EVALI Research Articles

Illness representations of vaping associated lung injury (VALI) and E-cigarette use: common sense model of self-regulation driven mixed-method approach

Objective The study explored differences in illness representations of VALI guided by the Common-Sense Model of Self-Regulation (CSM-SR) among non-patient adults. Design We employed a cross-sectional concurrent mixed-methods design. In the quantitative analysis, we used multivariate analysis of covariance (MANCOVA). Immersion/crystallization was used to analyze qualitative data. Main outcome measures We measured differences in illness representations of VALI by e-cigarette use status, gender, and urban/rural residence. Results E-cigarette use was associated with illness representations of VALI. Current e-cigarette users discounted the detrimental nature of VALI, compared to former and never e-cigarette users. Gender and urban/rural residence moderated the association between e-cigarette use and illness representation of VALI. In the qualitative analysis, 49.3% respondents reported components of the timeline (e.g. permanent), identity (e.g. shortness of breath), causes (e.g. THC products), consequences (e.g. life-threatening), cure/control (e.g. stop vaping), and worry (e.g. fearful). Conclusion Perceptions about VALI, such as cure and timeline, were associated with e-cigarettes use. Understanding the context in which adults perceive VALI, such as gender and rurality, may contribute to developing interventions that influence e-cigarette cessation. Future research employing CSM-SR to target strategies for promoting vaping abstinence is warranted.

Vaping discussion in the COVID-19 pandemic: An observational study using Twitter data.

BackgroundWith the spread of COVID-19, significant concerns have been raised about the potential increased risk for electronic cigarette (e-cigarette) users for COVID-19 infection and related syndromes. Social media is an increasingly popular source for health information dissemination and discussion, and can affect health outcomes.ObjectiveThis study aims to identify the topics in the public vaping discussion in COVID-19–related Twitter posts in order to get insight into public vaping-related perceptions, attitudes and concerns, and to discern possible misinformation and misconceptions around vaping in the COVID-19 pandemic.MethodsUsing the tweets ID database maintained by Georgia State University’s Panacea Lab, we downloaded the tweets related to COVID-19 from March 11, 2020, when the World Health Organization declared COVID-19 a pandemic, to February 12, 2021. We used R to analyze the tweets that contained a list of 79 keywords related to vaping. After removing duplicates and tweets created by faked accounts or bots, the final data set consisted of 11,337 unique tweets from 7,710 different users. We performed the latent Dirichlet allocation (LDA) algorithm for topic modeling and carried out a sentiment analysis.ResultsDespite fluctuations, the number of daily tweets was relatively stable (average number of daily tweets = 33.4) with a sole conspicuous spike happening on a few days after August 11, 2020 when a research team published findings that teenagers and young adults who vape face a much higher risk of COVID-19 infection than their peers who do not vape. Topic modeling generated 8 topics: linkage between vaping and risk of COVID-19 infection, vaping pneumonia and the origin of COVID-19, vaping and spread of COVID-19, vaping regulation, calling for quitting vaping, protecting youth, similarity between e-cigarette or vaping-associated lung injury (EVALI) and COVID-19, and sales information. Daily sentiment scores showed that the public sentiment was predominantly negative, but became slightly more positive over the course of the study time period.ConclusionsWhile some content in the public discourse on vaping before the COVID-19 pandemic continued in Twitter posts during the COVID-19 time period, new topics emerged. We found a substantial amount of anti-vaping discussion and dominantly negative sentiment around vaping during COVID-19, a sharp contrast to the predominantly pro-vaping voice on social media in the pre-COVID-19 period. Continued monitoring of social media conversations around vaping is needed, and the public health community may consider using social media platforms to actively convey scientific information around vaping and vaping cessation.

Fundamentals of vaping-associated pulmonary injury leading to severe respiratory distress.

Vaping of flavored liquids has been touted as safe alternative to traditional cigarette smoking with decreased health risks. The popularity of vaping has dramatically increased over the last decade, particularly among teenagers who incorporate vaping into their daily life as a social activity. Despite widespread and increasing adoption of vaping among young adults, there is little information on long-term consequences of vaping and potential health risks. This study demonstrates vaping-induced pulmonary injury using commercial JUUL pens with flavored vape juice using an inhalation exposure murine model. Profound pathological changes to upper airway, lung tissue architecture, and cellular structure are evident within 9 wk of exposure. Marked histologic changes include increased parenchyma tissue density, cellular infiltrates proximal to airway passages, alveolar rarefaction, increased collagen deposition, and bronchial thickening with elastin fiber disruption. Transcriptional reprogramming includes significant changes to gene families coding for xenobiotic response, glycerolipid metabolic processes, and oxidative stress. Cardiac systemic output is moderately but significantly impaired with pulmonary side ventricular chamber enlargement. This vaping-induced pulmonary injury model demonstrates mechanistic underpinnings of vaping-related pathologic injury.

