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Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine : Anesthesia & Analgesia
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Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine
Rusy, Deborah A. MD, MBA, FASA*; Honkanen, Anita MD†; Landrigan-Ossar, Mary F. MD, PhD, FASA, FAAP‡; Chatterjee, Debnath MD, FAAP, FASA§; Schwartz, Lawrence I. MD‖; Lalwani, Kirk MBBS, FRCA, MCR¶; Dollar, Jennifer R. MD#; Clark, Randall MD, FASA‖; Diaz, Christina D. MD, FASA, FAAP**; Deutsch, Nina MD††; Warner, David O. MD‡‡; Soriano, Sulpicio G. MD‡
From the *Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
†Department of Anesthesia, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, California
‡Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
§Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
‖Department of Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
¶Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
#Pediatric Anesthesia Associates, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
**Department of Anesthesiology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
††Department of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, The George Washington School of Medicine and Health Sciences, Washington, DC
‡‡Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota.
Published ahead of print 29 March 2021.
Accepted for publication February 5, 2021.
Funding: None.
Reprints will not be available from the authors.
Address correspondence to Deborah A. Rusy, MD, MBA, FASA, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 CSC, 600 Highland Ave, Madison, WI 53792. Address e-mail to [email protected].
Anesthesia & Analgesia 133(3):p 562-568, September 2021. | DOI: 10.1213/ANE.0000000000005519
Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.
See Article, p 561
Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population.1,2 Vaping is a term referring to the inhalation of aerosols produced by a variety of devices that heat a liquid generally containing nicotine, flavoring, and various other chemicals. Other names for vaping devices, or electronic nicotine delivery systems (ENDS), include mods, vapes, subohms, vape pens, e-hookahs, tank systems, and e-cigarettes. Over 460 brands of vaping devices were described in an article published in 2014.3 They are marketed with the trendy names, such as GeekVape Aegis (Shenzhen, China), Baton V2 (Baton Vapor, Seattle, WA), Suorin Shine (Suorin USA, Brea, CA), Mango Ice (Vaporlax, Shenzhen, China), and Strawberry Ice (Tripl3, Ft. Mill, SC), and contain flavor additives targeting the appetites of children and teens.
These devices function through 4 key components, such as a container for the liquid solution, a heating element to vaporize the liquid, a power source, and a mouthpiece to channel the vapor to the user. They are often not only made to resemble a variety of traditional nicotine-producing products, such as cigarettes, cigars, and pipes, but also disguised in many everyday object designs, such as pens or memory sticks, enabling surreptitious use.
Vaping products may have significantly higher nicotine levels when compared to traditional cigarettes, and no consensus exists on how the strength of nicotine is reported on these products. Vaping liquid nicotine strength is often characterized as low (6–12 mg/mL), medium (18 mg/mL), and high (24 mg/mL). Products exceeding 24 mg/mL are also commercially available.4 In comparison, the average cigarette has 10–12 mg of nicotine.
Since 2014, e-cigarettes have become the most commonly used tobacco-based products among youth in the United States. E-cigarette use among the US middle and high school students increased by 900% during 2011–2015.5 Following a decline in use between 2015 and 2017, e-cigarette use again increased by 78% between 2017 and 2018.6 In 2019, an estimated 27.5% of high school students and 10.5% of middle school students reported using e-cigarettes within the past 30 days. Among those e-cigarette users, an estimated 34% of high school students and 18% of middle school students reported frequent use (20 or more days in the past 30 days), and 21% of high school students and 8.8% of middle school students reported daily use.7 JUUL (San Francisco, CA) was the most popular brand among the youth e-cigarette users. Seventy-eight percent of young users have seen a television advertisement for e-cigarettes.8 Furthermore, the use of flavored products, such as fruit, candy, and mint, has been successful in marketing to children and adolescents. Notably, 72% of high school students who vape and 59% of middle school students used flavored products.5 Children and adolescents are 3–4 times more likely to use these flavored substances than adults.9 Marijuana products are also becoming increasingly popular among students who vape. From 2017 to 2018, the reported prevalence of marijuana use in e-cigarettes among all students increased by 3.6%.10 Furthermore, youth who use e-cigarettes are more likely to use traditional cigarettes or other tobacco products. In a recent meta-analysis, adolescents and young adults who have used e-cigarettes are 3.6 times more likely to report subsequent cigarette smoking compared with those who have not.11
The addictive nature of e-cigarettes is at least equivalent to the addictive nature of conventional cigarettes, if not more.5 Multiple studies continue to confirm the increased risk of long-term nicotine use, including conventional cigarettes, in youth who use e-cigarettes. Nicotine is a central nervous system stimulant that activates the release of multiple neurotransmitters throughout the brain with subsequent positive mood–modulating effects.12 Adding to the risk of addiction, at least 1 study has determined that e-cigarettes are less irritating during use compared to the Food and Drug Administration (FDA)–approved nicotine inhalers for smoking cessation.13 The availability of enticing flavors for e-cigarettes in addition to less noticeable irritation with possibly higher inhaled nicotine levels makes these products much more attractive to youth and young adults leading to an increased risk of long-term nicotine addiction.
CLINICAL PRESENTATION OF E-CIGARETTE, OR VAPING, PRODUCT USE–ASSOCIATED LUNG INJURY
