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Stein J, Kay HE, Sites J, Pirzadeh A, Joyner BL, Darville T, Bjurlin MA, Rose TL, Jaspers I, Milowsky MI. Electronic cigarette, or vaping, product use-associated lung injury (EVALI) in a patient with testicular cancer: A case report. TUMORI JOURNAL 2023; 109:NP11-NP13. [PMID: 37165581 DOI: 10.1177/03008916231172806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Electronic cigarette, or vaping, product use-associated lung injury (EVALI) is an increasingly recognized entity with the potential for severe pulmonary toxicity. We present the case of a young man first evaluated at a tertiary care center in the United States in 2019 with newly diagnosed testicular cancer with acute respiratory failure, which was initially attributed to possible metastatic disease but eventually determined to be related to EVALI. This case highlights the clinical features of EVALI, the potential diagnostic dilemma that can arise with EVALI when occurring in the setting of malignancy and the importance of inquiring about vaping use among patients with malignancy, especially in adolescents and young adults.
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Affiliation(s)
- Jacob Stein
- Department of Medicine, Division of Hematology/Oncology, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Hannah E Kay
- Department of Urology, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Jeremy Sites
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Afsaneh Pirzadeh
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Benny L Joyner
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Toni Darville
- Department of Pediatrics, Division of Pediatric Infectious Disease, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Marc A Bjurlin
- Department of Urology, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Tracy L Rose
- Department of Medicine, Division of Hematology/Oncology, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Ilona Jaspers
- Department of Pediatrics, Division of Microbiology and Immunology, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Matthew I Milowsky
- Department of Medicine, Division of Hematology/Oncology, UNC Chapel Hill, Chapel Hill, NC, USA
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Clendennen SL, Rangwala S, Sumbe A, Case KR, Wilkinson AV, Loukas A, Harrell MB. Understanding college students' experiences using e-cigarettes and marijuana through qualitative interviews. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2023; 71:2848-2858. [PMID: 34871132 PMCID: PMC9178769 DOI: 10.1080/07448481.2021.1998073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/28/2021] [Accepted: 10/17/2021] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the contexts in which college students use e-cigarettes and marijuana, perceptions about the benefits and harms, and health effects of use. PARTICIPANTS College student e-cigarette and marijuana ever users (n = 20; 18-21 years old) from the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS). METHODS Participants completed a one-hour long online interview about their experiences using e-cigarettes and marijuana. Thematic content analysis in NVivo identified prominent themes. RESULTS Vaping nicotine and marijuana were preferred and perceived as normal, trendy and useful in circumventing smoke-free campus policies. Preference for nicotine versus marijuana fluctuates during the academic school year in response to campus restrictions and work and school-related activities. College students commonly experienced health effects (shortness of breath, wheezing) attributed to vaping, did not perceive their use as very harmful, and perceived their use as a college-related phase. CONCLUSIONS Findings have implications for college-based health education, resources, and smoke-free policies.
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Affiliation(s)
- Stephanie L. Clendennen
- Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in Austin, Austin, Texas, USA
| | - Shazia Rangwala
- Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in Austin, Austin, Texas, USA
| | - Aslesha Sumbe
- Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in Austin, Austin, Texas, USA
| | - Kathleen R. Case
- Center for Research to Advance Community Health (ReACH), UTHealth San Antonio, San Antonio, Texas, USA
| | - Anna V. Wilkinson
- Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in Austin, Austin, Texas, USA
| | - Alexandra Loukas
- Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas, USA
| | - Melissa B. Harrell
- Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in Austin, Austin, Texas, USA
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Rai S, Hormozdyaran S, Burns J, Amodio JB, Quizon AI. Diagnosis of EVALI in Adolescents During the COVID-19 Pandemic: A Case Series. Hosp Pediatr 2022; 12:538-543. [PMID: 35388412 DOI: 10.1542/hpeds.2021-006110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Electronic-cigarette or vaping use-associated lung injury (EVALI) is an illness that requires further awareness for appropriate diagnosis and management. This series is a retrospective chart review of EVALI cases admitted from June to December 2020 at a large academic children's hospital in New York. METHODS Notably during this time, the coronavirus disease 2019 (COVID-19) global pandemic rendered the world under strict quarantine mandates. We discuss 7 patients, all of whom were seen in a clinic, urgent care, or emergency department before presentation to our hospital. RESULTS Patients presented with respiratory, gastroenterology, and constitutional complaints typically seen with EVALI and COVID-19. However, given their complex presentations in the setting of the COVID-19 pandemic, EVALI was not considered as pertinent history was not elicited. CONCLUSIONS With the COVID-19 pandemic as a setting for these cases, we emphasize the importance of eliciting a complete psychosocial history for all adolescents because without vaping disclosure, EVALI will go undiagnosed. It is also imperative to ensure consistent outpatient follow-up, although difficult because of limited access or hesitation and fear of acquiring COVID-19 in health care settings during the pandemic, and to stress vaping cessation, both of which are crucial in preventing further complications.