Abstract 12450: Inflammatory Gene Expression Changes and Immune System Depression in Rats Exposed to a Single 4-hr Exposure to Electronic Cigarette Vapor

Introduction: lectronic cigarette (eC) or Vaping induced Lung Injury (EVALI) was first described in the summer of 2019 in patients presenting with acute respiratory distress. Several factors contributing to EVALI are suspected, including use of oil carriers, and heating and power elements. This study examined whether a single acute exposure to eC smoke using two popular heating elements on high or low power levels would induce inflammatory gene expression and proteins, and changes in alveolar macrophage function. Hypothesis: We hypothesize that nichrome, but not stainless-steel atomizers and high power wattage used in the eC device contribute to the extent of changes in pulmonary inflammatory response and alveolar macrophage activity. Methods: Adult Sprague Dawley rats were exposed to clean air (n=8) or eC vapor (50% propylene glycol, 50% vegetable glycerin, tobacco flavoring, no nicotine, n=8) for a single four hour period using devices equipped with stainless steel (SS) or nichrome (NC) heating elements at 45 or 70 wattage power (5 exposure conditions per sex group). Rats were euthanized and bronchoalveolar lavage was performed to collect alveolar macrophages for ex-vivo cell studies. The remaining lung tissue was homogenized for inflammatory protein and gene expression analyses. Results: Significant changes were observed in animals assigned to 70 watts. Increases ranging from 1.5-fold to 2-fold change in expression of the inflammation related genes IL-6, TNF-α and CRP occurred in rats assigned to NC atomizers (p ≤ 0.05), predominantly in males. While the concentration of CRP protein was significantly increased in females, CRP gene expression was decreased at the time point examined. Other proteins were not significantly elevated. Significant (p ≤ 0.05) changes in phagocytic activity were only observed in males exposed to 70 watts NC vapor, which generated exaggerated superoxide production by 4-fold during ex-vivo incubation. Evidence of depressed phagocytic activity was observed in other exposure groups, although not statistically significant. Conclusions: These results demonstrate that a single 4-hr exposure to e-cigarettes can initiate increased gene expression of inflammatory markers IL-6, TNF-α and CRP and oxidative changes in the lung.

Cannabis and Lung Health: Does the Bad Outweigh the Good?

Cannabis use is growing, with multiple medical ‘indications’ and approval for recreational use in many countries. This article will review some of the respiratory complications to cannabis use, which include lung function changes, lung destruction, increased risk of lung and head and neck cancer, and others. These are mostly related to smoking, and the co-administration of nicotine makes the risks a bit difficult to measure. However, with many reports of EVALI, electronic vaping-associated lung injury, being related to cannabis coadministration, it appears that the safest administration of cannabis, as far as lung health, is orally. Cannabis and Lung Health: Does the Bad Outweigh the Good? A video abstract (MP4 81,897 kb)Supplementary InformationThe online version contains supplementary material available at 10.1007/s41030-021-00171-8.

Open Characterization of Vaping Liquids in Canada: Chemical Profiles and Trends.

Currently, there is a lack of comprehensive data on the diversity of chemicals present in vaping liquids. To address this gap, a non-targeted analysis of 825 vaping liquids collected between 2017 and 2019 from Canadian retailers was conducted. Prior to mass spectrometry analysis, samples were diluted 1:500 v/v with methanol or acetonitrile. Chemical compound separation and analysis was carried out using gas chromatography and triple quadrupole mass spectrometry (GC-MS/MS) systems operated in the full scan mode and mass range of 35–450 m/z. Mass spectrum for each sample was obtained in electron ionization at 70 eV and processed. Non-targeted identification workflow included use of automated mass spectral deconvolution and identification system (AMDIS), where required, as well as a number of commercially available spectral libraries. In order to validate identities, an in-house database of expected compounds previously detected in vaping liquids was used along with genuine analytical standards for compounds of interest. This resulted in a dataset of over 1,500 unique detected chemicals. Approximately half of these chemical compounds were detected only once in a single product and not in multiple products analyzed. For any sample analyzed, on average, 40% of the chemical constituents appeared to have flavouring properties. The remainder were nicotine and related alkaloids, processing, degradation or indirect additives, natural extractives and compounds with unknown roles. Data published here from the project on the Open Characterization of vaping liquids is unique as it offers a detailed understanding of products’ flavour chemical profiles, the presence and frequency of chemicals of potential health concern, as well as trends and changes in products’ chemical complexity over a three-year period. Non-targeted chemical surveillance such as this present valuable tools to public health officials and researchers in responding to emergent issues such as vaping associated lung injury or informing chemical based strategies which may be aimed at addressing product safety or appeal.