E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease caused by vaping. Initial clinical presentation of EVALI can be varied, but most commonly includes the respiratory and gastrointestinal tracts as well as constitutional symptoms. Respiratory symptoms frequently include hypoxia, tachypnea, shortness of breath, pleuritic chest pain, chest pain, occasionally hemoptysis, and cough. Many patients present with concurrent nausea and vomiting, abdominal pain, diarrhea, anorexia, and weight loss. Occasionally, patients present with gastrointestinal symptoms before noting any respiratory symptoms. Constitutional symptoms include fever, malaise, and fatigue.14–18 Patients may also present with headache, and 1 episode of seizures has been reported.15 The majority of patients present with respiratory symptoms, and respiratory failure can progress quickly and may even develop into acute respiratory distress syndrome (ARDS).19 Radiologic imaging generally demonstrates bilateral diffuse lung opacities on chest radiograph. Computerized tomography (CT) scan shows lower lobe predominant ground glass and consolidative opacities, often with subpleural space or lobular sparing. Pleural effusion is not common.20,21
As part of the diagnostic workup, some patients may undergo flexible bronchoscopy with bronchoalveolar lavage (BAL). BAL specimens have demonstrated the presence of neutrophils and lipid-laden macrophages.22 Bronchoscopy has demonstrated mucosal hypervascularity and erythema, edema, hemorrhage, and lesions in the airway.17 Flexible bronchoscopy with BAL and the associated anesthesia has led to the prolonged intubation and the progression of respiratory distress in patients and was noted to trigger an increased airway reactivity during the procedure.19 Some patients have also undergone either an open lung biopsy or a transtracheal lung biopsy as part of their diagnostic workup.23 While the mechanism of injury is not well defined, EVALI is considered a diagnosis of exclusion and infectious, oncologic, and rheumatologic etiologies need to be considered and ruled out.24
The treatment consisted of supportive therapy including supplemental oxygen, noninvasive ventilation, mechanical ventilation, and rarely extracorporeal membrane oxygenation (ECMO).14,19,22 Empiric antibiotics are typically administered during the diagnostic workup.14 EVALI is treated with vaping cessation and, when necessary, the initiation of a course of glucosteroids.14,17,23,25,26 The length and dose of steroid treatment are yet to be determined, as some patients have required a second course or hospital readmission.17,18
While most patients recover, a significant portion of patients identified with EVALI require hospitalization and treatment, and some patients have died as a result of the disease.27 Furthermore, EVALI patients who are older or with preexisting conditions are at a greater risk of death. Although there is a resolution of symptoms and CT scan findings in the patients who were followed up after discharge,26 2 other articles described persistent increased airway reactivity and impaired diffusion capacity on pulmonary function tests at 2- to 6-week follow-up.17,18 The Center for Disease Control published a comprehensive report of pulmonary histopathology from lung tissue from 23 individuals with a history of e-cigarette use.28 Acute to subacute lung injuries ranging from pneumonia to diffuse alveolar damage were noted in these specimens.
RISK FACTORS AND SUSPECTED CAUSES OF EVALI
Risk factors for EVALI are still undetermined. In a recent report on EVALI in Illinois and Wisconsin, the median age of patients was 21 years (range, 15–53), with 26% <18 years. The majority of patients had no underlying chronic lung disease, with the exception of asthma in 22%.14 Similarly, in a case series from Utah, nearly a quarter of patients who presented with EVALI had a history of asthma, bringing into question whether this is an association or whether those with asthma are predisposed to this form of lung injury.18
The more frequent use of vaping products is associated with EVALI as well, with 87% of patients reporting e-cigarette use 90 days prior in 1 study.28 In a survey conducted by the Illinois Department of Health, EVALI patients reported a higher incidence of frequent use (more than 5 times per day) compared to those who vaped and were not affected by EVALI.29
Pathologically, EVALI can present in many forms though the exact causative agents remain unknown. Identification of these agents is complicated by the fact that numerous compounds are often present in vaping mixtures, many of which are bought from the black market. In a recent evaluation of EVALI patients, most of the used products were obtained illicitly or informally (from friends and family members).30 Many patients are also not forthcoming with known information due to concerns that some of these agents are illegal in many states, further confusing the picture.
Tetrahydrocannabinol (THC)-containing products have most commonly been associated with EVALI nationwide, with 89% of affected patients having an exposure to THC in 1 cohort.28 Vitamin E acetate is also contained in THC-containing e-cigarette products. Its presence in the BAL samples of 94% of affected patients and complete lack of presence in control patients are highly suggestive of its association with interstitial lung injuries.31 However, nicotine alone has been associated with acute interstitial lung disease, including acute eosinophilic pneumonia, respiratory bronchiolitis-associated interstitial lung disease, and hypersensitivity pneumonitis.28,32
Propylene glycol, another agent commonly found in vaping products, activates irritant receptors, which have been shown to promote asthmatic inflammation and airway hyperreactivity. An in vitro study found that varying concentrations of some flavors, most notably vanillin and cinnamaldehyde, correlate with cytotoxicity and ciliary dysfunction.33 Interactions of these flavors with propylene glycol may form acetal compounds that have respiratory effects.34 Diacetyl, a compound previously used in the flavoring of popcorn, is also found in many e-cigarette flavors. It is known to cause bronchiolitis obliterans when inhaled, and this clinical presentation has been seen in some cases of EVALI.35 Other potentially toxic compounds linked to vaping and potentially EVALI include benzene, toluene, and trace metals.36 Ultimately, the cause of EVALI may be multifactorial. As vaping involves heating an e-liquid with the aforementioned solvents, there may be a production of new toxins that cause further inhalational burn injury.18,28
