niman Posted October 2, 2019 Report Share Posted October 2, 2019 none of our cases showed histologic evidence of exogenous lipoid pneumonia and no radiologic evidence thereof has been found2; this calls into question the diagnostic utility of identifying lipid-laden macrophages or performing oil red O staining on bronchioloalveolar lavage fluid as a marker of vaping-associated lung injury https://www.nejm.org/doi/full/10.1056/NEJMc1913069?query=featured_home Link to comment Share on other sites More sharing options...
niman Posted October 2, 2019 Author Report Share Posted October 2, 2019 Pathology of Vaping-Associated Lung Injury TO THE EDITOR: Figure 1.Histopathology of Acute Lung Injury Associated with Vaping. Despite the accumulating data on the clinical and imaging features of vaping-associated lung injury,1,2 its pathology is poorly understood. We reviewed lung biopsies from 17 patients (13 men; median age, 35 years [range, 19–67]), all of whom had a history of vaping (71% with marijuana or cannabis oils) and were clinically suspected to have vaping-associated lung injury. Presentation was acute or subacute in all cases, with bilateral pulmonary opacities; all but two patients presented in 2019. Eleven met the criteria for a “confirmed” diagnosis of vaping-related lung injury; the remaining six met the criteria for a “probable” designation. In all cases, histopathological findings showed patterns of acute lung injury, including acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia, usually bronchiolocentric and accompanied by bronchiolitis (Figure 1; also see the Supplementary Appendix, available with the full text of this letter at NEJM.org). No histologic findings were specific, but foamy macrophages and pneumocyte vacuolization were seen in all cases and may be useful diagnostic clues in an appropriate clinical context. Pigmented macrophages were sometimes present but were never a dominant feature. Neutrophils were often prominent, but eosinophils were rare and granulomas were not seen. In two cases, bronchioloalveolar lavage fluid was available and contained abundant foamy macrophages. Despite treatment with glucocorticoids and maximum supportive care, two patients with diffuse alveolar damage died. To date, few reports of vaping-associated lung injury have included histopathological findings. Our cases corroborate many of these descriptions and provide some preliminary insight into the pathogenesis of this injury. Much recent attention has been given to the possibility that vaping-associated lung injury may represent exogenous lipoid pneumonia.3 However, none of our cases showed histologic evidence of exogenous lipoid pneumonia and no radiologic evidence thereof has been found2; this calls into question the diagnostic utility of identifying lipid-laden macrophages or performing oil red O staining on bronchioloalveolar lavage fluid as a marker of vaping-associated lung injury, as has been proposed.3,4 The significance of this observation remains unclear, particularly in patients with a known vaping history; until more data accumulate, our observations suggest that this finding should be interpreted with caution, as it may simply be a marker of exposure and not necessarily a marker of toxicity. Although it is difficult to discount the potential role of lipid, we believe that the histologic changes instead suggest that vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown. Yasmeen M. Butt, M.D. Maxwell L. Smith, M.D. Henry D. Tazelaar, M.D. Laszlo T. Vaszar, M.D. Karen L. Swanson, D.O. Mayo Clinic, Scottsdale, AZ Matthew J. Cecchini, M.D., Ph.D. Jennifer M. Boland, M.D. Melanie C. Bois, M.D. James H. Boyum, M.D. Adam T. Froemming, M.D. Mayo Clinic, Rochester, MN Andras Khoor, M.D., Ph.D. Isabel Mira-Avendano, M.D. Mayo Clinic, Jacksonville, FL Aiyub Patel, M.D. UnityPoint Health, Peoria, IL Brandon T. Larsen, M.D., Ph.D. Mayo Clinic, Scottsdale, AZ[email protected] Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on October 2, 2019, at NEJM.org. 4 References 1.Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — preliminary report. N Engl J Med. DOI: 10.1056/NEJMoa1911614. Free Full Text Google Scholar. opens in new tab 2.Henry TS, Kanne JP, Kligerman SJ. Imaging of vaping-associated lung disease. N Engl J Med. DOI: . Free Full Text Google Scholar. opens in new tab 3.Maddock SD, Cirulis MM, Callahan SJ, et al. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. DOI:. Free Full Text Google Scholar. opens in new tab 4.Davidson K, Brancato A, Heetderks P, et al. Outbreak of electronic-cigarette–associated acute lipoid pneumonia — North Carolina, July–August 2019. MMWR Morb Mortal Wkly Rep 2019;68:784-786. Crossref. opens in new tab Medline. opens in new tab Google Scholar Link to comment Share on other sites More sharing options...
