Self-inflicted very-low-velocity penetrating head injury: A CARE-compliant case report.

RATIONALE: Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported. PATIENT CONCERNS: A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself. DIAGNOSES: Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury. INTERVENTIONS: Conservative treatment without surgery. OUTCOMES: Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69. LESSONS: Very-low-velocity PHI might be successfully treated with conservative treatment.

Sites of blood collection and topical disinfectants associated with contaminated cultures: An ambidirectional cohort study.

Background: We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single institution. Methods: This single-center, ambidirectional cohort study of 548 consecutive patients ≥20 years of age was performed in the ED of a university hospital in Japan over a 13-month period. Pairs of blood samples were collected for aerobic and anaerobic cultures from patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference. Results: Potential contamination was identified in 110 of the 548 patients (20.1%). One hundred fourteen (20.8%) patients showed true-positive results for bacteremia, and 324 (59.1%) patients showed true-negative results. Multivariate analysis revealed more frequent contamination when puncture sites were disinfected with povidone-iodine (PVI) than with alcohol/chlorhexidine (ACHX) (adjusted risk difference, 19.1%; 95% confidence interval [CI]), 15.7-22.6; p < 0.001). In terms of blood collection sites, femoral and central venous (CV) catheter with PVI disinfection showed more frequent contamination than venous sites with ACHX (adjusted risk differences: 26.6%, 95% CI 21.3-31.9, p < 0.001 and 41.1%, 95% CI 22.2-59.9, p < 0.001, respectively). Conclusion: Rates of contaminated blood cultures were significantly higher when blood was collected from the CV catheter or femoral sites with PVI as the topical disinfectant.

Anisocoria without extraocular muscle impairment due to moderate traumatic brain injury with midbrain contusion: a case report.

BACKGROUND: New-onset anisocoria is an important clinical clue to life-threatening intracranial injury. Anisocoria alone without impairment of extraocular muscles is a rare presentation of moderate traumatic brain injury (TBI). CASE PRESENTATION: A 79-year-old woman was transported to hospital soon after falling off a bicycle. Glasgow Coma Scale score on arrival was 11 (E3V3M5). On examination at admission, she was found to be drowsy. Bruising was seen around the right eye and pupil diameters differed (right, 4.5 mm; left, 3.0 mm; both reactive to light). Computed tomography of the head revealed hemorrhagic contusion in the left temporal lobe and left pretectal area of the midbrain, right clavicular fracture, and pulmonary contusion with fractures of the 3rd and 4th ribs. Magnetic resonance imaging confirmed hemorrhagic contusion of the midbrain. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 17. CONCLUSION: We encountered a case of anisocoria without major extraocular muscle impairment due to moderate TBI with midbrain contusion.

Epidemiology of patients with dizziness over a 3-year period, requiring utilization of the emergency medical serviced system: A pre- and post-COVID pandemic comparative study using the population-based ORION registry.

OBJECTIVE: We aimed to identify the proportion of each medical condition or disease contributing to dizziness and their disposition in the Emergency Department (ED). METHODS: This retrospective, descriptive study examined data from the Osaka Emergency Information Research Intelligent Operation Network system in Japan for the period from January 1, 2018 to December 31, 2020. The inclusion criteria were patients with presumptive ICD-10 codes including "dizziness" or "vertigo". Patient demographics were compared using the χ2 test and Kruskal-Wallis test. Logistic regression analysis was performed to calculate disposition from ED (emergency admission or discharge) over the 3-year study period. The adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated using multivariate analyses. RESULTS: During the 3-year study period, a total of 1,346,457 patients (462,773 in 2018, 468,697 in 2019, and 414,987 in 2020; P < 0.001), including 53,190 patients with dizziness (18,396 in 2018, 18,649 in 2019, and 16,145 in 2020; P = 0.058), were identified as having been transported to hospitals by ambulance in Osaka Prefecture. Dizziness and giddiness (R42) was the most common form of dizziness, in 27,075 cases (9,570 in 2018, 9,613 in 2019, and 7,892 in 2020; P < 0.001; Gender composition showed 10,483 males and 16,592 females.) Vestibular Neuronitis (H81.2) showed significant increase in 2020 compared to the two preceding years (91 in 2018, 119 in 2019, and 130 in 2020, P = 0.003; including 174 males and 167 females, respectively). Of the 53,190 patients with dizziness, 11,862 (22.3%; 4,323 males, 7,539 females) were admitted to hospital. The odds ratio (OR) for emergency admission for dizziness in 2020 during the COVID-19 pandemic was 0.98 (95% confidence interval (CI), 0.93- 1.03) with reference to 2018. CONCLUSION: Patients with dizziness accounted approximately 4% of ED transportations, with about 20% requiring hospital admission, irrespective of the COVID-19 pandemic. Vestibular neuronitis was significantly increased in 2020.