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Affiliation(s)
| | | | | | - John B Amodio
- Pediatric Radiology, Cohen Children's Medical Center, New Hyde Park, New York.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Annabelle I Quizon
- Departments of Pediatrics.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Alampoondi Venkataramanan SV, George L, Sahu KK. Spontaneous Pneumorachis - A Case-Based Review. J Asthma Allergy 2021; 14:1539-1554. [PMID: 34955642 PMCID: PMC8694274 DOI: 10.2147/jaa.s325293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022] Open
Abstract
Pneumorachis is characterized by the presence of free air in the spinal canal. It is referred by different names in literature such as epidural emphysema, intraspinal air, intraspinal pneumoc(o)ele, spinal epidural and subarachnoid pneumatosis, spinal and epidural emphysema, aerorachia, pneumosaccus, air myelogram, etc. Pneumorachis can be broadly classified as traumatic, iatrogenic, or spontaneous. In this case-based review, we present a case of spontaneous pneumorachis secondary to asthma exacerbation. This is followed by a systematic review of all cases of spontaneous pneumorachis identified in PubMed. The aim of this review is to understand the pathophysiology, common causes and the management of spontaneous pneumorachis.
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Affiliation(s)
| | - Lovin George
- Department of Medicine, Saint Vincent Hospital, Worcester, MA, USA
| | - Kamal Kant Sahu
- Department of Hematology and Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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Lal A, Mishra AK, Akhtar J, Nabzdyk C. Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome. Monaldi Arch Chest Dis 2021; 91. [PMID: 33926176 DOI: 10.4081/monaldi.2021.1608] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/06/2021] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.
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Affiliation(s)
- Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Jamal Akhtar
- Department of Sleep Medicine, Montefiore Medical Center, Bronx, New York, NY.
| | - Christoph Nabzdyk
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN.
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A 23-year-old man with acute lung injury after using a tetrahydrocannabinol-containing vaping device: a case report. J Med Case Rep 2021; 15:70. [PMID: 33573662 PMCID: PMC7876532 DOI: 10.1186/s13256-020-02549-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022] Open
Abstract
Background Vaping-associated lung injury is a newly emerging disease process with the potential for serious health implications and high mortality, even despite the lack of underlying lung disease. We present a case of a young, otherwise healthy patient with tetrahydrocannabinol vaping-associated lung injury. Case presentation A 23-year-old Caucasian man with a past history of tetrahydrocannabinol vaping and benzodiazepine and methamphetamine abuse presented to the emergency department of our institution with a complaint of “feeling malnourished” over the past 5 days, along with associated fevers, cough, and vomiting. His past medical, surgical, family, and social histories were significant only for the recent use of marijuana vaping pens. Upon initial presentation, the patient appeared to be in significant respiratory distress. A computed tomographic scan of his chest demonstrated diffuse central predominant interstitial opacities, and he was admitted to the medical intensive care unit, where he was eventually intubated for hypoxic respiratory failure. No other cause of his respiratory failure was found, and it was ultimately believed that the patient had sustained a vaping-associated lung injury. Conclusion Tetrahydrocannabinol-containing vaping-associated lung injury is still poorly understood overall and is currently being investigated by the Centers for Disease Control and Prevention. In the meantime, physicians should consider vaping to be a public health emergency. We summarize the appropriate history, physical examination, appropriate workup, and therapies that physicians should be aware of in order to appropriately manage and treat patients presenting with suspected vaping-associated lung injury.
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Feldman R, Stanton M, Suelzer EM. Compiling Evidence for EVALI: A Scoping Review of In Vivo Pulmonary Effects After Inhaling Vitamin E or Vitamin E Acetate. J Med Toxicol 2021; 17:278-288. [PMID: 33528766 DOI: 10.1007/s13181-021-00823-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/28/2020] [Accepted: 01/05/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Vitamin E acetate (VEA) has come under significant scrutiny due to its association with E-cigarette or vaping product use-associated lung injury (EVALI). Various theoretical mechanisms have been proposed for toxicity, including tocopherol (vitamin E)-mediated surfactant damage, recruitment of inflammation, and pyrolysis of acetate to the pulmonary irritant ketene. OBJECTIVE Characterize studies in mammals evaluating inhaled VEA, vitamin E analogues, or pyrolyzed acetate that describe subsequent effects on the lung. ELIGIBILITY Research in all languages from time of inception to October 1, 2020, regarding mammals (human or animal) exposed to inhaled vitamin E analogues, or any compound containing acetate administered via inhalation after pyrolysis, and subsequent description of pulmonary effect. SOURCES OF EVIDENCE Ovid MEDLINE, Scopus, and Web of Science Core Collection. RESULTS In total, 786 unique articles were identified. After duplicate reviewer screening, 16 articles were eligible for inclusion. Tocopherol was evaluated in 68.8% (11/16) of the studies, VEA in 18.8% (3/16), and both VEA and tocopherol were evaluated in 12.5% (2/16). Of the five studies evaluating VEA, it was given by pyrolysis in 60.0% (3/5). No human studies were identified. All included trials were conducted on non-human mammals: 75.0% (12/16) rodent models and 25.0% (4/16) sheep models. Outcomes assessed were heterogeneous and included 57 unique outcomes. CONCLUSIONS Several questions still exist regarding the pulmonary toxicity of inhaled tocopherol and VEA. More studies are needed to determine whether tocopherol alone (i.e., without acetate) can cause pulmonary injury. Additionally, further studies of VEA should evaluate the impact that pyrolysis and co-administration with other compounds, such as tetrahydrocannabinol, have on the toxic potential of VEA.
