Rapidly progressive empyema in the setting of vaping in an otherwise healthy patient.

Vaping is defined as inhaling and exhaling vapour that is a product of heating a liquid or wax-like material. Electronic cigarettes (e-cigarettes) have become a popular method of smoking in the last decade and are advertised as an alternative to conventional smoking. Since the increase in e-cigarette use, various lung injury patterns have started to appear among users. Recent studies have shown an increased susceptibility to respiratory tract infections among e-cigarette/vaping product users. We present a case of pneumonia caused by Pseudomonas fluorescens complicated by rapidly developing empyema in an otherwise healthy patient.

Mesalamine-induced eosinophilic pleural effusion.

A 45-year-old woman with a medical history of ulcerative colitis (UC) presented with difficulty in breathing. The patient was diagnosed with UC a month prior to presentation and was started on mesalamine suppository. Chest x-ray (CXR) on presentation showed bilateral pleural effusion, which was confirmed on CT angiogram of the chest. Diagnostic and therapeutic thoracentesis was performed and 0.7 L of pleural fluid was removed from the left side. The pleural fluid analysis was consistent with exudative pleural effusion with eosinophilia. Symptomatic improvement was noted after thoracentesis. Mesalamine was stopped and repeat CXR was obtained on the follow-up visit, which showed no pleural effusion. The Naranjo score was calculated to be 7, indicating that the eosinophilic pleural effusion was most probably secondary to adverse reaction from mesalamine.

When thyroid labs do not add up, physicians should ask patients about biotin supplements.

A 69-year-old woman with a remote history of Graves' disease treated with radioactive iodine ablation, who was maintained on a stable dose of levothyroxine for 15 years, presented with abnormal and fluctuating thyroid function tests which were confusing. After extensive evaluation, no diagnosis could be made, and it became difficult to optimise the levothyroxine dose, until we became aware of the recently recognised biotin-induced lab interference. It was then noticed that her medication list included biotin 10 mg two times per day. After holding the biotin and repeating the thyroid function tests, the labs made more sense, and the patient was easily made euthyroid with appropriate dose adjustment. We also investigated our own laboratory, and identified the thyroid labs that are performed with biotin-containing assays and developed strategies to increase the awareness about this lab artefact in our clinics.

Efficacy and safety of figure-of-eight suture versus manual pressure for venous access closure: a systematic review and meta-analysis.

BACKGROUND: Vascular hemostasis after venous access in cardiovascular procedures remains a challenge. Figure-of-eight (FoE) emerged as an alternative technique to manual pressure. However, its feasibility and safety is unknown. METHODS: A comprehensive search in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to December 1, 2018, was performed. A meta-analysis was performed using random effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI). RESULTS: Seven studies were eligible and included 1978 patients, of whom 982 patients received the FoE suture, while 996 received manual pressure. There was no difference in the risk of access site pseudoaneurysm (RR 0.48, 95%CI 0.13 to 1.73, p = 0.26) and fistula (RR 0.90, 95%CI 0.22 to 3.75, p = 0.89) between the two techniques. Compared with manual pressure, FoE was associated with lower risk of access site complications (RR 0.37, 95%CI 0.24 to 0.58, 0.65, p < 0.0001) including bleeding (RR 0.30, 95%CI 0.18 to 0.50, p < 0.00001) and hematoma (RR 0.41, 95%CI 0.25 to 0.68, 0.83, p = 0.0005). Time to hemostasis was significantly lower in FoE group compared with manual pressure (MD - 21.04 min, 95%CI - 35.66 to - 6.42, p = 0.005). CONCLUSIONS: The results of our meta-analysis showed that there was no difference in the risk of access site pseudoaneurysm and fistula between FoE and manual pressure. FoE was associated with lower risk of access site hematoma and bleeding compared with manual pressure. Our results reiterate the safety and feasibility of FoE suture for venous access closure.

The dilemma in the management of haemodynamically stable pulmonary embolism with right heart thrombus.

Right ventricular thrombus (RVT) can be life-threatening, since it has the potential to embolise and cause saddle pulmonary embolism (PE). We present a patient who initially presented with haemodynamically stable PE with evidence of RVT on echocardiogram. She was placed on heparin drip; however, she later developed cardiac arrest and died due to embolisation of RVT to the pulmonary vasculature. Although management of haemodynamically stable PE in patients with RVT is still a matter of debate, 1 given the outcome we suggest that thrombolysis or emergent embolectomy at the presentation, in this case, may have had a favourable outcome.

Delayed Presentation of Isolated Adrenocorticotropin Insufficiency after Nivolumab Therapy for Advanced Non-small-cell lung carcinoma (NSCLC).

We describe a 73-year-old man who developed adrenal insufficiency 7 months after completing nivolumab therapy for advanced non-small cell lung cancer. He presented with non-specific symptoms of malaise and fatigue with an insidious 13.6 kilogram weight loss, prompting an evaluation for disease progression, which was negative. Subsequent evaluation revealed isolated adrenocorticotropin insufficiency as the aetiology, attributed to a delayed side effect of nivolumab therapy.

Three-dimensional transthoracic echocardiographic identification of individual cusps of the pulmonary valve: Potential misidentification by the two-dimensional technique.

We demonstrate the incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional modality in the identification of all three cusps of the pulmonary valve in patients in whom only two leaflets could be detected by the latter technique. This was because of the ability of 3DTTE to view the cusps enface permitting assessment of relationship to one another and the surrounding cardiac structures. In addition, 3DTTE showed not only the potential errors that can occur in pulmonary valve cusp identification when the two-dimensional modality is used alone but also how some of these errors can be avoided by paying attention to the surrounding structures.