Effect of the COVID-19 outbreak on emergency transport of children by an emergency medical service system: a population-based, ORION registry study.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2, has spread rapidly around the world. OBJECTIVE: To assess the effect of the COVID-19 pandemic on the emergency medical service (EMS) and hospital admission course for children transported by ambulance. METHODS: This study was a retrospective, descriptive study with a study period from January 1, 2018 to December 31, 2020 using the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. All children who were transported by ambulance in Osaka Prefecture were included. The main outcome of this study was the rate of difficult-to-transfer cases, which was calculated by univariate and multivariate Poisson regression analyses. RESULTS: Over the 3 years between January 1, 2018 and December 31 2020, 1,436,212 patients were transported to hospitals by ambulances in Osaka Prefecture, with children accounting for 102,473 (37,064, 39,590, and 25,819, in 2018, 2019, and 2020, respectively). Poisson regression analysis showed that children were negatively associated with difficult-to-transfer cases (risk ratio (RR) 0.35, 95% CI 0.33 to 0.37). With reference to 2018, 2020 was not significantly associated with difficult-to-transfer cases in children (RR 1.14, 95% CI 0.99 to 1.32, P = 0.075), but was significantly related (RR 1.24, 95% CI 1.21 to 1.27, P < 0.001) to difficult-to-transfer cases in the general population. CONCLUSION: Children were consistently associated with a reduced RR for difficult-to-transfer cases, even in the COVID-19 pandemic in 2020.

Influence of the COVID-19 outbreak on transportation of pregnant women in an emergency medical service system: Population-based, ORION registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2, has spread rapidly across the world. OBJECTIVE: To assess the influence of the COVID-19 pandemic on the emergency medical service (EMS) for transportation of pregnant women by ambulance. METHODS: This study was a retrospective, descriptive study using the Osaka Emergency Information Research Intelligent Operation Network system, and included pregnant women transported by ambulance in Osaka Prefecture between January 1, 2018 and December 31, 2020. The main outcome of the study was difficulty in obtaining hospital acceptance for transfer of patients (difficult-to-transfer cases). We calculated the rates of difficult-to-transfer cases using univariate and multivariate analyses. RESULTS: Of the 1 346 457 total patients transported to hospitals by ambulance in Osaka Prefecture during the study period, pregnant women accounted for 2586 (909, 943, and 734, in 2018, 2019, and 2020, respectively). Logistic regression analysis revealed that pregnant women were negatively associated with difficult-to-transfer cases (adjusted OR 0.36, 95% CI 0.26-0.50). Compared with 2018, 2020 was significantly associated with difficult-to-transfer cases (adjusted OR 1.27, 95% CI 1.24-1.30). CONCLUSION: Pregnant women were consistently associated with reduced odds for being difficult-to-transfer cases. The COVID-19 pandemic might have influenced difficult-to-transfer cases in 2020.

Regression discontinuity of blood culture contamination rate after changing of disinfectants: retrospective observational study.

