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Jackler RK, et al

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Of the 44 patients who received antibiotics: Azithromycin = 20 Amoxicillin-clavulanate = 6 Levofloxacin = 5 Doxycycline = 4 All patients respiratory symptoms progressed and required hospital admission Clinical Course: 93/98 patients required hospitalization Median duration of hospital stay = 6 days ICU admission for respiratory failure = 53% of patients Intubation = 26% Met Berlin criteria for ARDS = 12/25 (48% with average PaO2/FiO2 = 189mmHg No tracheostomies required 2 patients required ECMO 1 death Strengths: Thorough details provided about presenting symptoms, laboratory results, imaging results, and treatment using chart reviews and patient interviews First case series to describe a large cluster of temporally related pulmonary illnesses linked to the use of e-cigarettes A case definition of EVALI was developed and refined in coordination with the CDC Medical charts were reviewed with at least two reviewers per chart and discrepancies between reviewers were adjudicated by means of consensus IDPH performed near real-time pre-diagnosis surveillance by searching data sources from regional EDs that could provide early detection of a potential public health threat using the National Syndromic Surveillance Program Limitations : The paper is a case series, which inherently limits the conclusions that can be drawn Unfortunately, the bronchoalveolar lavage samples were not sent for mass spectrometry to determine if vitamin E acetate was present There is the potential for misclassification: patients may be reluctant to admit to using THC due to its legal status, so cases of recent vaping and/or vaping of THC may be underreported (recall bias) 43 patients received antibiotics and glucocorticoids prior to bronchoalveloar lavage which may alter the results of the samples This case series may represent more severe cases and may not give information on more mild clinical presentations as they typically do not come to the hospital Many patients did not have exhaustive negative findings on serologic tests for infectious causes, cultures, or molecular studies which means several patients may have been labelled EVALI, when in fact they had a different diagnosis Discussion: EVALI Case Definitions: Laboratory analysis conducted by the Food and Drug Administration identified vitamin E acetate in THC-containing e-cigarette products and testing by the CDC on clinical bronchoalveolar lavage samples have consistently identified this as well while vitamin E acetate is not identified in control samples