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Background and Aim: Sarcoidosis of the central nervous system (CNS) often presents deleterious effects on affected patients. Data and available literature discussing the diagnosis and treatment of this condition are scarce and inconsistent. In this study, we aim to shed light on demographics, management, diagnostics, and clinical complications of CNS sarcoidosis patients within the United States (US) based on a nation-wide registry questionnaire., Methods: Our retrospective study was conducted based on a national registry investigating 3,835 respondents to the Foundation for Sarcoidosis Research Sarcoidosis Advanced Registry for Cures Questionnaire (FSR-SARC). This national registry data was collected during the period of June 2014 to August 2019. We performed propensity score matching, summary, univariate, and multivariate analyses to establish a comparison between the presence and absence of central nervous system sarcoidosis., Results: We identified a total of 420/3634 (11.55%) patients having CNS sarcoidosis; 296 (70.5%) were females, 307 (73.1%) were Caucasian and 81 (19.3%) were African American. The mean (±SD) age at diagnosis of CNS sarcoidosis was 43.3 (±12) years old. Multiorgan involvement (≥3 organs) was present in 318/420 (75.7%) patients. Brain magnetic resonance imaging was the most common ancillary diagnostic modality used and reported to be abnormal 251/328 (76.5%). Corticosteroids were the most used treatment by CNS sarcoidosis patients 206/420 (49.0%) followed by cytotoxic agents 180/420 (42.9%)., Conclusions: CNS sarcoidosis prevalence in our cohort was similar to what has been described previously. The most prevalent imaging modality used was cranial MRI. Corticosteroids were the most used medications. Lastly, CNS sarcoidosis showed a propensity to cause several clinical complications such as chronic pain syndrome and disability.

Background: Heart failure (HF) and breast cancer are major health concerns with overlapping risk factors. This study investigated the impact of breast cancer on in-hospital mortality, length of stay, and health care charges in patients with HF., Methods: A retrospective cohort study was conducted using data from the National Inpatient Sample, focusing on female patients diagnosed with both breast cancer and HF. A control group of patients with HF without breast cancer was also analyzed. Main outcomes included in-hospital mortality, length of stay, and health care charges. Statistical analysis involved logistic and linear regression models., Results: The study included 17,551 unweighted cases of breast cancer, corresponding to 87,755 weighted cases. Breast cancer, particularly metastatic, was associated with increased in-hospital mortality across various types of HF. Patients with breast cancer and HF had longer hospital stays, which was more pronounced in metastatic cases. However, the impact on hospital charges was not consistent across the different HF types. Racial disparities were evident, with Native Americans showing the highest mortality risk in acute HF., Conclusion: Breast cancer significantly increases the in-hospital mortality risk and length of hospital stay in patients with HF. These findings highlight the need for integrated cardiovascular and oncological care, especially in the presence of metastatic breast cancer. The study underscores the importance of tailored management strategies for patients with HF with concurrent breast cancer and points toward the necessity for addressing racial disparities in health care., Competing Interests: The authors report no funding or conflicts of interests., (Copyright © 2024 Baylor University Medical Center.)

Background: Internal Medicine residents have historically expressed hesitancy in pursuing a career in pulmonary and critical care medicine (PCCM). However, recent studies have demonstrated newfound competitiveness. The coronavirus disease (COVID-19) global outbreak prompted the implementation of a virtual interviewing model for PCCM fellowship match. The effect of this new paradigm on PCCM match results has not been studied previously., Objective: With the shift to virtual interviewing, we aim to determine how this new method of interviewing may influence the selection of candidates for fellowship training programs., Methods: We acquired data of 4,333 applicants ranking PCCM for the years 2017-2021 from the National Resident Matching Program and the Electronic Residency Application Service websites for the years 2017-2021. Chi-square (χ 2 ) analysis of the applicants' demographics and the percentage of applicants matching at their first choice versus those who matched at lower than their third-choice program before and after the implementation of virtual interviews season was performed., Results: The matching probability for the U.S. Doctors of Osteopathic Medicine significantly increased after the implementation of virtual interviews compared with the years 2017-2020 (χ 2  = 8.569; P  = 0.003). The matching probability remained unchanged for U.S. Doctors of Medicine (χ 2  = 2.448; P  = 0.118). Overall, an applicant's probability of matching at their first choice has significantly decreased after the virtual interview format (χ 2  = 4.14; P  = 0.04). Conversely, the probability of matching at a program that is lower than the third choice has significantly increased (χ 2  = 11.039; P  < 0.001)., Conclusion: Our study provides evidence regarding the effect of the virtual interview format on PCCM match results. Strikingly, applicants are more likely to match at lower-ranked programs in their rank list after the implementation of the virtual interview process. These results can be helpful for both programs and applicants, to guide their future expectations and decisions while going through the interview process., (Copyright © 2024 by the American Thoracic Society.)