Blood cultures are indispensable for detecting life-threatening bacteremia. Little is known about associations between contamination rates and topical disinfectants for blood collection in adults. We sought to determine whether a change in topical disinfectants was associated with the rates of contaminated blood cultures in the emergency department of a single institution. This single-center, retrospective observational study of consecutive patients aged 20 years or older was conducted in the emergency department (ED) of a university hospital in Japan between August 1, 2018 and September 30, 2020. Pairs of blood samples were collected for aerobic and anaerobic culture from the patients in the ED. Physicians selected topical disinfectants according to their personal preference before September 1, 2019; alcohol/chlorhexidine gluconate (ACHX) was mandatory thereafter, unless the patient was allergic to alcohol. Regression discontinuity analysis was used to detect the effect of the mandatory usage of ACHX on rates of contaminated blood cultures. We collected 2141 blood culture samples from 1097 patients and found 164 (7.7%) potentially contaminated blood cultures. Among these, 445 (20.8%) were true bacteremia and 1532 (71.6%) were true negatives. Puncture site disinfection was performed with ACHX for 1345 (62.8%) cases and with povidone-iodine (PVI) for 767 (35.8%) cases. The regression discontinuity analysis showed that mandatory ACHX usage was significantly associated with lower rates of contaminated blood cultures by 9.6% (95% confidence interval (CI): 5.0%-14.2%, P < 0.001). Rates of contaminated blood cultures were significantly lower when ACHX was used as the topical disinfectant.

Altered consciousness with transient abnormal signals in the hippocampus: A case report.

Hippocampal infarction is relatively rare. Many different diseases can mimic hippocampal infarction including transient global amnesia, Alzheimer's disease, epilepsy, encephalitis, and encephalopathies. An 89-year-old man was transported to our hospital for altered consciousness. Diffusion-weighted magnetic resonance imaging revealed slightly intense signals in the hippocampus with a mildly decreased apparent diffusion coefficient. Serial magnetic resonance imaging revealed features of hippocampal infarction. Symptoms and cognitive function gradually improved with rehabilitation, and he was transferred to a rehabilitation facility on Hospital Day 38. Hippocampal infarction is rare in patients with altered mental status, but should be considered when magnetic resonance imaging shows findings suggestive of this condition. Other differential diseases should be ruled out by serial magnetic resonance imaging and observation of the clinical course.

Focused Assessment with Sonography for Trauma (FAST) training for first-year resident physicians at a university hospital in Japan: A longitudinal, observational study.

BACKGROUND: Ultrasound training is an essential part of residency programs during emergency medicine rotations for first-year trainees (postgraduate year 1). The Focused Assessment with Sonography for Trauma examination used to assess for internal bleeding in trauma patients is one of the essential skills postgraduate year 1 residents must acquire during the emergency medicine rotation. METHOD: A prospective, longitudinal, observational study of postgraduate year 1 residents during a 2-month long emergency medicine rotation conducted from 1 April 2019 to 31 May 2021. The primary outcome was the mean difference between the hands-on Focused Assessment with Sonography for Trauma examination scores of the first week of the emergency medicine rotation and the same hands-on Focused Assessment with Sonography for Trauma examination scores of the last week of the emergency medicine rotation. All postgraduate year 1 residents had open access to the ultrasound machine to practice examining on other postgraduate year 1 residents or could use it on real patients under supervision of emergency medicine physicians. RESULT: A total of 91 postgraduate year 1 residents (65 male and 26 female) were recruited and submitted to the hands-on Focused Assessment with Sonography for Trauma test in both the first and last weeks of the rotation. The mean test score for the postgraduate year 1 residents in the first week was 7.81 (standard deviation = 2.11). The mean test score in the last week was 16.17 (standard deviation = 2.60). The primary outcome of this study was the score difference between the first and last weeks (mean = 8.35, 95% confidence interval = 7.73 to 8.94, p < 0.001, paired t-test). CONCLUSION: Hands-on practical Focused Assessment with Sonography for Trauma training for postgraduate year 1 residents during emergency medicine rotations significantly improved their Focused Assessment with Sonography for Trauma test scores.