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Affiliation(s)
- Ryan Feldman
- The Wisconsin Poison Center, Milwaukee, USA. .,School of Pharmacy, The Medical College of Wisconsin, Milwaukee, USA. .,Department of Emergency Medicine, The Medical College of Wisconsin, Milwaukee, USA. .,Department of Pharmacy, Froedtert Hospital, Milwaukee, USA.
| | - Matthew Stanton
- The Wisconsin Poison Center, Milwaukee, USA.,School of Pharmacy, The Medical College of Wisconsin, Milwaukee, USA.,Department of Emergency Medicine, The Medical College of Wisconsin, Milwaukee, USA.,Department of Pharmacy, Froedtert Hospital, Milwaukee, USA
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Anderson KR, Villafranco N, Hatzenbuehler Cameron L, Schallert EK, Joshi-Patel A, Arrington A, Dean A. A 16-Year-Old Boy With Cough and Fever in the Era of COVID-19. Pediatrics 2021; 147:peds.2020-008235. [PMID: 32788269 DOI: 10.1542/peds.2020-008235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 11/24/2022] Open
Abstract
A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.
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Affiliation(s)
- Kelsey R Anderson
- Baylor College of Medicine, Houston, Texas; and.,Texas Children's Hospital, Houston, Texas
| | - Natalie Villafranco
- Baylor College of Medicine, Houston, Texas; and.,Texas Children's Hospital, Houston, Texas
| | | | - Erica K Schallert
- Baylor College of Medicine, Houston, Texas; and.,Texas Children's Hospital, Houston, Texas
| | - Ashley Joshi-Patel
- Baylor College of Medicine, Houston, Texas; and.,Texas Children's Hospital, Houston, Texas
| | - Amy Arrington
- Baylor College of Medicine, Houston, Texas; and.,Texas Children's Hospital, Houston, Texas
| | - Andrea Dean
- Baylor College of Medicine, Houston, Texas; and .,Texas Children's Hospital, Houston, Texas
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E-Cigarette, or Vaping, Product Use-associated Lung Injury: A Response to Perez and Crotty Alexander. Ann Am Thorac Soc 2020; 17:907. [PMID: 32320262 PMCID: PMC7328172 DOI: 10.1513/annalsats.202002-138le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
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Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
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Sahu KK, Mishra AK, Lal A. Trajectory of the COVID-19 pandemic: chasing a moving target. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:694. [PMID: 32617314 PMCID: PMC7327313 DOI: 10.21037/atm-20-2793] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023]
Abstract
The spread of COVID-19 has already taken a pandemic form, affecting over 180 countries in a matter of three months. The full continuum of disease ranges from mild, self-limiting illness to severe progressive COVID-19 pneumonia, multiorgan failure, cytokine storm and death. Younger and healthy population is now getting affected than before. Possibilities of airborne and fecal oral routes of transmission has increased the concern. In the absence of any specific therapeutic agent for coronavirus infections, the most effective manner to contain this pandemic is probably the non-pharmacological interventions (NPIs). The damage due to the pandemic disease is multifaceted and crippling to economy, trade, and health of the citizens of the countries. The extent of damage in such scenarios is something that is beyond calculation by Gross Domestic Product rate or currency value of the country. Unfortunately, unlike many other diseases, we are still away from the target antiviral drug and vaccine for severe acute respiratory syndrome (SARS-CoV-2) infection. The prime importance of NPIs like social distancing, staying in home, work from home, self-monitoring, public awareness, self-quarantine, etc. are constantly being emphasized by CDC, WHO, health ministries of all countries and social media houses. This is time of introspection and learning from our mistakes. Countries like China and South Korea who were initially the most hit countries could contain the disease spread by liberal testing of their population, stringent quarantine of people under investigation and isolation of the positive cases. Rest of the countries need to act urgently as well to bring an immediate halt in the community transmission.
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Affiliation(s)
- Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ajay Kumar Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Amos Lal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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