Content Analysis of E-cigarette News Articles Amidst the 2019 Vaping-Associated Lung Injury (EVALI) Outbreak in the United States.

IntroductionNews media can shape public perceptions about e-cigarettes, particularly in the context of ongoing uncertainty from the recent outbreak of e-cigarette or vaping product use-associated lung injury (EVALI). This study aimed to characterize news articles published about e-cigarettes in 2019, including before and during the EVALI outbreak.Aims and MethodsUsing 24 e-cigarette-related search terms, we gathered all articles published in leading print and online U.S. news sources in 2019 from databases (i.e., Factiva, Access World News) and archival web sites (i.e., www.newspapers.com). We conducted a content analysis of e-cigarette themes and statements, identifying differences in themes between articles that did and did not mention EVALI. ResultsOf the 1643 e-cigarette news articles published in 2019, 62% mentioned EVALI. Frequency of e-cigarette articles peaked in September (n = 532) at the height of the EVALI outbreak. Among all articles discussing e-cigarettes, the most prevalent main topics were policy/regulation (45%) and health effects (35%). Articles that mentioned EVALI frequently discussed youth e-cigarette use (40%) and JUUL (33%). Compared to non-EVALI articles, EVALI articles were more likely to discuss health effects (p < .001) but less likely to discuss policies/regulations, except for flavor bans (47% of EVALI articles vs. 39% of non-EVALI articles, p = .002). EVALI articles were also less likely to discuss e-cigarettes being less risky than cigarettes (p = .005).ConclusionsE-cigarette news coverage was prevalent in 2019, and patterns in frequency and content reflected major events (i.e., EVALI). In turn, news media can shape public perceptions, and even policy, about e-cigarettes and must continue to be monitored.ImplicationsE-cigarette news coverage in 2019 was high, driven in large part by news coverage of the EVALI outbreak. Indeed, the peak in e-cigarette news articles in September directly coincided with the peak in EVALI cases in the United States. Of note, articles that mentioned EVALI frequently discussed youth e-cigarette use, JUUL, and flavor bans, which may have triggered national and state-level policy responses, and likely influenced public perceptions (including misperceptions) regarding the harms of e-cigarettes.

43.3 Cannabis Vaping in Adolescents: A Review of Prevalence, Comorbidities, Appraisal of Lung Injury, and Long-Term Complications

As of 2020, there were 2807 hospitalizations for electronic cigarette (e-cigarette)- or vaping-associated lung injury (EVALI) reported to the CDC, of which 15% were adolescents. As per a 2020 NIDA survey, there was a twofold increase in marijuana vaping in adolescents from 2017 to 2019. Recent studies have shown associations between marijuana smoking or vaping with bronchitis, increased risk of respiratory infections, and acute lung injury. Eighty-five percent of patients with vaping-associated lung injury had tetrahydrocannabinol (THC) or its metabolites in alveolar fluid samples. The objective of this study is to review the available literature on cannabis vaping in adolescents and understand the possible risks and pulmonary complications of vaping. We conducted a systematic review of literature using PubMed with keywords “cannabis” OR “marijuana,” “vaping” OR "e-cigarettes," “lung injury” OR “pneumonia,” in all fields. We included RCTs, cross-sectional studies, longitudinal studies, review articles, and case reports published until December 2020. The search resulted in 63 articles. After filtering for children and adolescents, 15 articles (2 cross-sectional surveys, 1 retrospective cohort, 7 case series or reports, 4 review articles, and 1 novel mental health metric) were identified for abstract and full paper review. We are currently conducting retrospective chart reviews of patients admitted to a tertiary care children’s hospital for lung infection or injury. Upon review of the selected 15 articles, there were no relevant longitudinal studies, which focused on the adolescents with e-cigarette- and cannabis-associated lung injuries or pneumonia. Out of the works that included adolescents, many focused on and surveyed only adults. The literature from PubMed about adolescent cannabis vaping was limited to a few case reports and case series. There are no comprehensive studies that have rigorously investigated cannabis vaping in adolescents. There needs to be more investigations into how e-cigarettes containing THC affects the adolescent population. Many complications have been associated with vaping of cannabis, nicotine, and combined products, such as COVID-19 susceptibility, EVALI, and pain and sedative management. More research needs to be done to explore these connections, especially in adolescents.