Obesity is reported to have a protective effect on mortality in pulmonary hypertension (PH), a phenomenon known as obesity paradox. However, the data are conflicting, with some studies showing decreased mortality while other studies found no effect of obesity on mortality. Therefore, we performed a systematic review and meta-analysis to examine whether there is an association between obesity and mortality in PH. Only patients with PH diagnosed by right heart catheterization were included. We also performed a sub-group analysis of subjects with pre-capillary PH only. A total of six studies met the inclusion criteria, with a sample size of 13,987 patients. Obese subjects had lower mortality compared to non-obese subjects in the combined pre- and post-capillary PH group (hazard ratio 0.79, 95% CI 0.66-0.95, p = 0.01). While obesity was associated with reduction in mortality in the pre-capillary PH group (hazard ratio 0.77, 95% CI 0.60 to 0.98, p = 0.03), this was not uniform across all studies.

Background and Aim: Cardiac sarcoidosis (CS) is the second most common cause of death in patients with sarcoidosis and data pertaining to its diagnosis and management is limited. We sought to describe diagnostic modalities and management of patients with CS in the United States, based on a national registry questionnaire., Methods: We conducted a retrospective study based on a national registry investigating 3,835 respondents to the Foundation for Sarcoidosis Research Questionnaire. The registry includes patient surveys completed between June 2014 and August 2019. Summary and univariate analyses were performed., Results: A total of 394 patients (10.3%) with CS were identified; 57% (n=223) were women and 81% (n=317) were white. The mean (±SD) age at diagnosis was 45 years (±13). CS was the initial presentation of sarcoidosis in 30%. Multiorgan involvement (≥3 organs) was present in 68%. Two-thirds of patients were admitted at least once to the hospital. Cardiac magnetic resonance imaging (74.4%) was the most common diagnostic modality used followed by positron emission tomography (PET) scan (59.3%) and cardiac biopsy (n=52, 13%).  Most patients received corticosteroids (86%) and steroid-sparing medications (61%) including methotrexate (26%) and tumor necrosis factor (TNF) inhibitors (19%). A combined cardioverter defibrillator and pacemaker (39%) was the most common cardiac device implanted., Conclusions: The prevalence of CS in this cohort was higher than previously described. CS was a common initial presentation of sarcoidosis. The diagnosis was most likely made using cMRI. Steroids, methotrexate and infliximab are the most common medications used. Conduction abnormalities and arrhythmias often occurred.

