression, and multivariate analyses were via (SAS JMP, 12.0.1). Discussion: Through 31-Mar-2020, PCs reported 822 EVALI cases. The EVALI profile over time 15-Aug - 12-Sep-2019 for 196 cases was described by an exponential increase with a doubling time [95% CI] of 8.31 [8.24, 8.37] days. Age: median [min, max] was 22 [1, 77] years, Male: 64.9%, Chronic 50.3%. Medical Outcomes included Death 1.95%, Major 17.9%, and Moderate 57.1%. Multivariate analysis of the first 107 EVALI cases as of 14-Sep-2019 implicated Marijuana Products (p=0.0007). Similar analyses of all 822 cases confirmed Marijuana (p&lt;0.00001), Chronicity (p=0.00031), and Age (p=0.0152) contributing to CE score. Of the 23,252 eCig exposures (23,463 - 211 EVALI cases), 133 (0.567%) had an ECS &gt; median and 370 (1.57%) scored &gt; 25%tile of EVALI cases (EVALI-25+). The time course of these 370 eCig cases showed a distinct increase (inflection) ~16- Aug-2019. Conclusions: The first 107 NPDS EVALI case scores were related to marijuana product exposure. This was confirmed via similar analyses for all 822 cases. The numbers of EVALI-25+ cases show a distinct increase in Aug-2019, suggesting EVALI was a newly emerging phenomenon. Our analysis should encourage public health agencies to utilize NPDS, especially in data collection.

Welcome to volume 18 of Nanomedicine.

Welcome to volume 18 of Nanomedicine.

The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report.

E-cigarette or vaping product use-associated lung injury (EVALI) is a severe pulmonary illness associated with the use of e-cigarettes or vaping products that was officially identified and named in 2019. This American Thoracic Society workshop was convened in 2021 to identify and prioritize research and regulatory needs to adequately respond to the EVALI outbreak and to prevent similar instances of disease associated with e-cigarette or vaping product use. An interdisciplinary group of 26 experts in adult and pediatric clinical care, public health, regulatory oversight, and toxicology were convened for the workshop. Four major topics were examined: 1) the public health and regulatory response to EVALI; 2) EVALI clinical care; 3) mechanisms contributing to EVALI; and 4) needed actions to address the health effects of EVALI. Oral presentations and group discussion were the primary modes used to identify top priorities for addressing EVALI. Initiatives including a national EVALI case registry and biorepository, integrated electronic medical record coding system, U.S. Food and Drug Administration regulation and enforcement of nicotine e-cigarette standards, regulatory authority over nontobacco-derived e-cigarettes, training in evaluating exogenous exposures, prospective clinical studies, standardized clinical follow-up assessments, ability to more readily study effects of cannabinoid e-cigarettes, and research to identify biomarkers of exposure and disease were identified as critical needs. These initiatives will require substantial federal investment as well as changes to regulatory policy. Overall, the workshop identified the need to address the root causes of EVALI to prevent future outbreaks. An integrated approach from multiple perspectives is required, including public health; clinical, basic, and translational research; regulators; and users of e-cigarettes. Improving the public health response to reduce the risk of another substantial disease-inducing event depends on coordinated actions to better understand the inhalational toxicity of these products, informing the public of the risks, anddeveloping and enforcing regulatory standards for all e-cigarettes.