Fortunately, the number of EVALI cases has been rapidly declined because of its peak in the United States in September 2019.37 Contributing factors to this decline may include increased public awareness of the risk associated with THC-containing e-cigarette or vaping product use as a result of the rapid public health response, removal of vitamin E acetate from some products, and law enforcement actions related to the illicit products. Nonetheless, EVALI serves as a cautionary tale of the potential dangers of inhaling vapors and that both the short- and long-term effects of these vapors remain largely unknown.
ASSOCIATION OF E-CIGARETTE USE WITH NON-EVALI RESPIRATORY CONDITIONS
A cross-sectional study of 705,159 respondents from the 2016 and 2017 Behavioral Risk Factor Surveillance System pooled data reported that among e-cigarette users who were never combustible cigarette smokers, there was an associated 75% higher odds of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease compared with never e-cigarette users.38
Another large cohort study of 21,618 US adults demonstrated that e-cigarette use was associated with significantly increased risk of major respiratory diseases, independent of cigarette smoking, and other tobacco product use.39 Among current e-cigarette respondents with good self-reported health, the incidence rate ratio (IRR) was 1.33 (95% confidence interval [CI], 1.06-1.67) for chronic bronchitis, 1.69 (95% CI, 1.15-2.49) for emphysema, 1.57 (95% CI, 1.15-2.13) for chronic obstructive lung disease (COPD), and 1.31 (95% CI, 1.01-1.71) for asthma. The limitations of this study included a reliance on self-reported data. They concluded that despite existing evidence, the long-term effects of e-cigarette use on clinical respiratory end points remain unclear. As COPD is typically a disease that is evident after years of smoking, future studies, such as serial pulmonary function tests, may be needed to understand the full risk of e-cigarette–attributable lung disease, such as COPD.
COVID-19 PANDEMIC AND VAPING
Coronavirus disease 2019 (COVID-19) has not only wreaked havoc on global health but has also had an impact on the vaping community. A case series of adolescents who had symptoms consistent with COVID-19 but negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA test and respiratory viral panels revealed significant e-cigarette use by these individuals.40 A recent survey of individuals aged 13–24 years who vaped alone, or with smoking, were at 5 or 7 times increased risk, respectively, of a COVID-19 diagnosis compared with naive cohorts.41 This alarming finding underscores the need for vaping and smoking education, cessation, and adjustments in risk stratification in these doubly vulnerable individuals.42 During the COVID-19 pandemic, the reported use of e-cigarettes by youth changed due to diminished access to vape shops.43
PARALLELS BETWEEN E-CIGARETTES AND SMOKING TOBACCO
Studies have shown that cigarette smoking has been implicated as a risk factor for postoperative complications in many different surgical subspecialties. Patients who smoke and undergo surgery have longer hospital stays, a higher risk of readmission, a higher rate of being admitted to an intensive care unit, and an increased risk of in-hospital mortality in comparison to nonsmoking patients.44–47 Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications. A systematic review of 25 studies on the optimal timing of smoking cessation concluded that at least 4 weeks of abstinence from smoking reduced respiratory complications, and abstinence of at least 3–4 weeks reduced wound healing complications.48 A retrospective review of ambulatory surgeries demonstrated that smokers may be at a greater risk of postoperative complications, such as delayed wound healing, pulmonary complications, and mortality than nonsmokers.49
Smoking and vaping appear to be equally detrimental to wound healing and to be associated with a statistically significant increase in flap necrosis compared with the unexposed group. The results suggest that vaping should not be seen as a better alternative to cigarette smoking in the context of wound healing.50
E-cigarettes may have just as much of a detrimental effect on tissue oxygenation as traditional cigarettes. Thermal imaging has demonstrated that the use of ENDS reduced cutaneous blood flow in the peripheral circulation in humans.51 Despite the normal pulmonary function tests, asymptomatic patients with a daily use of e-cigarettes for at least 1 year had a significant ventilation–perfusion mismatching that worsen immediately after vaping.52 Studies suggest that subclinical alterations in the lung function in asymptomatic patients who routinely use e-cigarettes are usually not detected by routine spirometry.53 It is, therefore, not practical to perform preoperative pulmonary function tests in asymptomatic vapers.
IMPLICATIONS FOR PERIOPERATIVE MANAGEMENT
There is a clear evidence that demonstrates the benefits of preoperative and long-term postoperative smoking cessation. Smoking cessation discussions should be introduced early by patient's primary care provider; however, it is also imperative that this topic is discussed in both the surgical and anesthesia preoperative screening clinics.54–56 We recommend that screening regarding vaping use is done on all adolescents undergoing preoperative evaluations. A clear distinction between e-cigarette and cigarette use should be made during the preoperative interview. Nonthreatening and nonjudgmental queries into inhalant use that include nicotine and cannabis either through smoking or ENDS should routinely be obtained in this vulnerable patient group.
If suspected that a patient may have EVALI, preoperative workup should include a thorough history enquiring about smoking history including e-cigarette and vaping use, respiratory symptoms (eg, cough, chest pain, and shortness of breath), gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea), fever, chills, and weight loss. Physical examination should include vital signs and pulse oximetry, as these patients may present with tachycardia, tachypnea, and O2 saturation <95% at rest on room air. If respiratory symptoms are present, consider chest X-ray or chest CT scan.25 Consider consultation with a pulmonologist in patients with significant findings. The decision to perform bronchoscopy and BAL to rule out other diagnoses such as pulmonary infection should be made on an individual patient basis. A recent case series reported a significant intraoperative reactive airway disease and hypoxia and postoperative mechanical ventilation for respiratory failure in adolescents with EVALI.57 As noted earlier, the most severe cases may require the administration of steroids.17