Background: Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) caused by an immunological reaction to repeated inhalational exposure to antigens. The etiology and exact immunopathology are poorly understood. Autoimmunity overlapping with HP has been described but the role of concomitant autoimmunity in the clinical course and outcome of the HP is not clearly established. In this study, we examined patients diagnosed with HP and compare them to patients with concomitant HP and autoimmunity., Methods: Patients were retrospectively screened from a single-center ILD registry. Patients > 18 years with an established multidisciplinary diagnosis of HP were included in the study. Patients with HP without autoimmune features and patients with HP with autoimmune features (HPAF) were assessed. We compared the demographics, clinical characteristics, treatment, and outcomes between the two groups. We used a Cox proportional hazards model to compare lung transplant-free survival outcomes of patients with HPAF to those with non-HPAF HP patients., Results: Of 73 patients with HP, 43 were diagnosed with HPAF. Patients with HPAF had a higher echocardiographic probability of pulmonary hypertension as compared to non-HPAF HP patients [48.8 vs 23.3%, p = 0.028, Crude odds ratio (cOR) = 3.14]. Symptomatically, those with HPAF reported a higher prevalence of arthritis as compared to non-HPAF HP (20.9 vs 3.3%, p = 0.040, cOR = 7.68). No significant differences between pulmonary function tests, oxygen requirements, mortality, and lung transplantation rates were found between the two groups. There was no statistically significant difference in transplant-free survival (p = 0.836)., Conclusion: Patients with HPAF had a higher echocardiographic probability of pulmonary hypertension as compared to patients with non-HPAF HP. The clinical characteristics and outcomes did not differ between the two groups and concomitant autoimmunity among the HP group did not portend a poorer prognosis., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: We aimed to determine the prevalence and clinical characteristics of self-reported hyperthyroidism in patients with sarcoidosis., Methods: A national registry-based study investigating 3836 respondents to the Sarcoidosis Advanced Registry for Cures questionnaire in the period between June 2014 and August 2019 was conducted. This registry is generated from a web-based questionnaire that is self-reported by patients with sarcoidosis. We compared patients with sarcoidosis who had hyperthyroidism with those who did not. We used multivariate logistic regression analysis to study the association between hyperthyroidism and different cardiac manifestations in patients with sarcoidosis., Results: Three percent of the study respondents self-reported having hyperthyroidism and were generally middle-aged Caucasian women. Compared with patients without hyperthyroidism, patients with hyperthyroidism had more sarcoidosis-related comorbidities (59% vs 43%, P = .001) and more steroid-related comorbidities (56% vs 44%, P = .01), but there was no difference in the sarcoidosis-specific treatments they received, which included corticosteroids. Patients with hyperthyroidism reported sarcoidosis involvement of the heart (26.6% vs 14.9%, P = .005), kidneys (14.9% vs 8%, P = .033) and sinuses (17.7% vs 10.2%, P = .030) more frequently. Cardiac manifestations that were more frequently reported in patients with hyperthyroidism included atrial arrhythmias (11.3% vs 6.3%, P = .046), ventricular arrhythmias (17.2% vs 7.5%, P < .001), congestive heart failure (10.4% vs 5%, P = .017), and heart block (9.4% vs 4.7%, P = .036)., Conclusion: Hyperthyroidism is infrequent in patients with sarcoidosis but is potentially associated with different cardiac manifestations. We suggest considering routine screening for hyperthyroidism in patients with sarcoidosis, especially in those with cardiac involvement. Further studies are needed to investigate the impact of identifying and treating hyperthyroidism in patients with sarcoidosis., (Copyright © 2022 AACE. Published by Elsevier Inc. All rights reserved.)