A CASE OF VAPING-RELATED LUNG INJURY MIMICKING COVID-19

TOPIC: Tobacco Cessation and Prevention TYPE: Medical Student/Resident Case Reports INTRODUCTION: E-cigarette and vaping associated lung injury (EVALI) was first recognized in 2019 and can present with acute onset respiratory distress mimicking that of COVID-19. It is important to consider in a young patient with a significant vaping history. CASE PRESENTATION: A 19-year-old male with a history of anxiety, depression, and delusional disorder presented with worsening dyspnea, fever and productive cough, nausea, vomiting, diarrhea for 1 week. He had gone to urgent care where he had tested negative for COVID19 twice and was started on Azithromycin. He denied any exposure to COVID positive individuals but reported that his siblings' school had a recent outbreak. Vitals on admission were temperature 100.3F, Heart rate 121, Respiratory rate 24, Blood Pressure 157/97, pulse oximetry 81% on Room Air, improved after 6L supplemental oxygen. Labs significant for leukocytosis of 19.4K, normal procalcitonin, ESR >130, ferritin 443, LDH 694, CRP 358. Urine drug screen positive for THC (tetrahydrocannabinol). Urine was negative for Legionella and Strep pneumoniae. COVID testing were negative on 3 separate occasions. Chest x-ray showed mild-moderate pulmonary congestion, but no effusions. Chest CTA showed patchy parenchymal interstitial infiltrates bilaterally, suspicious for nonspecific pneumonitis/atypical viral pneumonia or pulmonary edema, but no pulmonary embolus. Blood cultures and sputum cultures negative.On further questioning, he attested to vaping and smoking marijuana through a bong; he had recently bought a new THC product off the street for vaping that contained vitamin E acetate. Given his history of vaping and his failed treatment with antibiotics, we considered EVALI. He was started on prednisone 40mg daily and 5 day course of Azithromycin and Ceftriaxone. On the 4th day of hospitalization, he showed significant clinical improvement and was no longer requiring oxygen supplementation. The patient was discharged on Day 5. Repeat chest xray 5 days after discharge showed no evidence of active disease. DISCUSSION: EVALI is a diagnosis of exclusion; it can mimic atypical and viral pneumonias, most notably COVID-19. Vitamin E acetate is the main causative agent, resulting in an acute lung injury with findings of acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia. Patients are usually treated with supportive care, antibiotics, and systemic steroids. The COVID19 pandemic poses a diagnostic challenge to accurately diagnose cases of EVALI due to the similar presentation of both diseases: acute to subacute respiratory symptoms with gastrointestinal symptoms, ground-glass opacities on CT, and elevated inflammatory markers. CONCLUSIONS: Similar to COVID19, EVALI can also be fatal, and should not be overlooked as a diagnosis. A thorough history is imperative in reaching a diagnosis, and can save PPE use, and decrease hospitalization cost. REFERENCE #1: "Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 27 Nov. 2020, www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#overview. REFERENCE #2: Blount, Benjamin C., et al. "Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI." New England Journal of Medicine, vol. 382, no. 8, 2020, pp. 697–705., doi:10.1056/nejmoa1916433. REFERENCE #3: Hollingsworth, Helen. UpToDate, 9 Feb. 2021, www.uptodate.com/contents/e-cigarette-or-vaping-product-use-associated-lung-injury-evali?search=evali&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1#H4113759245. DISCLOSURES: No relevant relationships by Rebecca Greenspan, source=Web Response No relevant relationships by Areej Khan, source=Web Response No relevant relationships by Manpreet Mann, source=Web Response No relevant relationships by Krishnaveni Sirigaddi, source=Web Response