niman Posted October 2, 2019 Author Report Share Posted October 2, 2019 Lung Damage From Vaping Resembles Chemical Burns, Report Says Doctors at the Mayo Clinic examined samples of lung tissue from 17 patients, all of which looked as if the people had been exposed to toxic chemicals, the researchers said. Image Four examples of severe vaping-related injury. In two of these cases, the patients died.CreditCreditLarsen et al., New England Journal of Medicine By Denise Grady Oct. 2, 2019Updated 5:19 p.m. ET The lung damage seen in some people who have become ill after vaping nicotine or marijuana products resembles a chemical burn, doctors from the Mayo Clinic reported on Wednesday. Their findings are based on samples of lung tissue from 17 patients around the country whose biopsy specimens were sent to Mayo to be examined under the microscope by experts in lung pathology. Two samples came from patients who died. “All 17 of our cases show a pattern of injury in the lung that looks like a toxic chemical exposure, a toxic chemical fume exposure, or a chemical burn injury,” said Dr. Brandon T. Larsen, a surgical pathologist at the Mayo Clinic in Scottsdale, Ariz. “To be honest, they look like the kind of change you would expect to see in an unfortunate worker in an industrial accident where a big barrel of toxic chemicals spills, and that person is exposed to toxic fumes and there is a chemical burn in the airways.” The findings were published on Wednesday in The New England Journal of Medicine. More than 800 cases of lung illness in 46 states have been linked to vaping, and 16 people have died. The majority have vaped THC, the psychoactive ingredient in marijuana, but some say they have vaped only nicotine. Medical investigators have been unable to identify exactly what is causing the lung damage, or even how many harmful substances are involved. They do not know whether the source is the liquids being vaped, or a toxin released from the materials used to make vaping devices. It is also unclear whether some devices used in vaping may be defective. Last Friday, the Centers for Disease Control and Prevention identified several names of THC-related products in prefilled cartridges that they said patients had reported using before becoming ill. Dank Vapes, Moon Rocks, Off White and TKO were among those listed by health officials who interviewed patients in Wisconsin and Illinois. But officials said they did not know if vaping illnesses or deaths in other parts of the country were related to the same THC labels identified in those two states. Officials also said that Dank Vapes was not an actual brand, but just a label and packaging that anyone selling THC vaping liquid could buy and stick on a product. The extensive use of prefilled THC cartridges suggests they might play an important role in the outbreak, the C.D.C. said. According to the C.D.C. report last week, of 771 patients nationwide in the outbreak, 91 percent had been hospitalized; 69 percent were male; and a little more than 60 percent were between the ages of 18 and 34. Of the 13 known deaths at the end of last week, the C.D.C. said that nearly 60 percent were of men, and the median age was 50 years old. Nebraska, Virginia and New Jersey reported deaths this week, bringing the total to 16. Many of the patients who died were older with underlying illnesses, although few details have been released in some states. https://www.nytimes.com/2019/10/02/health/vaping-illnesses.html Link to comment Share on other sites More sharing options...
niman Posted October 2, 2019 Author Report Share Posted October 2, 2019 In preferred embodiments, the tobacco or botanical is heated to about 300.degree. C. at most. In other preferred embodiments, the tobacco or botanical is heated to about 200.degree. C. at most. In still other preferred embodiments, the tobacco or botanical is heated to about 160.degree. C. at most. It should be noted that in these lower temperature ranges (<300.degree. C.), pyrolysis of tobacco or botanical does not typically occur, yet vapor formation of the tobacco or botanical components and flavoring products does occur. In addition, vapor formation of the components of the humectant, mixed at various ratios will also occur, resulting in nearly complete vaporization, depending on the temperature, since propylene glycol has a boiling point of about 180.degree.-190.degree. C. and vegetable glycerin will boil at approximately 280.degree.-290.degree. C. http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO2&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearch-bool.html&r=29&f=G&l=50&co1=AND&d=PTXT&s1=pax.ASNM.&OS=AN/pax&RS=AN/pax Link to comment Share on other sites More sharing options...
