There has been a significant increase in electronic cigarette (e-cigarette) use since its introduction in 2007. Ironically, there remains very few published literature on the respiratory complications of e-cigarettes. The use of personalized vaporizers or commonly known as “vaping” has started to overtake standard e-cigarette. Its dynamic vaporizer customization makes it challenging to assess long-term health effects. Case reports on the pulmonary complications of e-cigarettes are limited to bronchiectasis, eosinophilic pneumonia, pleural effusion, and suspected hypersensitivity pneumonitis. Diffuse alveolar hemorrhage (DAH) is bleeding into the alveolar spaces of the lung secondary to disruption of the alveolar-capillary basement membrane. We report a case of young male presenting with subacute respiratory failure. He was later found to have diffuse alveolar hemorrhage syndrome that is likely induced by aggressive vaping. This adds up to the rising concern on the possible serious complications of this innovative technology designed as a safer alternative to traditional cigarettes.

Rationale. The impact of emergency department length of stay (EDLOS) upon sepsis outcomes needs clarification. We sought to better understand the relationship between EDLOS and both outcomes and protocol compliance in sepsis. Methods. We performed a retrospective observational study of septic patients admitted to the ICU from the ED between January 2012 and December 2015 in a single tertiary care teaching hospital. 287 patients with severe sepsis and septic shock were included. Study population was divided into patients with EDLOS < 6 hrs (early admission) versus ≥6 hours (delayed admission). We assessed the impact of EDLOS on hospital mortality, compliance with sepsis protocol, and resuscitation. Statistical significance was determined by chi-square test. Results. Of the 287 septic ED patients, 137 (47%) were admitted to the ICU in <6 hours. There was no significant in-hospital mortality difference between early and delayed admissions (p = 0.68). Both groups have similar compliance with the 3-hour protocol (p = 0.77). There was no significant difference in achieving optimal resuscitation within 12 hours (p = 0.35). Conclusion. We found that clinical outcomes were not significantly different between early and delayed ICU admissions. Additionally, EDLOS did not impact compliance with the sepsis protocol with the exception of repeat lactate draw.

Every project in any aspect of the creative industry must start with an ideation process. The essence of this process is to allow rapid exploration of ideas with very little resource expenditure. For ideation to be successful an idea must be explorable in hours if not minutes. The tools that are used should be readily accessible to designers in the field. The video game industry is a production oriented industry and thus the majority of the technology in this industry has focused on production tools. Very little attention has been paid to the ideation stage in the game industry. In this paper we explore the cultural and technical reasons for this lack of focus on ideation within the video game industry.We introduce the concept of game sketching. Game sketching is not a technology, rather it is a set of technologies and methodologies intended to encourage exploration at a very early stage. We present an overview of one tool we have developed and then discuss our users' experiences. We finish the paper with a set of examples of game sketching. In particular we include two examples of a game sketch where our technology was not used at all. The intention of this paper is to introduce the concept of game sketching, and in so doing to get people to ask questions early in the ideation stage.

Methamphetamines are commonly abused drugs for their stimulant and euphoric effects. Inhaled and intravenous use may cause damage to the respiratory system. Spontaneous pneumomediastinum is a condition where changes in intrathoracic pressure leads to alveolar rupture and dissection of air along the tracheobronchial tree. Massive subcutaneous emphysema may result from pneumomediastinum which may compromise the central airway. In this case report, we present an unusual case of spontaneous pneumomediastinum and severe subcutaneous emphysema following inhalation of methamphetamine. This case emphasizes the rising concern on the acute respiratory complications of methamphetamine use.

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Bronchial varix is a rare pulmonary disorder which may lead to life-threatening hemorrhage. Diagnosis is difficult because of the subtle abnormalities on radiographic and bronchoscopic examination. We present a case of massive hemoptysis from a bleeding bronchial varix. In the absence of immediate complex endobronchial therapy in the island of Guam, this case was initially managed with nebulized and intravenous tranexamic acid. This was followed by endobronchial blockade of the bleeding airway with endobronchial epinephrine instillation. Selective bronchial artery embolization alleviated the acute-phase bleeding. Prone positioning was initiated due to severe hypoxia after blood clots compromised the patency of bilateral bronchial airways. Prone ventilation was employed for 17 hours for 2 consecutive days with intermittent bronchoscopic forceps extraction of airway blood clots while in the prone position. These maneuvers resulted to improved lung ventilation and oxygenation. The patient underwent bronchial sleeve resection surgery for definitive management.

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Background: Dyspnea in obesity is common and dyspnea questionnaires are mostly validated for chronic respiratory diseases. The study aims to assess how modified Medical Research Council (mMRC) dyspnea scale correlates with post exercise dyspnea Borg scale in 6-minute walk test of the obese population. Methods: We performed a retrospective observational study on 342 obese patients with 6 MWT tests from February 2008 to November 2014 at a single tertiary hospital. Linear regression analysis was used to assess the relationship between mMRC and Borg dyspnea score. Fractional polynomial regression was used to analyze the relationship of mMRC and Borg scores with BMI. Results: MMRC dyspnea score was a strong predictor of post exercise dyspnea Borg score in the obese population in a univariate regression model (coefficient = 0.764, p ≤ 0.001). When adjusted to age, BMI, 6 MWT distance and PFT parameters in a multivariate regression model, the relationship remained statistically significant (coefficient = 0.587, p ≤ 0.001). The relationship was stronger in obese group with no airflow obstruction. Conclusion: In obese population, pre-exercise mMRC dyspnea score correlates significantly with post exercise dyspnea Borg score regardless of airflow obstruction. This is the first validity study regarding mMRC scale in assessing dyspnea in the obese population.