CANNABINOID HYPEREMESIS SYNDROME AND CHRONIC VAPING USE COMPLICATED BY MULTISYSTEM ORGAN FAILURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Vaping and e-cigarettes are devices with aerosolized substances such as nicotine, tetrahydrocannabinol (THC), or cannabinoids (CBD) along with a carrying media. Their introduction in the past two decades has coincided with the advent of devastating lung injuries.3 Cannabinoid hyperemesis syndrome is a paradoxical condition where chronic cannabinoid use causes cyclic episodes of nausea or vomiting. Vaping injury to the lungs combined with cyclical emesis episodes has the potential to cause severe damage as shown in our case. CASE PRESENTATION: A 32 year-old male with a six-month chronic cough, daily marijuana and vape use presented with a headache, abdominal discomfort, nausea and loose stools after one week of acutely worsened cough and emesis. On the second day of admission he developed a leukocytosis, acute renal failure, an elevated lactate and transaminitis. Abdominal Computed Tomography(CT) scan showed hepatic steatosis with normal lung bases. Rapid encephalopathy and shock necessitated endotracheal intubation and vasopressor support. He transferred to our tertiary care center for emergent hemodialysis while on four vasopressor medications, stress dose steroids, minimal ventilator settings and no sedation. Initial minimal ventilator support worsened to severe acute respiratory distress syndrome (ARDS) by 48 hours with a calculated PaO2/FiO2 ratio of 97 on 15 positive end-expiratory pressure. Broad spectrum coverage was narrowed to empiric pneumonic coverage after an unrevealing infectious lumbar puncture. Figure 1 shows the diffuse airspace disease with air bronchograms and dense bibasilar consolidations four days into admission in the coronal and axial view. He slowly weaned from high ventilator settings and was successfully extubated on day fourteen. DISCUSSION: Our case shows the rapid development of pulmonary decompensation and evolution of multisystem failure in a patient with aspiration pneumonia secondary to cannabinoid vaping use. Imaging of electronic vaping associated lung injury often shows basilar-predominant consolidation and ground-glass opacity with areas of lobular or subpleural sparing. 1,2 His clinical presentation and imaging was suggestive of the novel VARDS classification. With his minimal response to steroids and routine supportive care, we propose the patient's chronic vaping history predisposed our patient to a prolonged and unusually severe presentation. CONCLUSIONS: More research is needed regarding the relation between vaping associated lung injury and its progression to ARDS and multisystem organ failure. REFERENCE #1: Aberegg SK, Maddock SD, Blagev DP, Callahan SJ. Diagnosis of EVALI: General Approach and the Role of Bronchoscopy. Chest. 2020;158(2):820-827. doi:10.1016/j.chest.2020.02.018 REFERENCE #2: Henry TS, Kanne JP, Kligerman SJ. Imaging of vaping-associated lung disease. N Engl J Med. 2019;381(15):1486-1487. doi:10.1056/NEJMc1911995 REFERENCE #3: Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019;7(12):1017-1026. doi:10.1016/S2213-2600(19)30415-1 DISCLOSURES: No relevant relationships by Catherine Fiore, source=Web Response No relevant relationships by Kyle Halligan, source=Web Response No relevant relationships by Siddhartha Narayanan, source=Web Response

VAPING-INDUCED ALVEOLAR RUPTURE LEADING TO PNEUMOMEDIASTINUM IN A YOUNG FEMALE

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Electronic cigarette use or "vaping" has been on the rise in America over the last decade. Literature shows that approximately 8.1 million Americans admitted to vaping in 2018. Vaping is when one inhales and exhales an aerosolized solution (Vaper) through a cigarette-like electrical device. Some chemicals found in vapers have been linked to disease processes. While using E-cigarettes, the participant inhales a large amount of vaper, exaggerating the Valsalva maneuver, subsequently increasing intra-thoracic pressure. This increase in thoracic pressure places the participant at risk for spontaneous pneumomediastinum. We present a case of a 19-year-old female diagnosed with spontaneous pneumomediastinum. The only risk factor, the use of electric cigarettes. CASE PRESENTATION: A 19-year-old female with a history of type 1 diabetes mellitus and vape dependence presents with a 3-day history of abdominal pain, chest pain, and retching. She admitted to vaping daily for one year before the presentation. Physical examination revealed no evidence of respiratory distress along with slight crepitus tracheal area at the level above the clavicle. She was found to be in diabetic ketoacidosis (DKA), which was also treated. She continued to have epigastric burning along with chest pain. For this reason, computed tomography (CT) of the chest was performed and showed pneumomediastinum. She did not meet the Pittsburg criteria for esophageal rupture. Barium swallow eventually ruled out esophageal rupture. The pneumomediastinum likely occurred secondary to vape-induced alveolar rupture. She was treated with supplemental oxygen, and serial chest radiograph showed gradual resolution of pneumomediastinum. DISCUSSION: Laennec first described pneumomediastinum (PM) in 1819 as a consequence of traumatic injury. The clinical presentation could be very vague, ranging from classic chest pain to unspecific symptoms, which lead to delayed diagnosis. The pathophysiology of can be described by the Macklin effect as follows: (a) alveolar rupture, (b) air dissection along the bronchovascular sheath, and (c) free air reaching the mediastinum. Chest radiography, the standard diagnostic procedure, diagnosis can be confirmed by chest computed tomography scan. Once the diagnosis is approved, the patient should be admitted for monitoring and treatment consisting of avoidance of the trigger factors, oxygen, and bed rest. CONCLUSIONS: Spontaneous pneumomediastinum secondary to vaping is on the rise. The diagnosis of vaping-induced lung injury continues to be a dilemma among physicians. A high index of suspicion is necessary for early detection and treatment. Although most cases are benign, it will be prudent for health care providers to actively query patients about their use and educate patients on their potential severe side effects. REFERENCE #1: Pneumomediastinum: Practice Essentials, Pathophysiology, Epidemiology. Accessed April 28, 2021. https://emedicine.medscape.com/article/1003409-overview REFERENCE #2: Marasco RD, Loizzi D, Ard NP, Fatone FN, Sollitto F. Spontaneous Pneumomediastinum After Electronic Cigarette Use. Ann Thorac Surg. 2018;105:e269-e271. doi:10.1016/j.athoracsur.2017.12.037 REFERENCE #3: Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF. Spontaneous pneumomediastinum: Clinical and natural history. Ann Emerg Med. 1992;21(10):1222-1227. doi:10.1016/S0196-0644(05)81750-0 DISCLOSURES: No relevant relationships by Esiemoghie Akhigbe, source=Web Response No relevant relationships by Ebubechukwu Ezeh, source=Web Response No relevant relationships by Mackenzie Hamilton, source=Web Response No relevant relationships by Mohamed Suliman, source=Web Response