Background: Acute exacerbations of interstitial lung diseases (AE-ILD) have a high mortality rate with no effective medical therapies. Lung transplantation is a potentially life-saving option for patients with AE-ILD, but its role is not well established. The aim of this study is to determine if this therapy during AE-ILD significantly affects post-transplant outcomes in comparison to those transplanted with stable disease., Methods: We conducted a retrospective study of consecutive patients with AE-ILD admitted to our institution from 2015 to 2018. The comparison group included patients with stable ILD listed for lung transplant during the same period. The primary end-points were in-hospital mortality for patients admitted with AE-ILD and 1-year survival for the transplanted patients., Results: Of 53 patients admitted for AE-ILD, 28 were treated with medical therapy alone and 25 underwent transplantation. All patients with AE-ILD who underwent transplantation survived to hospital discharge, whereas only 43% of the AE-ILD medically treated did. During the same period, 67 patients with stable ILD underwent transplantation. Survival at 1 year for the transplanted patients was not different for the AE-ILD group versus stable ILD group (96% vs 92.5%). The rates of primary graft dysfunction, post-transplant hospital length-of-stay and acute cellular rejection were similar between the groups., Conclusion: Patients with ILD transplanted during AE-ILD had no meaningful difference in overall survival, rate of primary graft dysfunction or acute rejection compared with those transplanted with stable disease. Our results suggest that lung transplantation can be considered as a therapeutic option for selected patients with AE-ILD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Little is known about the association between sarcoidosis and lymphoma. We aim to determine the prevalence of lymphoma in US sarcoidosis patients and compare the clinical characteristics of patients with and without lymphoma., Methods: Using a national registry-based study investigating 3560 respondents to the Foundation for Sarcoidosis Research Sarcoidosis Advanced Registry for Cures Questionnaire (FSR-SARC) completed between June 2014 and August 2019, we identified patients who reported the diagnosis of lymphoma following sarcoidosis and randomly selected a computer-generated control sample of sarcoidosis patients with no reported lymphoma with a 2:1 ratio., Results: Among 3560 patients with sarcoidosis, 43 (1.2%) reported developing lymphoma following their sarcoidosis diagnosis. Patients with lymphoma were more likely to be diagnosed with sarcoidosis at a younger age (median, IQR) 40 (27-50) vs 45 (34.8-56, p = 0.017) years, were more likely to be African-Americans OR 95% CI 3.9 (1.6-9.6, p = 0.002), and have low annual income (OR 2.7, 1.1-6.4 p = 0.026). The sarcoidosis-lymphoma group were more likely to have salivary gland (16% vs 5%, p = 0.026) (OR 4; 1.1-14.5) and cutaneous (46% vs 23%, p = 0.023) (OR 2.9; 1.1-7.3) sarcoidosis. They also reported more chronic fatigue (42% vs 23%, p = 0.029), chronic pain (37% vs 13%, p = 0.001), and depression (42% vs 22%, p = 0.019)., Conclusion: The prevalence of lymphoma reported in sarcoidosis patients is higher than the general population which further supports the possible increased risk of lymphoma in sarcoidosis. Diagnosis of sarcoidosis at a younger age, African-American race, cutaneous, and salivary glands sarcoidosis were associated with lymphoma. Sarcoidosis patients who developed lymphoma reported higher disease burden and more non-organ-specific manifestations., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Little is known about the prevalence, clinical characteristics and impact of hypothyroidism in patients with sarcoidosis. We aimed to determine the prevalence and clinical features of hypothyroidism and its relation to organ involvement and other clinical manifestations in patients with sarcoidosis. We conducted a national registry-based study investigating 3835 respondents to the Sarcoidosis Advanced Registry for Cures Questionnaire between June 2014 and August 2019. This registry is based on a self-reported, web-based questionnaire that provides data related to demographics, diagnostics, sarcoidosis manifestations and treatment. We compared sarcoidosis patients with and without self-reported hypothyroidism. We used multivariable logistic regression and adjusted for potential confounders to determine the association of hypothyroidism with nonorgan-specific manifestations. 14% of the sarcoidosis patients self-reported hypothyroidism and were generally middle-aged white women. Hypothyroid patients had more comorbid conditions and were more likely to have multiorgan sarcoidosis involvement, especially with cutaneous, ocular, joints, liver and lacrimal gland involvement. Self-reported hypothyroidism was associated with depression (adjusted odds ratio (aOR) 1.3, 95% CI 1.01-1.6), antidepressant use (aOR 1.3, 95% CI 1.1-1.7), obesity (aOR 1.7, 95% CI 1.4-2.1), sleep apnoea (aOR 1.7, 95% CI 1.3-2.2), chronic fatigue syndrome (aOR 1.5, 95% CI 1.2-2) and was borderline associated with fibromyalgia (aOR 1.3, 95% CI 1-1.8). Physical impairment was more common in patients with hypothyroidism. Hypothyroidism is a frequent comorbidity in sarcoidosis patients that might be a potentially reversible contributor to fatigue, depression and physical impairment in this population. We recommend considering routine screening for hypothyroidism in sarcoidosis patients especially in those with multiorgan sarcoidosis, fatigue and depression., Competing Interests: Conflict of interest: B.N. Alzghoul has nothing to disclose. Conflict of interest: F.N. Amer has nothing to disclose. Conflict of interest: D. Barb has nothing to disclose. Conflict of interest: A. Innabi has nothing to disclose. Conflict of interest: M.T. Mardini has nothing to disclose. Conflict of interest: C. Bai has nothing to disclose. Conflict of interest: B. Alzghoul has nothing to disclose. Conflict of interest: T. Al-Hakim reports helping with the FSR-SARC registry design and enrollment. Conflict of interest: N. Singh reports helping with the FSR-SARC registry design and enrollment. Conflict of interest: M. Buchanan reports helping with the FSR-SARC registry design and enrollment. Conflict of interest: L. Serchuck reports helping with the FSR-SARC registry design and enrollment. Conflict of interest: D. Gomez Manjarres has nothing to disclose. Conflict of interest: W.W. Woodmansee has nothing to disclose. Conflict of interest: L.A. Maier reports being a nonpaid member of the Scientific Advisory Board of the FSR, and receives grant funding for research as a member of the FSR-Clinical Studies Network. She helped with the FSR-SARC registry design and enrolment. Conflict of interest: D.C. Patel has nothing to disclose., (Copyright ©The authors 2021.)

