Exclusion criteria were gastrointestinal and central nervous system manifestations without interstitial pulmonary involvement, ingestions of cannabinoids, duplicate visits, and if it was unclear whether vaping device was used or not. We used descriptive statistics to analyze the data. Median and interquartile range were calculated for continuous variables, and proportions were calculated with 95% confidence intervals for categorical variables. The study was approved by the Loma Linda University Institutional Review Board.We identified 16 encounters with the ICD-10 codes for EVALI during the one-year period. Using the exclusion criteria mentioned in the Methods section, we excluded seven patients. Four of these patients presented with CNS manifestations and vomiting without pulmonary involvement. In one patient, the history of vaping was unclear. One patient had ingested cannabinoids without vaping. Two encounters were excluded because they were duplicate visits. Of the seven patients included in the analysis, six were male. The median age was 16 years . The median weight in our series was 70 kilograms . The medians for vital signs recorded in the ED were the following: temperature of 100.2º Fahrenheit ; respiratory rate 24 breaths per minute ; oxygen saturation, 90% ; heart rate 130 beats per minute ; systolic blood pressure 128 millimeters of mercury ; and diastolic blood pressure 76 mm HG . Three patients had documented fever in the ED. The most common symptoms reported in our study were cough, shortness of breath, and vomiting, each occurring separately in five patients. Three patients presented with chest pain. Two patients presented with altered mental status in the form of unresponsiveness, with one patient requiring intubation. The other unresponsive patient, a 16-year-old male, returned to a normal mentation with bag-valve-mask ventilation and naloxone but required high-flow nasal cannula for shortness of breath. On physical examination, accessory muscle use was the most common finding, reported in four patients. Rales were appreciated in two patients,cannabis grow supplies while no patients were found to have wheezing . In our study, six patients presented with respiratory failure. Four required HFNC.

One patient was intubated; one patient required simple nasal cannula oxygen at two liters per minute; and one patient maintained normal oxygen saturations in room air during his ED visit and was discharged home. A brief clinical presentation, summary of findings on imaging, and type of respiratory support needed are summarized in Table 2. Five patients were admitted to the pediatric intensive care unit, and one patient was admitted to the normal pediatric unit. The median hospital length of stay was six days . All patients were discharged with no comorbidities or deaths reported. Six patients were treated with steroids. The median duration of treatment with steroids during admission and after discharge was nine days . Our patients had a variety of laboratory tests ordered. Most common were complete blood count, respiratory virus panel, respiratory cultures, and urine drug screen. All patients had a complete blood count, and the median for white cell count was 16 thousand cells per cubic millimeter .Respiratory cultures were collected from two patients and both resulted negative. A urine drug screen was performed for six patients and was positive for cannabinoids in all six . Three patients followed up at different intervals in the pulmonology clinic . Spirometry showed normal results in all three patients at that time. Case 1 followed up one week after discharge, at which time spirometry showed evidence of obstructive lung disease, which returned to normal at three-month follow-up visit. No repeat imaging was performed for that patient. Case 2 followed up six weeks after discharge with near-complete resolution of ground-glass appearance on repeat CT and normal spirometry. Case 4 followed up two weeks after discharge with improvement in lung opacities on repeat radiograph and normal spirometry. All three patients had received steroids for 10 days when they were originally diagnosed with EVALI. No follow-up data was available for the remaining four patients.EVALI was an emerging disease entity in 2019. In our case series, we describe adolescents diagnosed with EVALI and their clinical course in the ED and the hospital. In our study, the most common symptoms of cough, shortness of breath, and vomiting presented with an equal frequency of 71%. In a study by Layden et al, shortness of breath and cough was noticed in 85% of patients and vomiting in 61%; whereas, according to Belgaev et al, 90% of patients in their study presented with gastrointestinal and respiratory symptoms.

In a report by the CDC, 85% of the EVALI population had respiratory symptoms and 57% had GI symptoms.The results of our study are similar to previous literature in suggesting that respiratory and GI symptoms are common in patients with EVALI. According to Balgaev et al, 67% of patients had clinical and radiological improvement with residual findings on radiological and pulmonary function tests at time of followup.In our study, the three patients who had documented follow-up visits had normal spirometry without residual deficits. Only two of those patients had repeat imaging, and both showed improvement without residual abnormalities. E-cigarette liquids and aerosols have been shown to contain a variety of chemical constituents including flavors that can be cytotoxic to human pulmonary fibroblasts and stem cells.Exposure to heavy metals such as chromium, nickel, and lead has also been reported.None of our patients were tested for heavy metal exposure. Most of the delivery systems have nicotine in them, with one cartridge providing the nicotine equivalent to a pack of cigarettes.In addition to nicotine, e-cigarette devices can be used to deliver THC-based oils.According to Trivers et al, one-third of the adolescents who used e-cigarettes had used cannabinoids in their e-cigarettes.In our patients with EVALI, urinary drug screen was positive for cannabinoids in all patients. One caveat is that we do not know whether our patients used only THC-containing products or a combination of nicotine and THC-containing products. In our case series, the majority of patients presented with pulmonary disease requiring respiratory support and intensive care unit admission. None of these patients developed acute respiratory distress syndrome . We likely did not see this disease process due to our small sample size, as Layden et al reported ARDS development in several of their examined cases.In our series, we did not evaluate the pathologic pulmonary changes in different patients. In other case reports, different pathophysiologic patterns of pulmonary involvement, in the form of diffuse alveolar hemorrhage, exogenous lipoid pneumonia, acute eosinophilic pneumonia, or hypersensitivity pneumonitis have been identified.Although the mechanism of EVALI is not clearly understood, the CDC suggests the use of steroids for treatment.According to a series of patients in Illinois, 51% of those patients had improvement in symptoms after the administration of steroids.In another study, patients showed clinical and radiological improvement following the use of antibiotics and steroids.In our study, six patients received steroids and six patients received antibiotics; three of those patients followed up in clinics with normal spirometry. But this evidence is not sufficient to establish that use of steroids or antibiotics is beneficial in EVALI.