Vaping-associated lung injury: a case report and literature review

Usage of vaping and electronic cigarettes products is a growing trend among young adults, with rising rates worldwide. Such products are gaining popularity for many reasons including an alternative to smoking cigarettes, trying something new, or as a means to relax. While users may feel that these products are less harmful or a safer substitute to smoking traditional products, the side effect profile of vape inhalation has the potential for profound injury to the lung tissue and significant respiratory failure. We would like to present a case in which a young male who was evaluated at our Emergency department for acute onset respiratory failure subsequently requiring invasive mechanical ventilation in the setting of vaping associated lung injury (VALI). In the case report, we will highlight the patient’s clinical course as well as a summary of the current evidence surrounding evaluation, diagnosis and management of this emerging pathology. We want to emphasize the importance of a detailed history which should include the use of vaping products when a young patient presents with acute respiratory failure, allowing VALI to be in the differential diagnosis. Additionally, we want to compare the clinical presentation of VALI to that of COVID-19 pneumonia as they both have many similar attributes including symptoms and findings on lung imaging studies.

State marijuana policies and vaping associated lung injuries in the US

BackgroundThe United States’ 2019 outbreak of e-cigarette or vaping-associated lung injuries (EVALI) was linked to an additive most common in informally-sourced vaporizable marijuana concentrates. This study estimates how states’ recreational and medical marijuana policies related to their 2019 EVALI incidence and residents’ likelihood of vaping as their primary mode of marijuana use. MethodsMultivariable negative binomial regressions estimated associations between states’ total 2019 EVALI cases and marijuana policies: recreational legalization, medical legalization only, and whether medical-only policies allowed home cultivation, prohibited combustible use, or had operational dispensaries. Logistic regressions used survey data from the Behavioral Risk Factor Surveillance System’s 2016–2019 marijuana supplements to assess how these policies related to past-30-day marijuana users’ selection of vaping as their primary mode of use. ResultsEVALI incidence was 42% lower in recreational marijuana states (95%CI=0.339,0.993), versus a positive but statistically insignificant association with medical legalization alone. Adjusting for policy attributes revealed heterogeneity: among medical-marijuana-only states, EVALI incidences were > 60% lower where laws allowed home cultivation (aIRR=0.374; 95%CI=0.196, 0.715). Similarly, among past-30-day marijuana users, odds of vaping as one’s primary mode of use were > 40% lower in medical-only states where home cultivation was allowed versus prohibited (aOR=0.588; 95%CI=0.365,0.946). ConclusionsMarijuana policy attributes linked to lower EVALI incidences were also associated with reduced likelihoods of vaping as one’s primary mode of use. As additives in informally-sourced vaping concentrates could drive future EVALI cases, marijuana policy design should account for effects on mode of use in licit and illicit markets, to limit the scope of future outbreaks.

Drug Repurposing Patent Applications April–June 2021

Drug Repurposing Patent Applications April–June 2021

Are vaporizers a lower-risk alternative to smoking cannabis?

Cannabis use is associated with various adverse physical and mental health outcomes as well as increased risk of motor vehicle collision. Many organizations and the "Lower-Risk Cannabis Use Guidelines" have recommended to use cannabis vaporizers instead of smoking to reduce the associated health risk. This commentary draws attention to the present evidence regarding harm reduction potential of cannabis vaping. Cannabis vaporizer use can reduce the emission of carbon monoxide, chronic respiratory symptoms, and exposure to several toxins while producing similar subjective effects and blood THC concentration compared with smoking cannabis, holding potential for harm reduction among habitual cannabis smokers. However, new cannabis users, regardless of method of administration of cannabis, may experience intense subjective effects and cognitive impairment with increased susceptibility to dependence. Hence, policy makers should consider limiting access to cannabis among young people and adopting strategies to reduce impaired driving under influence of cannabis. Future research should focus on impact of switching from cannabis smoking to dried herb vaping using cannabis vaporizers among chronic cannabis smokers, and long-term outcomes of medical cannabis vaping, and further explore association of vaping-associated lung injury with THC-containing e-liquids.