For patients using e-cigarettes, or vaping products, consider referral to tobacco cessation strategy therapies. The Society for Perioperative Assessment and Quality Improvement recently published a consensus statement that promotes perioperative smoking cessation as a modifiable risk factor for improving overall patient outcomes.56 Although this document stated that "There is insufficient evidence to determine the safety and efficacy of e-cigarettes for perioperative smoking cessation," EVALI clearly places these patients at an increased risk of perioperative pulmonary morbidity. Therefore, clinicians should identify "at-risk" individuals during preanesthetic evaluations and determine the substance that they vape because chronic bronchitis is more prevalent with cannabis when compared to nicotine.58 Given the relatively recent introduction of e-cigarettes, and the lack of published reports of the intraoperative course of e-cigarette users, no current evidence is available to guide the intraoperative management of these patients. As the long-term impact on adolescent health is unknown, there is a paucity of postoperative outcomes in this vulnerable population to propose evidence-based recommendations for the management of these patients.
There is, to date, no evidence to justify extended postoperative monitoring for the patients with a history of vaping. Patients who use tobacco vaping products may be at risk for nicotine withdrawal in the perioperative period. Caregivers should be aware of the potential physical (headaches, sweating, restlessness, tremors, and digestive issues) and psychological (irritability, anxiety, and mood swings) symptoms and how to manage them.
The current epidemic of youth e-cigarette use and EVALI demand immediate and swift action by regulatory bodies at the state and national level to protect public health.59 Vaping products are inherently unsafe whether they contain THC or not. Both nicotine and marijuana affect brain development in young adulthood and serve to increase the likelihood of tobacco and cannabis use disorders later in life. Strategies to address these epidemics include adding vaping products to tobacco control strategies, additional restrictions on flavors, as well as youth and provider education and long-term surveillance of the health outcomes of EVALI. Given the addictive nature and potential detrimental health consequences of nicotine, THC, and e-cigarettes, it is the recommendation of these health organizations to prevent the habit of vaping and to advocate cessation of use to our patients. A recent web-based review of current e-cigarette prevention and cessation programs noted the lack of evidence-based tools, resources, and evaluations available to assess and inform adolescents about e-cigarette risks and cessation.60 We encourage continued research on the longitudinal effects of e-cigarette use on symptomatology, especially the early subclinical effects of vaping, and further postoperative outcome studies of patients who use vaping products. We also recommend limiting access of vaping products and nicotine-containing products to our youth. We encourage continued education of the public and health care providers of the risks associated with vaping and encourage regular screening of patients with regard to smoking and vaping use. Finally, we recommend that advertising of the e-cigarette products no longer be directed toward children and adolescents.
Name: Deborah A. Rusy, MD, MBA, FASA.
Contribution: This author helped research, write, and submit the manuscript.
Name: Anita Honkanen, MD.
Contribution: This author helped research and write the manuscript.
Name: Mary F. Landrigan-Ossar, MD, PhD, FASA, FAAP.
Name: Debnath Chatterjee, MD, FAAP, FASA.
Name: Lawrence I. Schwartz, MD.
Name: Kirk Lalwani, MBBS, FRCA, MCR.
Name: Jennifer R. Dollar, MD.
Name: Randall Clark, MD, FASA.
Name: Christina D. Diaz, MD, FASA, FAAP.
Name: Nina Deutsch, MD.
Name: David O. Warner, MD.
Name: Sulpicio G. Soriano, MD.
This manuscript was handled by: James A. DiNardo, MD, FAAP.
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40. Darmawan DO, Gwal K, Goudy BD, Jhawar S, Nandalike K. Vaping in today's pandemic: e-cigarette, or vaping, product use-associated lung injury mimicking COVID-19 in teenagers presenting with respiratory distress. SAGE Open Med Case Rep. 2020;8:2050313X20969590.
41. Gaiha SM, Cheng J, Halpern-Felsher B. Association between youth smoking, electronic cigarette use, and COVID-19. J Adolesc Health. 2020;67:519–523.
42. The Lancet Respiratory Medicine. The EVALI outbreak and vaping in the COVID-19 era. Lancet Respir Med. 2020;8:831.
43. Stokes AC. Declines in electronic cigarette use among US youth in the era of COVID-19—a critical opportunity to stop youth vaping in its tracks. JAMA Netw Open. 2020;3(12):e2028221.
44. Gaiha SM, Lempert LK, Halpern-Felsher B. Underage youth and young adult e-Cigarette use and access before and during the coronavirus disease 2019 pandemic. JAMA Netw Open. 2020;3:e2027572.
45. Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res. 1999;;367:172–180.
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48. Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59:268–279.
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50. Troiano C, Jaleel Z, Spiegel JH. Association of electronic cigarette vaping and cigarette smoking with decreased random flap viability in rats. JAMA Facial Plast Surg. 2019;21:5–10.
51. Page F, Hamnett N, Wearn C, Hardwicke J, Moiemen N. The acute effects of electronic cigarette smoking on the cutaneous circulation. J Plast Reconstr Aesthet Surg. 2016;69:575–577.
52. Kizhakke Puliyakote AS, Elliott AR, Sá RC, Anderson KM, Crotty Alexander LE, Hopkins SR. Vaping disrupts ventilation-perfusion matching in asymptomatic users. J Appl Physiol (1985). 2021;130:308–317.