Background: When patients present with pleural effusion and structural abnormalities consistent with malignancy on imaging, the traditional approach has been to perform a thoracentesis and await the results before proceeding to more invasive diagnostic procedures. The objective of this study was to evaluate whether concurrent thoracentesis and tissue biopsy is superior to sequential sampling., Methods: Retrospective chart review was performed for patients who had a pleural cytology from May 2014 until January 2017. Patients without parenchymal, pleural, or mediastinal abnormalities and those with a prior primary thoracic malignancy were excluded. Patients with an effusion and additional suspect findings were grouped based upon whether initial approach was concurrent versus sequential. The following outcomes were documented: lag time to diagnosis from thoracentesis, lag time to hematology/oncology (HONC) service consult, time to molecular study results, lag time to therapy, and time to death., Results: Of 565 cases, 45 met criteria, 28 (62%) having undergone concurrent and 17 (38%) sequential sampling. The median lag time to biopsy for the concurrent group, 3 days, was significantly shorter than the 9-day lag time for the sequential group (P=0.006). Five patients in the sequential group and one in the concurrent group were lost to follow-up. Patients in the concurrent group had earlier diagnosis and oncology visits (2 d, 7 d) than those in the sequential group (6.5 d, 16 d) (P<0.001 and <0.039, respectively). Time from diagnosis to death did not differ for the 2 groups., Conclusion: For patients presenting with pleural effusion accompanied by additional suspect findings, concurrent tissue sampling, and thoracentesis may both reduce loss to follow up and accelerate care.

Introduction: Arteriovenous Pearson syndrome is a very rare multisystemic mitochondrial disease characterized by sideroblastic anemia and exocrine pancreatic insufficiency. It is usually fatal in infancy., Case Report: We reported a four-month-old infant presented with fever and pancytopenia. Bone marrow examination showed hypoplastic changes and sideroblastic features. Molecular Study showed a novel hetroplasmic mitochondrial deletions (m. 10760 -m. 15889+) in multiple genes (ND4,ND5,ND6, CYTB). In our patient the pathogenic mutation was 5.1 kb heteroplasmic deletions in multiple genes that are important and crucial for intact oxidative phosphorylation pathway and ATP production in the mitochondrial DNA. This mutation was not reported in literature including the mitomap.org website (which was last edited on Nov 30, 2017 and accessed on Jan 13, 2018).