Sites of blood collection and topical antiseptics associated with contaminated cultures: prospective observational study.

We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single institution. This single-center, prospective observational study of 249 consecutive patients aged ≥ 20 years proceeded in the ED of a university hospital in Japan during 6 months. Pairs of blood samples were collected for aerobic and anaerobic culture from all patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference. We found 50 (20.1%) patients with potentially contaminated blood cultures. Fifty-six (22.5%) patients were true bacteremia and 143 (57.4%) patients were true negatives. Multivariate analysis associated more frequent contamination when puncture sites were disinfected with povidone-iodine than with alcohol/chlorhexidine (adjusted risk difference, 12.9%; 95% confidence interval [CI] 8.8-16.9; P < 0.001). Sites of blood collection were also associated with contamination. Femoral and central venous with other sites were associated with contamination more frequently than venous sites (adjusted risk difference), 13.1% (95% CI 8.2-17.9; P < 0.001]) vs. 17.3% (95% CI 3.6-31.0; P = 0.013). Rates of contaminated blood cultures were significantly higher when blood was collected from femoral sites and when povidone-iodine was the topical antiseptic.

Tachyarrhythmia improved by management of low back pain in a patient with delayed diagnosis of infective spondylodiscitis: A case report.

A 77-year-old man presented to the emergency room with a 1-month history of persistent low back pain with the absence of vital sign abnormalities. On several previous orthopedic surgery clinic visits, pathological back pain had not been considered and pain killers had been prescribed because he had low back pain due to lumbar spinal canal stenosis. He was admitted to the intensive care unit for infectious spondylodiscitis and infective endocarditis with disseminated abscess caused by methicillin-resistant Staphylococcus aureus. Shock refractory tachyarrhythmia could not be managed with antiarrhythmic agent in the intensive care unit. Intractable low back pain and persistent tachyarrhythmia were adequately managed by pain control with fentanyl in the intensive care unit. Infectious spondylodiscitis and infective endocarditis were effectively managed with anti-methicillin-resistant Staphylococcus aureus drugs, initially in rotational usage, but the patient died of extended-spectrum beta-lactamase-producing Escherichia coli pneumonia on day 50 of hospitalization. Infectious spondylodiscitis should have been considered for persistent low back pain with hemodialysis, fever, and a history of device implantation. Pain management may be necessary for persistent tachycardia that proves unresponsive to usual antiarrhythmic medications.

Gastric submucosal abscess caused by Edwardsiella tarda infection: a case report.

BACKGROUND: Edwardsiella tarda is a motile, facultatively anaerobic gram-negative bacillus that is isolated from a wide spectrum of animals in aquatic environments but rarely causes infection in humans. Here, we describe the case of a gastric submucosal abscess caused by E. tarda infection. CASE PRESENTATION: The patient was a 74-year-old man with a history of hypertension and chronic alcohol consumption who was admitted to our hospital for abdominal pain, appetite loss and vomiting. Contrast-enhanced computed tomography (CT) revealed choledocholithiasis in the common bile duct, a gastric wall abscess and an intra-abdominal abscess. Endoscopic ultrasound (EUS)-guided drainage with antibiotics successfully cured the patient. CONCLUSION: The combination of CT, endoscopy and EUS-guided drainage with antibiotic therapy might be effective for diagnosis and treatment of a gastric submucosal abscess caused by E. tarda infection.

Effect of Shakuyaku-kanzo-to in patients with muscle cramps: A systematic literature review.