53. Polosa R, Cibella F, Caponnetto P, et al. Health impact of e-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked. Sci Rep. 2017;7:13825.
54. Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg. 2009;96:451–461.
55. Warner DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology. 2006;104:356–367.
56. Wong J, An D, Urman RD, et al. Society for perioperative assessment and quality improvement (SPAQI) consensus statement on perioperative smoking cessation. Anesth Analg. 2020;131:955–968.
57. Helm C, Labovsky K, Thakrar PD, Diaz CD. E-cigarette, or vaping, product use-associated lung injury-lessons learned: a case series. A A Pract. 2020;14:e01242.
58. Braymiller JL, Barrington-Trimis JL, Leventhal AM, et al. Assessment of nicotine and cannabis vaping and respiratory symptoms in young adults. JAMA Netw Open. 2020;3:e2030189.
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60. Liu J, Gaiha SM, Halpern-Felsher B. A breath of knowledge: overview of current adolescent e-cigarette prevention and cessation programs. Curr Addict Rep. 2020;12:1–13.
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Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for...
Anesthesia & Analgesia133(3):562-568, September 2021.
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The claimant was represented by Kirt Westfall, Esq., Westfall & Rudnik, 59 Elm Street, New Haven, CT 06510.
The respondent was represented by Richard T. Stabnick, Esq., Pomeranz, Drayton & Stabnick, 95 Glastonbury Boulevard, Glastonbury, CT 06033-4412.
This Petition for Review from the February 4, 2000 Finding of the Commissioner acting for the Fifth District was heard August 25, 2000 before a Compensation Review Board panel consisting of Commissioners Robin L. Wilson, Leonard S. Paoletta, and George A. Waldron.
ROBIN L. WILSON, COMMISSIONER. The claimant has petitioned for review from the February 4, 2000 Finding of the Commissioner acting for the Fifth District. In that decision, the trial commissioner concluded that the claimant failed to sustain his burden of proof regarding his claim that a January 26, 1997 automobile accident arose out of and in the course of his employment. The claimant argues on appeal that the trier erred by dismissing his claim even though he found that the claimant was in an accident while driving his police cruiser while on duty. We find no error.
We will briefly review some of the facts in this case, noting that the trial commissioner made 82 findings of fact, after conducting fourteen formal hearings during which extensive evidence was presented by both parties. On January 26, 1997, and for approximately eight years prior thereto, the claimant was employed by the Police Department of the respondent employer, Borough of Naugatuck. On January 26, 1997, at approximately 1:46 a.m., the claimant while on duty was involved in an automobile accident when his police cruiser struck a tree on Wooster Street in Naugatuck. The claimant alleged that he was searching for a reported reckless driver when he failed to negotiate a sharp curve and struck a tree. The claimant further alleged that he lost consciousness following the impact with the tree. The respondents have not contested the fact that the accident occurred while the claimant was on duty on January 26, 1997; however, the respondents argued during the formal hearings that the accident could not have occurred in the manner presented by the claimant.
In his findings, the trial commissioner noted numerous contradictions in the evidence presented by the claimant, and concluded that the claimant's testimony regarding the accident was not persuasive. The claimant testified that while searching for the reported reckless driver, while coming up Maple Hill Road he saw a set of taillights at the crest of the hill, and that he radioed to the station that he was attempting to catch up to said vehicle. The claimant further testified that he was travelling 35 to 50 miles per hour on Wooster Street, even though said street is a very hilly and bumpy road. The claimant further testified that he was spotlighting intersecting streets and driveways, and that after spotlighting Whitney Place, he looked up, saw the tree and struck the tree. The police report indicates that the claimant reported that he was travelling at 45 to 50 miles per hour and that he attempted to take evasive action. The trial commissioner found persuasive the opinion of Sergeant McLay, who is experienced in accident reconstruction and has investigated approximately 2,500 accidents. He testified that if the accident occurred as the claimant reported, the vehicle would not have ended in the position it did with the damages it sustained, but rather would have ended up to the right of the tree.
The trial commissioner noted contradictions in the claimant's account by comparing the claimant's testimony during the formal hearings with a videotape film narrated by the claimant which retraces the events leading up to the accident. (See Finding ¶ 20). In addition, the trial commissioner found that the claimant was conscious at the accident scene, but feigned unconsciousness during tests administered by the paramedic. Findings ¶66-72.
Initially, we must remind the parties that our standard of review is limited. Specifically, "'The determination of whether an injury arose out of and in the course of employment is a question of fact for the trial commissioner.'" Kolomiets v. Syncor International Corp., 51 Conn. App. 523, 526 (1999), quoting Spatafore v. Yale University, 239 Conn. 408, 418 (1996). This board may not retry the facts, as the power and duty of determining the facts rests upon the commissioner. Id. The "conclusions drawn by [the commissioner] from the facts found must stand unless they result from an incorrect application of the law to the subordinate facts or from an inference illegally or unreasonably drawn from them." Kolomiets, supra, 526-27, quoting Kish v. Nursing & Home Care, Inc., 47 Conn. App. 620, 623 (1998).