Background Complicated parapneumonic effusions empyema (CPEE) is fairly common and associated with increased morbidity and mortality. The Multicenter Intrapleural Sepsis Trial 2 (MIST 2) established the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (tPA) as an effective treatment for CPEE, thereby avoiding surgery and decreasing the length of hospitalization. MIST 2, however, used a labor-intensive protocol with some risk of bleeding. We hypothesize the simpler regimen of concurrent administration of intrapleural tPA and DNase (lower dose of tPA and a higher DNAse dose) to be equally effective with a decreased risk of bleeding. Methods Retrospective analysis of the concurrent administration of intrapleural tPA and DNase for CPEE during November 2014 to February 2016 was done at a tertiary care center. The inclusion criteria included 1) pleural fluid with any of the following: (a) exudative and loculated effusion in a patient with pneumonia, (b) gram stain/culture positive, (c) macroscopically purulent 2) chest tube placement during current hospitalization 3) concurrent administration of intrapleural tPA and DNase (4mg and 10mg per instillation respectively). The exclusion criteria was 1) chest tube placement prior to current hospitalization and 2) age < eighteen. Results Seventeen patients received concurrent tPA and DNase therapy for CPEE in the study period. Two had chest tubes placed prior to current hospitalization and were excluded. Twelve patients (80%) were successfully discharged with clinical resolution of CPEE with medical therapy. One (7%) patient required surgery. No mortality due to pleural sepsis was noted. The median number of concurrent tPA and DNase treatment was two. Median cumulative tPA dose was 8 mg (mean: 14.1±17 mg) and median cumulative DNase dose was 20mg (mean: 19.7 ± 12.2 mg). The median dwell time for the chest tubes was 8.5 days. Our regimen had similar success when compared to MIST 2 and allowed for lesser treatments and cumulative doses. No complication of intrapleural therapy with hemorrhagic conversion of CPEE, or worsening pain leading to discontinuation of therapy was noted. Conclusion The concurrent administration of intrapleural therapy at lower doses than the current standard MIST 2 protocol is practical, efficient and effective. We suggest a higher DNase dose with a lower tPA dose which may further decrease hemorrhagic complications. Further randomized trials are required to establish the optimal dose of intrapleural therapy for CPEE., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Patients with Cystic Fibrosis (CF) have increasing rates of hospitalization. We analyzed the burden and predictors of thirty-day readmission among patients with CF in the U.S., Material and Methods: Nationwide Readmission Database (NRD) 2013 was used to identify adults with CF who were hospitalized. These individuals were followed to determine the prevalence of readmission within thirty days of index discharge. Cox proportional hazard regression was used to identify independent predictors of readmission., Results: There were 14,616 index admissions of adults with CF in 2013. Of these, 2,606 (17.8%) patients were readmitted within 30 days of discharge. Female sex and chronic anemia were independent predictors of readmission. The most common causes of readmission were pulmonary exacerbation (31%), lung transplant complications (5.2%), and septicemia (3.4%)., Conclusion: Readmissions are frequent among adults with CF and contribute to significant healthcare burden and cost among this population.

The incidence of lung abscess caused by Serratia marcescens is extremely low and is only reported in the immunocompromised population. We present a previously healthy woman with Serratia lung abscess in close proximity with an accessory cardiac bronchus. The patient was treated with appropriate antibiotics which led to complete resolution of the lesion. Our case highlights that individuals without medical co-morbidities may develop atypical lung infections like Serratia when associated with anatomic anomalies.

Background: Standard instructions for biopsy using the convex curvilinear endobronchial ultrasound scope include visualization and adjustment of the sheath housing the biopsy needle before every puncture. In our practice, we pre-set this relationship before inserting the endobronchial ultrasound scope and leave it fixed for every puncture., Objective: We postulated that this approach is more efficient than repeated re-adjustment and aimed to show that it would not increase the frequency of endobronchial ultrasound scope damage., Methods: Retrospective review of every biopsy using the endobronchial ultrasound scope over a 6-year period with documentation of damages and costs., Results: There were 15 scope damages out of 1792 procedures (0.8%). Eight damages were determined to be due to needle damage, one due to patient bite, three due to Williams airway abrasions, and three were camera failures. All damages occurred during the first 5 years of the study. Costs totaled US$138,725, for an average of US$23,120 per year. This rate of damages appears to be similar to or lower than that reported when standard instructions are followed., Conclusion: Pre-setting of the biopsy needle when the endobronchial ultrasound scope is used leads to greater efficiency and no increase in scope damages., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The use of e-cigarettes (ECs) is rising globally. There is concern that e-cigarette may actually lead to smoking, especially amongst adolescents., Objective: To perform a comprehensive review of literature reporting the longitudinal effects of e-cigarette use on onset of smoking among adolescents and young adults., Methods: A search was conducted using PubMed, Google Scholar, Scopus, and Web of Science in February 2016 to identify the studies containing data on EC use among adolescents and young adults (age<30 years). We then narrowed our search to only include longitudinal studies with data on EC and conventional cigarette smoking among this population., Results: Four longitudinal studies were identified that analyzed the use of ECs and smoking at both baseline and follow-ups in the target population. These studies demonstrated that EC use is associated with an increase in combustible cigarette smoking, even amongst the adolescents who were not susceptible to smoking., Conclusion: This review highlights the strong evidence that not only are ECs are not an effective tool for smoking cessation among adolescents, they actually are associated with higher incidence of combustible cigarette smoking. Policy makers need to recognize of the insidious nature of this campaign by the tobacco industry and design policies to regulate it.