Alerting to the Dangers of E-Cigarettes

warning sign with e-cigarette

As the COVID-19 crisis unfolded this winter and spring, doctors warned that people with underlying health issues, particularly lung or pulmonary problems, were at much higher risk for serious illness or death should they come down with the virus.

Such warnings gave grim urgency to the work of Panagis Galiatsatos, the CIM Aliki Perroti Scholar, and his colleagues at Johns Hopkins’ Tobacco Treatment Clinic at Johns Hopkins Bayview Medical Center.

“We’re combating the one thing that kills more people than gun violence and opioid misuse combined,” says Galiatsatos, who is co-director of Medicine for the Greater Good, an important initiative of the Center for Innovative Medicine.

Indeed, smoking use causes more than 480,000 deaths per year in the United States, about one in five deaths annually, according to the U.S. Centers for Disease Control and Prevention. More than 16 million Americans are living with a disease caused by smoking.

In recent months, Galiatsatos has been campaigning tirelessly about the health consequences of electronic cigarettes in particular. “There is this misguided notion that e-cigarettes are a ‘safe’ alternative to traditional combustible cigarettes,” but that couldn’t be further from the truth, he says. “Our patients have no idea that e-cigarettes can cause refractory asthma or any pulmonary disease out there. They are coming into our clinic feeling like they have been duped. And they have been!”

“We’re combating the one thing that kills more people than gun violence and opioid misuse combined.” – Panagis Galiatsatos

E-cigarette use has seen a surge in popularity, particularly among younger generations, which has Galiatsatos and his colleagues very worried, for a number of reasons.

Top among those reasons: Since e-cigarettes are not regulated by the U.S. Food and Drug Administration, it’s impossible for Galiatsatos and other doctors to know just what their patients are inhaling.

This issue came most acutely to the fore last spring and summer, when hundreds of people who vaped suffered serious lung injury (and several dozen died) due to what was eventually discovered to be the injurious effects of vitamin E acetate.

The lack of regulation also makes it harder to counter nicotine addiction, says Galiatsatos. With traditional cigarettes, he says, “when a patient comes in who is addicted to nicotine, I’ll ask what brand they are smoking, and then I can figure out exactly how much tar, nicotine and other chemicals are in those cigarettes. We can create an individualized plan to help them manage their cessation efforts. But with e-cigarettes, all bets are off. I can’t tell them what chemicals they are dealing with, and it’s very difficult to develop a targeted treatment plan for their addiction. It’s like throwing antibiotics at a patient without knowing their infection.”

Galiatsatos also has growing concerns about the health risks of secondhand smoke from e-cigarettes. “In our clinic at Johns Hopkins, we have documented the first case of secondhand smoke from e-cigarettes causing pulmonary disease,” he says. The case study was published in March in The BMJ, and he hopes it will ring a warning bell in the medical community about a looming public health problem that is currently going relatively unnoticed.

Among high school students, the rate of e-cigarette use has grown at an alarming pace, with more than one in four students reporting that they use these products, according to preliminary results from the U.S. Centers for Disease Control and Prevention’s 2019 National Youth Tobacco Survey.

Reaching this audience – with accurate and compelling information about the risks of e-cigarette use and the dangers of secondhand smoke – is critical, says Galiatsatos. Toward that end, Medicine for the Greater Good has partnered with the American Lung Association and the Baltimore Breathe Center (also a part of Johns Hopkins Medicine) to create the Lung Health Ambassadors initiative for teens across the state.

This year, 341 students are participating in the program, at Armistead Gardens and Maree G. Farring elementary/middle schools in Baltimore City as well as Golden Ring Middle and Overlea High schools in Baltimore County. The program has also reached students in both St. Mary’s and Calvert county schools.

“We teach them that the only thing that should be going into their lungs is air. That can be really hard for them if they have family that smoke on a regular basis.” – Jocelyn Rubin

The Lung Health Ambassadors initiative uses hands-on projects in the classroom, such as constructing models of lungs from balloons, straws and tape, to show the consequences that e-cigarette use can have on the lungs. It also encourages students to raise awareness with their peers and families of the danger of e-cigarettes and trains them to manage peer pressure. Students participate in five one-hour sessions over the academic year, culminating with a graduation from the program.

“We teach them that the only thing that should be going into their lungs is air,” says Jocelyn Rubin, an M.S.N. Entry into Nursing Program student at Johns Hopkins. “That can be really hard for them if they have family that smoke on a regular basis. I think it’s brave of them to go back to their family members and share what they’ve learned. It’s exciting to know that they’re the ones who are going to make a difference.”

Galiatsatos is particularly excited about the peer-to-peer aspect of the Lung Ambassadors program. The students learn how to launch anti-vaping campaigns using social media and even podcasts. These and other communication efforts will be vital to stemming the tide of e-cigarette use, he says. “This epidemic is not something we can sit and expect public policy alone to handle, because it won’t,” says Galiatsatos.

“Just look at our history,” he says. “Cigarettes were first linked to lung cancer in 1964, but significant government restrictions on cigarette use did not occur until 1995. My heart will sink if a new generation of young people has their health robbed because we as physicians did nothing to stop the misinformation being thrown around. We need to act.”