BACKGROUND: Previous clinical studies have reported that Shakuyaku-kanzo-to (SKT) has a therapeutic effect on muscle cramps, but few studies have clarified how SKT acts to treat muscle cramps. The aim of this study was to perform an updated systematic review of clinical trials for SKT in patients with muscle cramps. METHODS: The literature was systematically reviewed to assess the effects of SKT in patients with muscle cramps. PubMed, Web of Science, Cochrane Library, Google Scholar, and Ichushi-Web were searched using the terms "Shakuyaku-kanzo-to" ("shakuyakukanzoto", etc), "clinical trials" and "muscle cramps". Two quality assessments were conducted independently by three authors. Data were extracted using a standardized extraction tool, and a qualitative synthesis of evidence was performed. RESULTS: Three randomized controlled articles were identified and enrolled in this study. A systematic review, but not a meta-analysis, was performed because of the high heterogeneity and limited number of studies. In patients with liver cirrhosis, the odds ratio (OR) for improvement with SKT compared to placebo was 1.27 (95% confidence interval [CI], 0.445-2.086) and compared to Goshajinkigan was 0.81 (95%CI, -1.734-0.114). The OR for improvement with SKT compared with eperisone hydrochloride in patients with lumbar spinal stenosis was 2.86 (95%CI, 0.980-4.744). CONCLUSIONS: Current evidence appears insufficient to allow a meta-analysis of the effects of SKT, but SKT might show efficacy in treating muscle cramps in patients with cirrhosis or lumbar spinal stenosis.

Massive abscess with prolonged respiratory failure due to newly diagnosed myotonic dystrophy: A case report.

RATIONALE: Myotonic dystrophy is a progressive multisystem genetic heterogeneous disorder. General anesthesia with opioids increases the risk of prolonged postanesthetic respiratory recovery in myotonic dystrophy patients. PATIENT CONCERNS: A 20-year-old previously healthy woman was transferred to our emergency department for further workup of respiratory failure, and massive ascites with abscess caused by endometriosis. Hypercapnic respiratory failure persisted under intensive care unit (ICU) management, but finally improved after cessation of fentanyl as a sedative agent. DIAGNOSIS: Myotonic dystrophy type 1. INTERVENTIONS: Massive ascites with abscess was accordingly managed by drainage, antibiotics, and an antifungal agent. Myotonic dystrophy type 1 was confirmed after molecular genetic testing revealed a cytosine-thymine-guanine repeat length of 400 to 450 in the DMPK gene. OUTCOMES: The patient was discharged without complications on hospital day 69. LESSONS: Myotonic dystrophy should be considered when hypercapnic respiratory failure persists in sedated ICU patients. Opioids should not be used for perioperative management of patients with myotonic dystrophy.

Killian-Jamieson diverticulum mimicking a thyroid nodule: A case report.

Killian-Jamieson diverticulum (KJD) is a rare disease of the cervical esophagus, often misidentified as thyroid nodules on ultrasonography. We performed carotid artery ultrasonography for an asymptomatic 68-year-old man. The ultrasound showed an oval nodule with heterogeneous echogenicity surrounded by a multilayered rim in the posterior left thyroid gland. As endoscopy and computed tomography confirmed pharyngoesophageal diverticulum in the anterolateral wall of the esophagus, we reached a final diagnosis of KJD. In cases where a thyroid nodule is detected by ultrasound, physicians should be aware of the possibility of KJD before performing invasive procedures.

The role of ultrasound imaging in adult patients with testicular torsion: a systematic review and meta-analysis.

PURPOSE: Our aim was to determine the accuracy of ultrasound (US) examination-based testicular torsion diagnosis in adult patients with acute scrotal pain. METHODS: A comprehensive electronic search was performed using internet retrieval systems up to 5 August 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The quality of eligible studies was assessed using Quality Assessment for Studies of Diagnostic Accuracy (QUADAS-2). The diagnostic value of ultrasound in patients with testicular torsion was evaluated using pooled estimates of sensitivity, specificity, likelihood ratio, and diagnostic odds ratio, as well as the summary receiver operating characteristics curve. RESULTS: Twenty-six studies with 2116 patients were included in the study. Overall diagnostic sensitivity was 0.86 [95% confidence interval (CI) 0.79-0.91] and specificity was 0.95 (95% CI: 0.92-0.97). Subgroup analysis of prospective studies showed pooled sensitivity of ultrasound for testicular torsion was 0.94 (95% CI 0.83-0.98), and pooled specificity was 0.98 (95% CI 0.94-1.00). Recent studies after 2010 showed diagnostic sensitivity of 0.95 (95% CI 0.84-0.99) and specificity of 0.98 (95% CI 0.93-0.99). CONCLUSIONS: This meta-analysis demonstrated that ultrasound represents an effective imaging modality for diagnosing testicular torsion in adult patients with acute scrotal pain.