niman Posted October 2, 2019 Author Report Share Posted October 2, 2019 Vaping-related lung injuries resemble chemical burns, study finds By ANDREW JOSEPH @DrewQJoseph OCTOBER 2, 2019 RICHARD VOGEL/AP The airways and lungs of some patients with a vaping-related illness appeared damaged in ways similar to those exposed to chemical spills or harmful gases, researchers reported Wednesday. The study did not provide any clues as to the kind of chemicals that might be causing the condition, but the authors said signs of damage were consistent. “What all these appeared to represent was some sort of toxic chemical fume injury, or chemical burn if you will,” said Dr. Brandon Larsen, a pathologist at Mayo Clinic Arizona and senior author of the paper, which was published in the New England Journal of Medicine. The report — based on biopsies — did not find any evidence to back some earlier suggestions that lipids, or fats, inhaled through vaping might be a possible contributor to the condition. The findings could offer a potential new approach to identifying new cases. “We wanted to understand the spectrum of changes that can be seen so that we can help provide diagnostic criteria for pathologists in the laboratory who are seeing these biopsies and for clinicians who are sending biopsies to the lab,” Larsen said. Health officials have said that many people suffering from the condition have been vaping cartridges acquired from informal sources like dealers or friends. It’s possible that a contaminant or additive could be the culprit, though experts are still not certain that’s the case. More than 800 confirmed and probable cases of the injury have occurred in the United States, according to federal data released last week, with at least a dozen deaths linked to the illness. Biopsy images from patients with vaping-associated lung injury.THE NEW ENGLAND JOURNAL OF MEDICINE For the new report, Larsen and colleagues examined biopsies from 17 patients suspected of having or confirmed to have vaping-associated lung injury, two of whom died from the condition. About 70% of the patients said they had vaped marijuana, echoing survey data released last week by health authorities that found 87% of a group of patients had vaped THC products. In all of the 17 cases, the researchers found signs of pneumonitis — inflammation of the lungs — and damage to the airway and lung tissue, suggesting, they wrote, the condition might be caused by “one or more inhaled toxic substances.” https://www.statnews.com/2019/10/02/vaping-related-lung-injuries-resemble-chemical-burns-study-finds/ Link to comment Share on other sites More sharing options...
niman Posted October 2, 2019 Author Report Share Posted October 2, 2019 (edited) 'A direct, toxic chemical injury': What vaping does to the lungs Despite the recent surge in vaping-related illnesses, doctors suspect they've seen such ca A new study shows how vaping can lead to chemical injury in lung tissue. Andrew Kelly / Reuters file Oct. 2, 2019, 5:01 PM EDT By Erika Edwards Toxic chemical burns may be behind the hundreds of vaping-linked illnesses spiking across the country, according to new images of lung tissue taken from people who got sick after vaping. The images and resulting analysis from pathologists were published Wednesday in the New England Journal of Medicine. The findings provide a better understanding of what's actually happening to the lungs in these cases. They're also meant to give other doctors a frame of reference for what the vaping-related lung injuries look like under a microscope, as well as help in diagnosis. It looks like the kind of injury that we normally see when a person is exposed to a spilled drum of toxic chemicals at their workplace. "It looks like the kind of injury that we normally see when a person is exposed to a spilled drum of toxic chemicals at their workplace," said Dr. Brandon Larsen, an author of the study and a surgical pathologist at the Mayo Clinic in Scottsdale, Arizona. He and his team are often called upon to examine lung tissue for a second opinion, or in cases that have perplexed other physicians. These images of lung tissue show severe chemical injuries caused by vaping unknown substances. On the top right is a cross section of a small airway. The pink circular structure is the airway wall. Pathologists explain there should be nothing in the middle of that structure so air can flow easily. Instead, the image shows widespread inflammation and injury, inhibiting oxygen flow. The New England Journal of Medicine Larsen and colleagues examined lung biopsy samples from 17 patients with lung illnesses linked to vaping, a small