A Case Series of Electronic or Vaping Induced Lung Injury

Introduction: Since their introduction, electronic cigarette use has increased and was even proposed as an alternative to traditional tobacco use. Recently, a series of patients with acute respiratory failure due electronic cigarette, or vaping, associated lung injury (EVALI) in 2019 has been described which has largely been attributed to tetrahydrocannabinol (THC) containing vaporizer itself, as well as vitamin E acetate. Several case series have been published regarding the acute presentation, diagnosis and management. In addition to diagnosis and management of EVALI, we sought to describe potential long-term effects of lung parenchyma in these patients. Methods: A retrospective review was performed on 16 patients with clinically diagnosed EVALI at OSF St Francis Medical Center between August 01 2019 and February 1 2020. Relevant demographic and clinical data were collected in patients diagnosed with EVALI. Results: Of the 16 patients in the study the median age (IQR) age was 25.25 (20-29) and 94% were male. The predominant presenting symptoms were dyspnea (94%), cough (56%), nausea 63%), vomiting (63%), abdominal pain (50%), diarrhea (50%), and fever (63%). 2 (13%) patients required endotracheal intubation. Common features of computerized tomography (CT) scan were bilateral diffuse ground glass opacity (93%), septal thickening (53%), and subpleural sparing (47%). Bronchoalveolar lavage (BAL) was obtained in 3 patients and all demonstrated neutrophil predominance of 69% (56-90). One BAL was significant for hemosiderin laden macrophages. Post hospital follow up pulmonary function tests were obtained in 3 and 2 of these were significant for obstructive lung disease. Conclusions: In this case series of patients diagnosed with vaping associated lung injury, obstructive lung disease may be seen on pulmonary function testing and surveillance of these patients should occur regardless of duration.

Analysis of a Vaping-Associated Lung Injury Outbreak through Participatory Surveillance and Archival Internet Data.

The US Centers for Disease Control and Prevention alerted of a suspected outbreak of lung illness associated with using E-cigarette products in September 2019. At the time that the CDC published its alert little was known about the causes of the outbreak or who was at risk for it. Here we provide insights into the outbreak through analysis of passive reporting and participatory surveillance. We collected data about vaping habits and associated adverse reactions from four data sources pertaining to people in the USA: A participatory surveillance platform (YouVape), Reddit, Google Trends, and Bing. Data were analyzed to identify vaping behaviors and reported adverse events. These were correlated among sources and with prior reports. Data was obtained from 720 YouVape users, 4331 Reddit users, and over 1 million Bing users. Large geographic variation was observed across vaping products. Significant correlation was found among the data sources in reported adverse reactions. Models of participatory surveillance data found specific product and adverse reaction associations. Specifically, cannabidiol was found to be associated with fever, while tetrahydrocannabinol was found to be correlated with diarrhea. Our results demonstrate that utilization of different, complementary, online data sources provide a holistic view of vaping associated lung injury while augmenting traditional data sources.

Effect of Massachusetts House Bill No. 4196 on electronic cigarette use: a mixed-methods study

BackgroundElectronic cigarettes, or e-cigarettes, are devices that deliver nicotine-containing aerosol and were used by 2.8% of American adults in 2017. Many people who smoke cigarettes have used e-cigarettes for smoking cessation, and the general consensus among health providers is that while vaping is not harmless, it is less harmful than smoking. To try to reduce youth e-cigarette use, the Commonwealth of Massachusetts imposed a 75% excise tax on nicotine-containing vaping products and banned the sale of all flavored tobacco products, including combustible tobacco, effective June 1, 2020. This tax, like similar taxes in other states, aimed to reduce e-cigarette consumption. However, past research has found that e-cigarettes and cigarettes are economic substitutes, meaning that an increase in e-cigarettes prices may push more people who smoke e-cigarettes to smoke combustible cigarettes.MethodsTo determine the impacts of several events, such as the e-cigarette and vaping-associated lung injury (EVALI) outbreak and implementation of the Massachusetts e-cigarette tax, on e-cigarette and cigarette purchasing, we conducted an interrupted time-series analysis of year-on-year consumer purchasing data to impute changes in e-cigarette and cigarette purchasing in the Greater Boston area and the entire USA after several intervention points. We then surveyed a subset of people who used e-cigarettes to evaluate the plausibility that some e-cigarette consumers would travel out-of-state to purchase e-cigarettes.ResultsThe purchasing data indicated that there was no significant decrease in e-cigarette purchases in the Greater Boston convenience market after tax implementation. However, we found that e-cigarette purchases decreased significantly while cigarette purchases increased after several bans on e-cigarettes and numerous policy statements related to the EVALI outbreak. The survey results suggested that people who smoke e-cigarettes did not decrease their consumption after the implementation of the tax, but instead obtained e-cigarettes outside of Massachusetts.ConclusionThese results suggest that the Massachusetts flavor ban and tax did not reduce e-cigarette consumption in the Greater Boston area, and that messaging questioning the safety of e-cigarettes led to an increase in combustible cigarette use. This suggests the need for health authorities to reconsider how they communicate the relative risks of smoking and vaping.