Massive hemothorax due to two bleeding sources with minor injury mechanism: a case report.

BACKGROUND: Massive hemothorax resulting from a minor injury mechanism is considered to be rare particularly when the diaphragm is injured. We report a case of massive hemothorax with bleeding from the intercostal artery and diaphragmatic damage caused by minor blunt trauma. CASE PRESENTATION: An 83-year-old Japanese man was transported to our hospital 3 hours after falling out of bed. Computed tomography revealed hemothorax and multiple rib fractures. He underwent fluid resuscitation and a tube thoracostomy, but he became hemodynamically unstable. Contrast-enhanced computed tomography revealed worsening hemothorax with contrast extravasation 4 hours after arrival at the hospital. Emergency angiography indicated hemorrhage in the area supplied by the tenth intercostal artery. Transcatheter arterial embolization stabilized his vital signs for a short period. However, further hemodynamic stabilization required a thoracotomy, which revealed diaphragmatic trauma, which was removed and sutured before fixing his fractured ribs. His postoperative course was uneventful, and he was transferred to another hospital for rehabilitation without complications on hospital day 29. CONCLUSIONS: Minor mechanisms of blunt trauma can cause rib fractures and massive hemothorax. Traumatic diaphragm injury should be considered a differential diagnosis if hemodynamic instability persists after transcatheter arterial embolization in patients with lower level rib fractures.

An atypical case of atypical pneumonia.

Atypical pneumonia has been thought to account for 7%-20% of community-acquired pneumonia (CAP). The treatment for the pathogens that cause atypical pneumonia is different from that of other bacterial pneumonia. Therefore, identification of the causative pathogen in a primary care situation is crucial for adequate treatment of CAP. Mycoplasma infection is prevalent in the general population, but Mycoplasma pneumoniae with extrapulmonary symptoms is relatively rare. Herein, we report a case of CAP because of M. pneumoniae that presented with a wide variety of extrapulmonary diseases. Delayed administration of appropriate antibiotics may contribute to development of extrapulmonary manifestations.

Atypical spinal cord infarction: A case report.

INTRODUCTION: The abrupt onset of sensorimotor deficits is a neurologic emergency that requires immediate management. Acute spontaneous spinal cord infarction (SCI) is rare, but can cause the sudden onset of quadriplegia or quadriparesis. Magnetic resonance imaging (MRI) is an essential imaging modality to diagnose SCI. CASE PRESENTATION: A 75-year-old man with a history of diabetes mellitus type 2, hypertension, and dyslipidemia was transferred to our facility for further workup of the sudden onset of quadriplegia. Diffusion-weighted contrast MRI (DWI) on hospital day 8 revealed hyperintense signals predominantly at the grey matter, and a contrast T2 signal abnormality with a decreased apparent diffusion coefficient (ADC). Steroid pulse therapy was initiated because myelitis could not be completely ruled out, but this did not improve the neurological deficits. Spontaneous SCI was finally diagnosed as an exclusion diagnosis. Symptoms were gradually recovered with rehabilitation, and he was transferred to a rehabilitation facility on hospital day 40. CONCLUSION: MRI with DWI of the spine should be considered for an early diagnosis of SCI. A combination of DWI with ADC maps is recommended to distinguish SCI from other differential disorders.