portion of the 805 cases confirmed by the Centers for Disease Control and Prevention. But their sample is similar to what's seen nationwide: Most of the patients in the Mayo Clinic study were men, between the ages of 19 and 67. And nearly three-quarters had vaped marijuana or cannabis oil. Previous investigations suggested that an accumulation of oil in the lungs was to blame, and many patients were diagnosed with a condition called lipoid pneumonia. That occurs when inflammatory cells with abnormally high levels of fatty substances, called lipids, collect in the lungs. But the Mayo researchers found no evidence to suggest lipoid pneumonia, at least in those 17 cases. Related "What appears to be going on in the lung itself is a direct toxic chemical injury, like a chemical fume injury or a poisonous gas injury," Larsen told NBC News. Public health investigators looking into the cases nationwide haven't been able to pinpoint any single ingredient that would explain the type of chemical injury shown in the Mayo study. However, the CDC has reported that a majority of patients said they used products containing THC (marijuana's psychoactive ingredient), and many said they got those products from friends, dealers or elsewhere off the street. Many investigators suspect that counterfeit vapes play a role in the problem. Doctors are learning more about the mysterious illnesses in real time, as patients arrive at the hospital with symptoms: difficulty breathing, cough, fever, fatigue and sometimes vomiting and diarrhea. Recommended But although there's been a surge in cases in recent months, some clinicians say they've seen such illnesses in the past. Indeed, two of the patients in the Mayo study had fallen ill before 2019. "We’ve seen this before," said Larsen. "We just had so little experience with it before that we weren’t sure what we were looking at." Long-term consequences Most patients with vaping-related lung injuries are able to recover with steroids and/or supplemental oxygen. But some have succumbed to the illness. On Wednesday, Alabama health officials confirmed that a resident died from a vaping-related lung illness, the first in that state. That brings the total number of deaths so far to 17, nationwide. Deaths have also been reported in California, Florida, Georgia, Illinois, Indiana, Kansas, Minnesota, Mississippi, Missouri, Nebraska, North Carolina and Oregon. The person who died in North Carolina was actually a resident of Virginia, health officials said Tuesday. For those who survive the illness, it's unclear whether they will continue to have breathing difficulties. "We don’t know what the long-term consequences will be," Larsen said. "But I will not be shocked when we discover 20 years from now that some patients have chronic lung disease because they’ve been vaping." https://www.nbcnews.com/health/vaping/direct-toxic-chemical-injury-what-vaping-does-lungs-n1061151 Edited October 2, 2019 by niman Link to comment Share on other sites More sharing options...
Oct. 2, 2019, 5:01 PM EDT By Erika Edwards Toxic chemical burns may be behind the hundreds of vaping-linked illnesses spiking across the country, according to new images of lung tissue taken from people who got sick after vaping. The images and resulting analysis from pathologists were published Wednesday in the New England Journal of Medicine. The findings provide a better understanding of what's actually happening to the lungs in these cases. They're also meant to give other doctors a frame of reference for what the vaping-related lung injuries look like under a microscope, as well as help in diagnosis. It looks like the kind of injury that we normally see when a person is exposed to a spilled drum of toxic chemicals at their workplace. "It looks like the kind of injury that we normally see when a person is exposed to a spilled drum of toxic chemicals at their workplace," said Dr. Brandon Larsen, an author of the study and a surgical pathologist at the Mayo Clinic in Scottsdale, Arizona. He and his team are often called upon to examine lung tissue for a second opinion, or in cases that have perplexed other physicians.
niman Posted October 3, 2019 Author Report Share Posted October 3, 2019 Tonight at 11 PM ET Dr. Henry Niman PhDMajor New Development In The Vaping Emergency Link to comment Share on other sites More sharing options...
niman Posted October 3, 2019 Author Report Share Posted October 3, 2019 1 hour ago, niman said: Tonight at 11 PM ET Dr. Henry Niman PhDMajor New Development In The Vaping Emergency https://www.renseradio.com/listenlive.php Link to comment Share on other sites More sharing options...