In January, Galiatsatos was interviewed for a health information segment about e-cigarettes for Good Morning America, and he’s also been interviewed on CNN and CNBC.

That same month, the U.S. Food and Drug Administration issued a ban on fruit- and mint-flavored products used in e-cigarettes and vaping products, targeting companies that market to youth.

While buoyed by that move, Galiatsatos says that in the months ahead, he will continue to pursue every possible forum to push for better regulation of e-cigarettes and to communicate the health dangers they pose. “This,” he says, “is my passion.”

May 31st, 2020

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a book

The two dozen Johns Hopkins Bayview Medical Center department directors who gathered with David Hellmann for dinner in January welcomed an unusual companion to their mealtime discussion: Ivan Ilyich, a high-court judge from 19th-century Russia. Ilyich’s long and painful dying process, compellingly captured in Leo Tolstoy’s classic novella The Death of Ivan Ilyich, inspired a thought-provoking discussion among all those assembled.

The Death of Ivan Ilyich is such a powerful example of how a work of literature can cut through a lot of the facades of regular life and get right down to the heart of big questions: of life and death, of loss and suffering, of love and God, and of what’s truly important,” says David Wu, director of palliative care at Bayview, who was invited to lead the book discussion. “And it had the same effect on all of us there – cutting like a scalpel through what might have been a typical dinner conversation, and drawing us all into thinking and talking about these big, important questions.”

While the first portion of the Bayview directors’ dinner meeting, held twice a year, is devoted to departmental issues, it is the literary discussion that comes afterward that participants say they look forward to most. “For as long as I’ve been at Bayview, David has been doing this book discussion, and the wide selection of works we’ve discussed – poetry, history, fiction – always generates really fascinating discussion,” says Cynthia Rand, senior associate dean for faculty and a CIM Scholar.

With The Death of Ivan Ilyich, she says, “I was most struck that there seemed to be a hunger to be talking about the human and emotional side of death, and about what patients need, rather than just the clinical or medical side, which is often the focus of our daily work.” She adds, “This is a really smart and engaged bunch of leaders, and they’ve embraced the idea that they are more than just their jobs.”

“For as long as I’ve been at Bayview, David has been doing this book discussion, and the wide selection of works we’ve discussed – poetry, history, fiction – always generates really fascinating discussion.” – Cynthia Rand

Jamie Wright, chief of urology at Bayview and a Miller Coulson Academy member, notes: “There were real moments of vulnerability during the discussion. As the conversation developed, some people shared very personal stories, of caring for a dying parent in her final days, for instance.” He adds, “By offering us all a chance to get to know each other as people, the book club discussions have really enhanced our cohesiveness and spirit of collaboration.”

Wu concurs: “People were delving in deeply, and in order to do that with a group this size, there has to be a strong underlying trust, warmth and collegiality. That’s a culture that already exists in this group of leaders – and across Bayview, at large.”

May 31st, 2020

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New Hope for Serious Lung Conditions

illustration of lungs

By the time many patients find their way to Johns Hopkins pulmonologist Keira Cohen, they have seen doctor after doctor to treat their lung ailment, but they only seem to get sicker.

“Many of our patients have been misdiagnosed and mismanaged,” she says. “They have bounced from specialist to specialist and have almost gotten whiplash from the different messages and treatments they have received.”

The outlook for these patients has improved dramatically with the launch of a multidisciplinary center at Johns Hopkins – co-created by Cohen, fellow pulmonologist Mark Jennings and infectious diseases specialist Jonathan Zenilman, Lavinia Currier CIM Scholar – that is specifically aimed at managing and studying two lung conditions that doctors are seeing with more frequency: bronchiectasis and nontuberculous mycobacterial infections.

Nontuberculous mycobacteria (NTM) are a category of organisms occurring in the environment, such as in water and soil. In most people, these bacteria do not cause health problems, but in some cases, these bacteria can infect the airways and lung tissue or organs outside the lungs. It can take years and multiple antibiotics to clear the infection. While related to tuberculosis (TB), these infections are not thought to pass from person to person.

“We hear a lot about TB, but we have more than 10 times as many cases of NTM disease than TB cases in the United States these days,” says Cohen.

“We hear a lot about TB, but we have more than 10 times as many cases of NTM disease than TB cases in the United States these days” – Keira Cohen

Bronchiectasis, a scarring of the airways, can develop from multiple causes. If not managed well, bronchiectasis can lead to worsening lung function, repeated lung infections and increased hospitalizations. While patients with bronchiectasis are at risk for all sorts of infections, one that occurs frequently is NTM, which is why the new center focuses on both conditions.

Crucially, says Cohen, “when patients come to our multidisciplinary center, it’s a one-stop affair.” At the Friday morning clinic in Johns Hopkins Bayview Medical Center’s Asthma and Allergy Center, they’ll see a pulmonologist (Cohen or Jennings), an infectious disease specialist (Zenilman or Chris Lippincott) and a physical therapist knowledgeable about airway clearance techniques. The center’s nurse practitioner, Meghan Ramsay, sees patients in clinic, acts as a bridge between these different specialists and communicates closely with patients between visits. The center also works with a chest radiologist and has relationships with specialists in rheumatology, allergy and immunology, gastroenterology, and otolaryngology. The in-house Clinical Mycobacteriology Laboratory at Johns Hopkins, directed by Nikki Parrish, allows physicians to quickly and accurately assess test results.