The court in Kolomiets, supra, explained as follows: "It is an axiom of [workers'] compensation law that awards are determined by a two-part test. The [claimant] has the burden of proving that the injury claimed arose out of the employment and occurred in the course of the employment. . . . The former requirement relates to the origin and cause of the accident, while the latter requirement relates to the time, place and circumstance of the accident." Kolomiets, supra, 527-28, quoting Mazzone v. Connecticut Transit Co., 240 Conn. 788, 792-93 (1997). "To establish that [the] injury occurred in the course of employment, the claimant has the burden of proving that the accident giving rise to the injury took place '(a) within the period of employment; (b) at a place [he] may reasonably [have been]; and (c) while [he was] reasonably fulfilling the duties of the employment or doing something incidental to it.'" Kolomiets, supra, 528, quoting Mazzone, supra, 793.
In the instant case, the claimant argues that because the trial commissioner found that the automobile accident occurred on January 27, 1997 while the claimant was on duty, that therefore the accident must be deemed to have arisen out of and in the course of his employment. We disagree. As stated above, it is the claimant's burden to prove that the injury arose out of the employment and occurred in the course of the employment. Where a claimant fails to meet that burden, it is not incumbent upon the respondent to disprove the claim. See Adams v. Leisure Limousine, 4054 CRB-4-99-6 (Aug. 9, 2000). Rather, where a claimant contends that an accident occurred in a specific manner, and the trial commissioner finds the claimant's explanation to lack credibility, we cannot say that the trial commissioner must find the accident to be compensable merely because it occurred while the claimant was on duty. Certainly, in the instant case it is unclear whether the claimant met the third requirement of "in the course of" the employment provision, specifically we do not know whether the accident occurred while he was reasonably fulfilling the duties of the employment or doing something incidental to it. See Kolomiets, supra, 528.
Unlike a situation where a claimant falls from a ladder while working on a job site and is found unconscious by his co-workers, where a presumption may be made by a trial commissioner that the accident arose out of and in the course of the employment, here the circumstances of the accident are shrouded in mystery. The claimant was driving an employer's vehicle and could have been engaged in various activities which would cause a trial commissioner to conclude that he was not reasonably fulfilling the duties of the employment or doing something incidental to it. The trial commissioner was not required to reach this issue, however, because he did not find the claimant's testimony to be credible regarding how the accident occurred. As the claimant did not sustain his burden of proving a compensable injury, it was neither incumbent upon the respondents, nor upon the trial commissioner, to disprove the compensability of the accident.
Additionally, in deciding whether a claimant's injury arose out of and in the course of his employment, the trial commissioner may draw a reasonable inference from the facts found. Fair v. People's Savings Bank, 207 Conn. 535, 539 (1988). If said inference is supported by the evidence and not inconsistent with the law, it cannot be set aside on appeal by a reviewing tribunal, as it is a "finding of a primary fact." Id., 539-41. Here, the trial commissioner made numerous findings of fact regarding the claimant's motive to intentionally crash his police cruiser into the tree.
Specifically, the trial commissioner found that the claimant had previously threatened to "crash" his cruiser. Finding ¶ 27-30. Moreover, the trial commissioner made numerous findings regarding the fact that on January 24, 1997 (only two days prior to the accident) the claimant became aware that there was an internal investigation being conducted regarding the claimant's possible violations of police procedures. Indeed, the trial commissioner found that the claimant signed an internal investigation warning form on January 24, 1997; that a videotape showed the claimant making an unauthorized entry into the administrative offices of the Police Department; that the claimant was accused of attempting to enter restricted files in the computer system; and that the claimant was found guilty of these charges and terminated from his employment. Findings ¶ 21-24. The trial commissioner also made numerous findings regarding the speed and location of the vehicle at the time of the accident, concluding that the accident did not occur as the claimant alleged, but that the claimant was driving to the left of the center line and drove straight into the tree. Findings ¶ 58-65. Thus, the inference that the claimant's accident was intentional is amply supported by the evidence.
We recognize that a respondent has the burden of proving an affirmative defense such as wilful misconduct. Crochiere v. Board of Education, 227 Conn. 333, 356 (1993). In the case at hand, the respondents presented ample evidence to support the conclusion that the accident was intentional. We do not agree with the claimant's argument on appeal that the trial commissioner was prevented from concluding that the claimant's conduct was intentional on the basis that the respondents failed to specifically plead this defense during the hearing. Section 31-298 specifically provides that "no formal pleadings shall be required" during workers' compensation hearings. See also Diogostine v. Somers Thin Strip, 3 Conn. Workers' Comp. Rev. Op. 139, 282 CRD-5-83 (Jan. 22, 1987). Contrary to the claimant's arguments on appeal, it is clear upon review of the evidence offered by the respondents during the formal hearings that the respondents were contending that the accident was intentional.1 Indeed, during the formal hearings the parties specifically acknowledged that the issue presented was "did he run into the tree on purpose . . ." Nov. 12, 1997 Transcript p. 114.
Our review of the findings and of the record indicates that the trial commissioner reasonably inferred that the accident was caused by the claimant's intentional conduct, and because that inference is supported by the findings and by the evidence in the record, it must stand. See Fair, supra. Even without reaching the issue of whether the accident was intentional, it was within the trial commissioner's discretion to dismiss the claim on the basis that the claimant did not sustain his burden of proof that the accident occurred while he was reasonably fulfilling the duties of his employment or doing something incidental to it.
Commissioners Leonard S. Paoletta and George A. Waldron concur.