niman Posted October 4, 2019 Author Report Share Posted October 4, 2019 On 10/2/2019 at 9:17 PM, niman said: Tonight at 11 PM ET Dr. Henry Niman PhDMajor New Development In The Vaping Emergency http://mediaarchives.gsradio.net/rense/special/rense_100219_hr3.mp3 Link to comment Share on other sites More sharing options...
niman Posted October 4, 2019 Author Report Share Posted October 4, 2019 On 10/2/2019 at 9:17 PM, niman said: Tonight at 11 PM ET Dr. Henry Niman PhDMajor New Development In The Vaping Emergency Link to comment Share on other sites More sharing options...
niman Posted October 18, 2019 Author Report Share Posted October 18, 2019 Tonight 11 PM ET Dr. Henry Niman PhDNEW Information About Vaping Crisis Possible Cause Coming Into Focus Link to comment Share on other sites More sharing options...
niman Posted October 18, 2019 Author Report Share Posted October 18, 2019 45 minutes ago, niman said: Tonight 11 PM ET Dr. Henry Niman PhDNEW Information About Vaping Crisis Possible Cause Coming Into Focus https://www.renseradio.com/listenlive.php Link to comment Share on other sites More sharing options...
niman Posted October 22, 2019 Author Report Share Posted October 22, 2019 (edited) Supplementary Table S1. Patient Demographics and Clinical Findings Age/Sex (Case #) Year Presenting Symptoms Duration of Symptoms At Time of Biopsy Medical History Occupational Exposures Smoking / Drug Use History Vaping History Serology/ Microbiology CDC Case Designation 44 M (#1) 2016 Acute presentation with 2-day history of hemoptysis and dyspnea 3 days None None Former tobacco smoker, 2.5 packyears Began vaping at the time of smoking cessation, 2 years before presentation Extensive serologic and infectious workup negative, ESR low Confirmed 42 M (#2) 2017 Acute hypoxic respiratory failure Approximately 1 week GERD, HTN Possible exposure to mold Former tobacco smoker, 20 packyears Started vaping to stop smoking approximately 1 year prior to presentation Unknown Probable 51 M (#3) 2019 Progressive subacute dyspnea and cough Approximately 4 weeks Obesity, asthma None Denied Vaping marijuana Infectious workup negative except for positive IgM for Mycoplasma pneumonia Probable 23 F (#4) 2019 Acute presentation with cough, myalgias, fever, nausea, vomiting, and respiratory failure eventually requiring intubation Acute, but further details unknown Anxiety, depression None Unknown Vaping THC for several months with tank style vaping device Infectious workup negative; positive ANA, elevated procalcitonin, and remaining serologic testing negative Confirmed 34 F (#5) 2019 Dyspnea and cough, progressing to acute respiratory failure requiring intubation 1 month Obesity None Unknown History of vaping, no details known Extensive serologic and infectious workup negative Confirmed 25 M (#6) 2019 Acute presentation with fever and cough, developed pneumomediastinum, highgrade fever, and respiratory failure requiring intubation. Acute, but further details unknown None Unknown Remote history of tobacco smoking History of vaping nicotine and mixing with cannabis oils Extensive serologic and infectious workup negative Confirmed 21 M (#7) 2019 Acute presentation with nausea, vomiting, fevers, night sweats, weight loss, progressive cough, pleuritic pain, and chest tightness 15 days IBD None Denied Vaping nicotine for 5 years; on weekend prior to presentation, started vaping nicotine with marijuana for the first time Extensive infectious workup negative; CRP 274, ESR 90, procalcitonin slightly elevated Confirmed 27 M (#8) 2019 Acute presentation with flu-like symptoms, fever of 40.6ºC, 2 days None None Former tobacco smoker Vaping cannabis daily Extensive serologic and Confirmed 22 nausea, vomiting, cough, and dyspnea progressing to respiratory failure requiring intubation infectious workup negative 38 M (#9) 2019 Acute respiratory failure, fevers, diarrhea, nausea, and vomiting Acute, but further details unknown Anemia, OSA None Denied Multiyear history of vaping with “heavy” use of CBD oil Extensive serologic and infectious workup negative Confirmed 34 F (#10) 2019 