Wide pulse pressure and Quincke's pulse in high-output heart failure.

A 74-year-old man with a history of chronic alcohol use presented with progressive exertional dyspnoea and weight gain. On physical examination, he was noted to have wide pulse pressure, elevated jugular venous pressure, and alternating flushing and blanching of the nail beds in concert with the cardiac cycle, known as Quincke's pulse. Transthoracic echocardiography demonstrated normal biventricular systolic function and valvular function, but noted a dilated inferior vena cava. Right heart catheterisation revealed elevated filling pressures, high cardiac output and low systemic vascular resistance, consistent with high-output heart failure. Whole blood concentration of thiamine was low, confirming the diagnosis of wet beriberi. The patient abstained from alcohol use and was started on thiamine replacement therapy, resulting in narrowing of the pulse pressure over time and complete resolution of symptoms without the need for diuretic therapy.

Aseptic abscess syndrome.

A 43-year-old woman with Crohn's disease was admitted to the hospital with weight loss and 1 week of fever, abdominal pain and diarrhoea. At presentation, the patient was not on steroids or other immunosuppressive agents. Cross-sectional imaging of the abdomen revealed active colitis and multiple splenic and hepatic abscesses. All culture data were negative, including aspiration of purulent material from the spleen. Despite weeks of intravenous antibiotics, daily fever and abdominal pain persisted, the intra-abdominal abscesses grew, and she developed pleuritic chest pain and consolidations of the right lung. The patient was ultimately diagnosed with aseptic abscess syndrome, a rare sequelae of inflammatory bowel disease. All antimicrobials were discontinued and she was treated with high-dose intravenous steroids, resulting in rapid clinical improvement. She was transitioned to infliximab and azathioprine as an outpatient and repeat imaging demonstrated complete resolution of the deep abscesses that had involved her spleen, liver and lungs.

Facial protection for healthcare workers during pandemics: a scoping review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to personal protective equipment (PPE) shortages, requiring mask reuse or improvisation. We provide a review of medical-grade facial protection (surgical masks, N95 respirators and face shields) for healthcare workers, the safety and efficacy of decontamination methods, and the utility of alternative strategies in emergency shortages or resource-scarce settings. METHODS: We conducted a scoping review of PubMed and grey literature related to facial protection and potential adaptation strategies in the setting of PPE shortages (January 2000 to March 2020). Limitations included few COVID-19-specific studies and exclusion of non-English language articles. We conducted a narrative synthesis of the evidence based on relevant healthcare settings to increase practical utility in decision-making. RESULTS: We retrieved 5462 peer-reviewed articles and 41 grey literature records. In total, we included 67 records which met inclusion criteria. Compared with surgical masks, N95 respirators perform better in laboratory testing, may provide superior protection in inpatient settings and perform equivalently in outpatient settings. Surgical mask and N95 respirator conservation strategies include extended use, reuse or decontamination, but these strategies may result in inferior protection. Limited evidence suggests that reused and improvised masks should be used when medical-grade protection is unavailable. CONCLUSION: The COVID-19 pandemic has led to critical shortages of medical-grade PPE. Alternative forms of facial protection offer inferior protection. More robust evidence is required on different types of medical-grade facial protection. As research on COVID-19 advances, investigators should continue to examine the impact on alternatives of medical-grade facial protection.