There are several limitations of our study. First, because it was a retrospective chart review we could not establish causation. Second,cannabis growing equipment all data may not have been recorded on all patients . We might have missed some if the ICD-10 codes were not correct on the chart. Only three had documented follow-up, so we don’t know whether the other four had any comorbidities after their hospitalization. Third, we had a small number of patients. Fourth, this was a single-center study; so results may not be generalizable to other hospitals with different patient demographics.A neurobiological model of risk-taking suggests that differential timing in the maturation of the brain networks associated with emotional processing and cognitive control may predispose adolescents to risky behavior, including alcohol and other substance use. Heavy alcohol use during adolescence has been shown to alter normative brain functioning, though it remains unknown whether alterations normalize with sustained abstinence or persist after cessation of use. The present study utilized fMRI to examine the effects of heavy alcohol use and short-term abstinence on adolescent neural functioning during a risky decision-making task. Heavy drinking adolescents and non-users completed three neuroimaging assessments, spaced two weeks apart . Adolescents abstained from alcohol and other substances for the duration of the study, confirmed through regular urinalysis screenings. During scanning, participants completed a modified Balloon Analog Risk Task to inflate balloons by entering a fixed number of “pumps”. Adolescents earned 1cent/pump unless the balloon popped according to a predetermined value; a higher pump number represented a riskier choice. Relevant neuroanatomical regions of interest were identified for each phase of decision making and between-group differences in blood oxygenated level dependent response were assessed at baseline. In addition, longitudinal analyses examined the main effects and interaction of Group and Time on BOLD response across the five-week period of abstinence.These differences were no longer evident at either follow-up time point. However, significant main effects of Group and interaction effects were observed in other regions. Overall, these findings highlight differential neural functioning during risky decision-making in heavy drinking adolescents and non-users. While group differences in BOLD response observed at baseline were no longer apparent after two weeks of abstinence, other differences persisted across a five-week period of sustained abstinence. This pattern of results suggests that alterations in neural functioning commonly observed in adolescent alcohol users may result from a combination of acute changes related to use as well as pre-existing vulnerabilities. Conversely, some brain functioning abnormalities may reverse after longer periods of abstinence. It is well established that adolescents are more likely to engage in risky behaviors compared to adults or younger children, and that rates of behaviors such as substance use, unsafe sexual activity, dangerous driving, and involvement in criminal activity emerge, increase, and peak during adolescence . Statistics from the Center for Disease Control and Prevention’s “Youth Risk Behavior Surveillance Survey” indicate that in 2011, 24% of adolescents in grades 9-12 knowingly rode in a car at least once with a driver who had been drinking alcohol, 22% of adolescents reported engaging in binge drinking activities , and of the 34% of adolescents who defined themselves as “sexually active,” 40% reported that they did not use a condom the last time they had sexual intercourse. Risk-taking is a complex and dynamic construct, yet not all adolescents are risk-takers. Studies have investigated individual differences in personality, sex, cognitive performance, and emotion regulation abilities, as well as complex socio-cultural influences in attempts to explain why some adolescents may be more likely to take risks than others. Recently, research has highlighted a neurobiological component that may underlie the trajectory of risk-taking commonly observed during adolescent development . This explanatory model derives from the rapidly changing nature of the adolescent brain, specifically in regions thought to play a role in risky decision-making and cognitive control.Alcohol use is a behavior that goes hand in hand with risk-taking; thus, it is no surprise that rates of alcohol consumption also rapidly increase during adolescence, with 65% of 12th graders endorsing some alcohol use over the past year, compared to only 29% of 8th graders. Self-reports of past-year “drunkenness” also increase by more than 30% between 8th and 12th grades, with 12% of 8th graders and 44% of 12th graders endorsing this behavior . Heavy episodic drinking is common among this age group, with 25% of high school seniors reporting at least one binge drinking episode within the past two weeks. In addition to increased binge drinking behavior, substance-related clinical disorders begin to emerge during adolescence, with 5% of youth ages 12 to 17 meeting diagnostic criteria for an alcohol use disorder . Cognitive decision-making capacity has been implicated as an important mechanism in the development of adolescent risk-taking behavior. Moore and Gullone define a “risky” behavior as “any behavior that involves potential negative consequences or loss, but is balanced in some way by perceived positive consequences or gain”. A behavior is considered more “risky” if the potential negative consequences outweigh the perceived positive consequences.