text:
Card Sharks: Is the ABC TV Series Cancelled or Renewed for Season Two?
(ABC/Eric McCandless)
Is everything aces? Has the Card Sharks TV show been cancelled or renewed for a second season on ABC? The television vulture is watching all the latest cancellation and renewal news, so this page is the place to track the status of Card Sharks, season two. Bookmark it, or subscribe for the latest updates. Remember, the television vulture is watching your shows. Are you?
What's This TV Show About?
An ABC game show from executive producers Scott St. John, Jack Martin, and Jennifer Mullin, Card Sharks is hosted by Joel McHale. Based on the card game Acey Deucey, two players face off on the series, each hoping to eliminate the other, with the goal of claiming a $10,000 cash prize and a chance for even bigger winnings. The winning contestant bets their prize on properly predicting the final seven cards of the game. The player's final prize is the amount of money remaining in the bank after all the predictions have been made and the results are revealed.
Season One Ratings
The first season of Card Sharks averaged a 0.60 rating in the 18-49 demographic and 3.35 million viewers. Find out how Card Sharks stacks up against other ABC TV shows.
O F F I C I A L S T A T U S
Card Sharks has been renewed for a second season which will debut (TBD). Stay tuned for further updates.
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Sign up for our FREE email alerts.
Telly's Take
Will ABC cancel or renew Card Sharks for season two? The numbers aren't great but I think they're good enough for a renewal. I'll update this page with breaking developments. Subscribe for free alerts on Card Sharks cancellation or renewal news.
11/20/19 update: ABC has renewed this and six other game shows for Summer 2020.
Card Sharks Cancellation & Renewal Related Links
TV show ratings are still important. Follow the weekly ups and downs.
Check the rankings for all of ABC's TV shows.
How do this show's ratings compare to other network TV shows?
Find more Card Sharks TV series news or other ABC TV show news.
Explore the ABC status page and other TV show status pages.
Check out our lists of already cancelled and ended TV shows.
What do you think? Are you glad the Card Sharks TV show has been renewed for a second season? How would you feel if ABC had cancelled this TV series, instead?
More about: ABC TV shows: canceled or renewed?, Card Sharks, Card Sharks: canceled or renewed?, Card Sharks: ratings
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Please bring a season 2.
Barbara A Kilcan
We really enjoyed Card Sharks, we hope to see season 2….please!
Cards sharks is a good show should be renewed is good for the summer and the host is funny
Horrible contestants! Clearly chosen on how "amp'd" they act, mug for cameras & chew scenery. It's fake, not interesting. I get the idea is for Joel to eye-roll about their annoying behavior. But irritating, over-acting contestants + sarcastic host who seems like he'd rather be somewhere else + an at-home audience who couldn't blame him, does not equal fun TV. P.S. – The "sound effect" when the first card is turned: WTF? At best it's like a deflating balloon, and at worst a suppressed fart. Like their "tension" background music, it doesn't add any drama or interest – it just… Read more »
Yes please renew
Card Sharks has great potential. Joel McHale seemed out of his element at first, but he will improve with time. I would like to see it have a Season 2. If they get a second season, here are a couple of changes I woke like to see: 1. In the Money Cards, getting the same card should result in a push where it won't count against you. 2. For anyone who busts, they should be given a cash prize of $2,000 for winning the main game. It would also serve as a consolation prize for losing on the Money Cards.… Read more »
there is a $10,000 prize for winning the main game already
Jill Brodnik
CANCEL It's stupid!