“As a multidisciplinary team, we meet to come up with a unified treatment plan that is individualized according to the needs of each patient,” says Cohen, who notes that the center has been designated a Johns Hopkins Precision Medicine Center of Excellence.

“Even though we’re seeing more patients with these lung conditions, there’s so little known about these diseases, so we are striving to develop new and better diagnostic strategies and treatments. It’s truly bench to bedside.” – Keira Cohen

Many patients coming to the center have sustained lung damage over the years, making it difficult for them to naturally clear their lungs of mucus. So an important part of their treatment plan is to learn to use methods – such as devices that can be held by hand or strapped on to vibrate the chest, in conjunction with inhaled saltwater – to keep airways clear.

“I reassure our patients that it usually takes several months before they’ll feel comfortable using these new techniques. But once they do, it can make a dramatic improvement in their quality of life,”
says Cohen.

Research is a crucial element of the multidisciplinary center. “I’m very proud of the research program we have built in parallel with our clinical program,” says Cohen. “Even though we’re seeing more patients with these lung conditions, there’s so little known about these diseases, so we are striving to develop new and better diagnostic strategies and treatments. It’s truly bench to bedside.”

Patients who come to the clinic have the option to donate biospecimens (blood and mucus) to the team’s biobank and to have data from their medical chart added to an ever-growing database.

“We can look at patient outcomes in a truly rigorous way,” says Cohen. One goal, she says: “to see if we can determine blood-based predictors of who might respond better to a particular medication or treatment plan.”

“Our goal is to develop a standard benchmark of antibiotic efficacy to serve as a guide the development of new drugs for NTM, which are desperately needed.” – Keira Cohen

In her laboratory, Cohen investigates drug resistance mechanisms in NTM and blood-based biomarkers of NTM lung disease. One of the ultimate goals of her research is to improve diagnostic strategies for NTM. These research efforts dovetail nicely with those of others at Johns Hopkins with an interest in NTM. In particular, Gyanu Lamichhane, a basic science researcher in infectious diseases, has recently developed a novel mouse model to study NTM lung disease.

Moreover, patients treated at the center often have the option of joining one or more clinical trial for either NTM or bronchiectasis. “In addition to our translational research program, I’m very proud of one of our pilot clinical trials that will look at early bactericidal activity of azithromycin for Mycobacterium avium lung disease. Our goal is to develop a standard benchmark of antibiotic efficacy to serve as a guide the development of new drugs for NTM, which are desperately needed,” Cohen says.

Since the clinic opened in July 2018, the Johns Hopkins team has seen about 275 unique patients, “and our numbers are growing quickly, with people coming from all over the country,” says Cohen. Lippincott recently joined the clinic, which will make it possible to expand the number of patients who can be evaluated, she says.

Excited about what the future holds, Cohen says that the center never could have opened its doors in summer 2018 without crucial startup funding from David Hellmann and the Center for Innovative Medicine. “Dr. Hellmann’s support and enthusiasm for our program were instrumental to our opening and to our success today,” she says. “We couldn’t be more grateful.”

May 31st, 2020

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Celebrating ‘the Best of the Best’


Each spring since 2009, members of the Miller Coulson Academy of Clinical Excellence have come together to welcome a class of new members. This year, the restrictions surrounding COVID-19 prevented plans to gather as originally planned on March 27, at the 12th annual Excellence in Patient Care Symposium, sponsored by the Center for Innovative Medicine. “But that doesn’t diminish the extraordinary accomplishments of this talented class of new inductees,” says Scott Wright, director of the Miller Coulson Academy and holder of The Anne Gaines and G. Thomas Miller Professorship. “These are all doctors who are passionate about providing the very best in patient care, and it’s an honor to welcome them into the academy, which now numbers more than 80 strong.”

Miller Coulson Academy of Clinical Excellence: Class of 2020

Gail Berkenblit, M.D., Ph.D.
Department of Medicine, General Internal Medicine

Ed Bessman, M.D., M.B.A., F.A.A.E.M., F.A.C.E.P.
Department of Emergency Medicine

Brian Garibaldi, M.D., M.E.H.P., F.A.C.P., F.R.C.P.(E)
Department of Medicine, Pulmonary and Critical Care Medicine

Neda Gould, Ph.D.
Department of Psychiatry and Behavioral Sciences

Elisabeth Marsh, M.D., F.A.H.A.
Department of Neurology, Neurovascular

Leslie Miller, M.D.
Department of Psychiatry and Behavioral Sciences

Heather Sateia, M.D.
Department of Medicine, General Internal Medicine

B. Douglas Smith, M.D.
Department of Oncology, Hematologic Malignancies

Sumeska Thavarajah, M.D.
Department of Medicine, Nephrology

May 31st, 2020

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