CT Findings and Patterns of e-Cigarette or Vaping Product Use-Associated Lung Injury: A Multicenter Cohort of 160 Cases

Backgrounde-Cigarette or vaping-induced lung injury (EVALI) causes a spectrum of CT lung injury patterns. Relative frequencies and associations with vaping behavior are unknown.Research QuestionWhat are the frequencies of imaging findings and CT patterns in EVALI and what is the relationship to vaping behavior?Study Design and MethodsCT scans of 160 subjects with EVALI from 15 institutions were retrospectively reviewed. CT findings and patterns were defined and agreed on via consensus. The parenchymal organizing pneumonia (OP) pattern was defined as regional or diffuse ground-glass opacity (GGO) ± consolidation without centrilobular nodules (CNs). An airway-centered OP pattern was defined as diffuse CNs with little or no GGO, whereas a mixed OP pattern was a combination of the two. Other patterns included diffuse alveolar damage (DAD), acute eosinophilic-like pneumonia, and pulmonary hemorrhage. Cases were classified as atypical if they did not fit into a pattern. Imaging findings, pattern frequencies, and injury severity were correlated with substance vaped (marijuana derives [tetrahydrocannabinol] [THC] only, nicotine derivates only, and both), vaping frequency, regional geography, and state recreational THC legality. One-way analysis of variance, χ2 test, and multivariable analyses were used for statistical analysis.ResultsA total of 160 patients (79.4% men) with a mean age of 28.2 years (range, 15-68 years) with EVALI underwent CT scan. Seventy-seven (48.1%), 15 (9.4%), and 68 (42.5%) patients admitted to vaping THC, nicotine, or both, respectively. Common findings included diffuse or lower lobe GGO with subpleural (78.1%), lobular (59.4%), or peribronchovascular (PBV) sparing (40%). Septal thickening (50.6%), lymphadenopathy (63.1%), and CNs (36.3%) were common. PBV sparing was associated with younger age (P = .02). Of 160 subjects, 156 (97.5%) had one of six defined patterns. Parenchymal, airway-centered, and mixed OP patterns were seen in 89 (55.6%), 14 (8.8%), and 32 (20%) patients, respectively. Acute eosinophilic-like pneumonia (six of 160, 3.8%), DAD (nine of 160, 5.6%), pulmonary hemorrhage (six of 160, 3.8%), and atypical (four of 160, 2.5%) patterns were less common. Increased vaping frequency was associated with more severe injury (P = .008). Multivariable analysis showed a negative association between vaping for > 6 months and DAD pattern (P = .03). Two subjects (1.25%) with DAD pattern died. There was no relation between pattern and injury severity, geographic location, and state legality of recreational use of THC.InterpretationEVALI typically causes an OP pattern but exists on a spectrum of acute lung injury. Vaping habits do not correlate with CT patterns except for negative correlation between vaping > 6 months and DAD pattern. PBV sparing, not previously described in acute lung injury, is a common finding.

Impact of JUULing (JUUL e‐cigarette) on Central Hemodynamics and Arterial Stiffness

Introduction Growing e-cigarette market, impact of JUUL e-cigarettes on youth as well as the vaping-associated lung injury (VALI) led to much discussion on the potential benefits and risks of pods, JUUL devices, and conventional e-cigarettes compared with combustible cigarettes. Independent data are required assessing the effects of these products on cardiovascular surrogate parameters and cardiovascular risk. Therefore, we conducted a study addressing the effects on arterial stiffness of different nicotine delivery devices compared to combustible cigarettes. Methods We recruited for the first study 32 participants (15 active smokers and 17 active vapers) performing a total of 39 measurements before and 5, 15, and 30 minutes after participants smoked a combustible cigarette or vaped a JUUL e-cigarette. Measurements included peripheral and central blood pressures and parameters of arterial stiffness using a Mobil-O-Graph (IEM, Germany). Results Within the study we show an significant increase of peripheral systolic blood pressure, central blood pressure, and peripheral pulse in all three groups (each P < 0.05). Heart rate (HR) changes lasted significantly longer than blood pressure changes. In additions the augmentation index and pulse wave velocity increased in all three groups, and a multivariate analysis of variance showed that the increases were independent of systolic blood pressure, sex, age, device, and HR. Conclusion In conclusion, changes in blood pressure and arterial stiffness are similar after smoking and JUULing. These changes may be associated with an increased cardiovascular risk compared with no product use. However, a long-term follow-up evaluation of JUULing and a head-to-head comparison with conventional e-cigarettes as well as heated tobacco products are still needed.