Acute presentation with dyspnea, fever, and suspected pneumonia treated with antibiotics without improvement; developed hypoxic respiratory failure requiring oxygen Acute, but further details unknown Anxiety None Denied “Heavy” vaping use over the past few months; vaping with cannabis Extensive serologic and infectious workup negative Confirmed 28 M (#11) 2019 Acute presentation with dyspnea Acute, but further details unknown Generalized anxiety disorder, opioid and ethanol use Unknown Denied tobacco smoking, but current marijuana smoker 1-year history of vaping 20-30 cartridges per day, also vaping THC Extensive serologic and infectious workup negative except for positive Aspergillus antibody in serum Probable 35 M (#12) 2019 Acute presentation with dyspnea and cough, with subsequent pneumothorax Acute, but further details unknown Previous admission months prior for respiratory failure, treated with steroids Unknown Former tobacco smoker, occasional marijuana smoking History of vaping for months previously and prior to present admission Unknown Probable 54 F (#13) 2019 Acute hypoxic respiratory failure with worsening dyspnea 2 weeks ADHD, anxiety, bipolar disorder, COPD, depression, diabetes, HTN, hepatitis C with cirrhosis Unknown Current tobacco smoker, 45 packyears History of vaping prior to presentation with nicotine and cannabis oil Negative respiratory viral panel, but other details unavailable Probable 67 M (#14) 2019 Subacute presentation with dyspnea and cough, rapidly progressing and requiring intubation. Acute, approximately 9 days None Unknown Current tobacco smoker History of vaping prior to presentation Extensive serologic and infectious workup negative Confirmed 19 M (#15) 2019 Acute presentation with abdominal pain, nausea, vomiting, and fever 4 days None Unknown Current marijuana smoker Vaping several times per week for several months, including cannabis oils Extensive serologic and infectious workup negative Confirmed 39 M (#16) 2019 Cough, dyspnea, night sweats, intermittent fevers, and fatigue 2 months Asthma None Remote tobacco smoker for 2 years; “Significant” vaping of non-nicotine ANA titer 1:40, remaining Confirmed 23 for 6 weeks current marijuana smoker products at time of presentation, further details unavailable serologic and infectious workup negative 40 M (#17) 2019 Worsening cough, myalgias, dyspnea, and fever for 1 week 1 week None Unknown Unknown Vaping for last 6 years, and vaping synthetic cannabinoids from “black market” for last 6½ months Cultures negative, serologic testing unavailable Probable ADHD, attention deficit hyperactivity disorder; ANA, Anti-Neutrophil Antibody; ANCA, Anti-Neutrophilic Cytoplasmic Antibody; CBD, cannabidiol; CDC, Centers for Disease Control and Prevention; COPD, chronic obstructive pulmonary disease; CRP, C-Reactive Protein; ESR, Erythrocyte Sedimentation Rate; GERD, Gastroesophageal Reflux Disease; HTN, Hypertension; IBD, Inflammatory Bowel Disease; OSA, obstructive sleep apnea; THC, tetrahydrocannabinol https://www.nejm.org/doi/suppl/10.1056/NEJMc1913069/suppl_file/nejmc1913069_appendix.pdf Edited October 22, 2019 by niman Link to comment Share on other sites More sharing options...
niman Posted October 23, 2019 Author Report Share Posted October 23, 2019 Tonight 9 PM ET Dr. Henry Niman PhDUpdate Major Developments in Vaping Crisis Link to comment Share on other sites More sharing options...
niman Posted October 23, 2019 Author Report Share Posted October 23, 2019 58 minutes ago, niman said: Tonight 9 PM ET Dr. Henry Niman PhDUpdate Major Developments in Vaping Crisis https://www.renseradio.com/listenlive.php Link to comment Share on other sites More sharing options...
niman Posted October 23, 2019 Author Report Share Posted October 23, 2019 (edited) 13 hours ago, niman said: Tonight 9 PM ET Dr. Henry Niman PhDUpdate Major Developments in Vaping Crisis http://mediaarchives.gsradio.net/rense/special/rense_102219_hr1.mp3 Edited October 23, 2019 by niman Link to comment Share on other sites More sharing options...
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