redpajama_set_name: RedPajamaCommonCrawl


text:
Phoenix Clark Sanders (born June 5, 1995) is an American professional baseball pitcher in the Baltimore Orioles organization. He made his MLB debut in 2022 for the Tampa Bay Rays.

Early life and amateur career
Sanders was born in Augsburg, Bavaria, Germany and grew up in Orlando, Florida. He attended Buchholz High School when his family moved to Gainesville, Florida in 2009. He was a member of the varsity baseball team in his final two years and won seven games with a 0.55 ERA as a senior.

Sanders began his college baseball career at Daytona State College after receiving no NCAA Division I scholarship offers out of high school. He played collegiate summer baseball for the Willmar Stingers of the Northwoods League after his freshman season and had a 1-0 record over three starts with a 1.89 ERA and 14 strikeouts. As a sophomore, Sanders made 16 appearances with 14 starts and went 6-6 with a 2.50 ERA and 71 strikeouts. After the season, he transferred to South Florida for his remaining collegiate eligibility. As a senior, Sanders was named second team All-American Athletic Conference after going 6-2 with a 2.78 ERA and 109 strikeouts over 16 starts.

Professional career

Tampa Bay Rays
Sanders was selected in the 10th round of the 2017 Major League Baseball draft by the Tampa Bay Rays. After signing with the team, he was assigned to the rookie-level Princeton Rays. Sanders began the 2018 with the Class-A Bowling Green Hot Rods, where he had a 3.02 ERA and struck out 71 batters in  innings over 28 relief appearances before being promoted to the Charlotte Stone Crabs of the Class A-Advanced Florida State League. He was assigned to the Double-A Montgomery Biscuits at the start of the 2019 season and was promoted to the Triple-A Durham Bulls after pitching in 37 games and posting a 3–3 record with a 1.81 ERA and 15 saves. He was invited to Rays' spring training as a non-roster invitee in 2020 but was eventually reassigned to the minor leagues. Sanders did not play in a game in 2020 due to the cancellation of the Minor League Baseball season because of the COVID-19 pandemic. He returned to Durham for the 2021 season and had a 5-2 record with a 3.38 ERA and 80 strikeouts in 64 innings pitched over 50 appearances.

Sanders was promoted to the Rays major league roster on April 14, 2022. He made his MLB debut the same day, giving up one earned run and striking out two batters in three innings pitched in a 3-6 loss to the Oakland Athletics. He was designated for assignment on August 22.

Baltimore Orioles
On August 24, 2022, Sanders was claimed off waivers by the Baltimore Orioles. On September 3, Sanders was designated for assignment and was sent outright to Triple-A.

References

External links

South Florida Bulls bio

1995 births
Living people
Baseball players from Gainesville, Florida
Bowling Green Hot Rods players
Charlotte Stone Crabs players
Daytona State Falcons baseball players
Durham Bulls players
Major League Baseball pitchers
Major League Baseball players from Germany
Montgomery Biscuits players
Peoria Javelinas players
Princeton Rays players
South Florida Bulls baseball players
Tampa Bay Rays players
Sportspeople from Augsburg

redpajama_set_name: RedPajamaWikipedia


Have you ever seen a Tibetan Mastiff? It's a huge dog that looks even bigger when next to a small child.
These beautiful animals can stand more than two feet tall and weigh up to 150 pounds. They are also fairly gentle creatures as you can see in the video. The big dog Simba is extremely patient with the young girl named Weiwei.
There's a part of me that fears for her safety should she do something to upset the dog, like pull on his ears or accidentally step on his head. He could probably swallow her whole if he wanted to, but he won't. Simba and Weiwei are best friends as you can tell.


If you are a spammer, stop reading and go kill yourself.
For the 10% of my readers who have a valid reason to research e-mail mailing lists, read on.
So as to not aid spammers, details will be left not exactly specific.
Note: email lists are no longer the hot topic on the web. Most people do not want to automatically become part of a mailing list, will not clearly remember when they get an email when they subscribed and why.
Any spreading of mass email must be done with adherence to local federal law, specifically the part about your recipients having an unsubscribe method, and complaint@, remove@, abuse@, postmaster@ mailboxes manned and processed. Also, you must clearly identify yourself.
You will not get into as much trouble if the list is an opt-in list, that users must actually check a checkmark to subscribe to. Of course, few people are interested in the lower subcription rate of such an option.
When choosing the program to send out mass e-mails, again, choose one that will comply with all of the regulations, with an unsubscribe option, one that watches bounces, etc. A third party paid solution like MailChimp or a program that you install on your server yourself like phplist should suffice.
This page was last modified on 27 June 2011, at 18:32.