54-year-old Woman with Chest Pain.

Chest pain is a common presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It can be challenging to differentiate life-threatening conditions from more benign causes. A 54-year-old woman presented to the ED complaining of chest pain with dyspnea in the setting of recent blunt trauma. This case offers a thorough yet practical approach to the diagnostic workup of chest pain with dyspnea in the ED setting. The surprising final diagnosis and case outcome are then revealed.

Management of Coronavirus Disease-2019 Infection in Pregnancy.

Although the majority of pregnant patients who contract severe acute respiratory syndrome coronavirus 2 will have a mild course of illness, pregnant patients with coronavirus disease-2019 are more likely than their nonpregnant counterparts to develop a severe illness with an increased risk of poor maternal and fetal outcomes. Although the extent of research in this specific patient population remains limited, there are tenets of care with which physicians and other providers must be familiar to increase the chances of better outcomes for the two patients in their care.

Emergency Department Evaluation and Management of Patients with Left Ventricular Assist Devices.

With the increasing use of left ventricular assist devices (LVADs) as destination therapy in patients with severe left heart failure, emergency physicians are more likely to encounter patients with LVAD in their emergency department (ED). Emergency physicians should have a basic understanding of LVAD mechanics, a specific approach to LVAD patient evaluation, and awareness of the must-not-miss LVAD therapy complications and their management to optimize outcomes in this patient population.

Resuscitation of the Critically Ill Older Adult.

In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.

Resuscitating the Crashing Pregnant Patient.

Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.

Evaluation of modelling study shows limits of COVID-19 importing risk simulations in sub-Saharan Africa.

Mathematical modelling studies predicting the spread of the coronavirus disease 2019 (COVID-19) have been used worldwide, but precisions are limited. Thus, continuous evaluation of the modelling studies is crucial. We investigated situations of virus importation in sub-Saharan Africa (SSA) to assess effectiveness of a modelling study by Haider N et al. titled 'Passengers' destinations from China: low risk of novel coronavirus (2019-nCoV) transmission into Africa and South America'. We obtained epidemiological data of 2417 COVID-19 cases reported by 40 countries in SSA within 30 days of the first case confirmed in Nigeria on 27 February. Out of 442 cases which had travel history available, only one (0.2%) had a travel history to China. These findings underline the result of the model. However, the fact that there were numbers of imported cases from other regions shows the limits of the model. The limits could be attributed to the characteristics of the COVID-19 which is infectious even when the patients do not express any symptoms. Therefore, there is a profound need for all modelling researchers to take asymptomatic cases into account when they establish modelling studies.

Characteristics of doctors' fatality due to COVID-19 in Western Europe and Asia-Pacific countries.

Under the coronavirus disease 2019 (COVID-19) pandemic, the deaths of healthcare professionals have been increasingly reported worldwide. We performed a cross-sectional, observational study using news reports on the websites among selected countries as of April 2020. We found 120 dead medical doctors due to COVID-19 in Western Europe and Asia-Pacific countries; 67 in Italy (47 in the Northern part), 34 in China (22 in Hubei), 6 in France, 4 in the UK, the USA and Spain and 1 in South Korea, respectively. Among them, 90% were men, and specialties were reported as general practitioners for 30% and as physicians for 11.6%. The overall proportions of dead medical doctors amounted to 1.9 per 10 000 confirmed cases and 30.2 per 10 000 dead cases, respectively. Proactive measures are warranted to protect doctors especially who often encounters with COVID-19 patients.

New physician specialty training system impact on distribution of trainees in Japan.

OBJECTIVES: The problem of uneven distribution of medical services and inequitable distribution of physicians is drawing much attention worldwide. Revealing how changes in the specialty training system in Japan have affected the distribution of doctors could help us understand this problem. In 2018, a new and standardized specialty training system was implemented by the Japanese Medical Specialty Board, which is recognized by the Ministry of Health, Labor and Welfare. The purpose of this study was to investigate how this new system has affected the geographical distribution of doctors commencing specialty training (trainees) and choice of specialty in Japan. STUDY DESIGN: Retrospective observational study. METHODS: The change in the number of trainees between the control period (2012-2014) and 2018 was investigated, taking into account the prefecture and specialty selected. Population, the proportion of residents aged 65 years or older (aging rate), and the total number of overall doctors in each prefecture were considered as the background characteristics of each prefecture. We created a Lorenz curve and calculated the Gini coefficient for the distribution of trainees. RESULTS: In 2018, the number of trainees per 100,000 population increased to 6.6 nationwide compared with 5.5 during the control period. The number of trainees per 100,000 population in 2018 increased in prefectures with a large population of ≧ 2,000,000, a low aging rate (<27%), and a high doctor density (≧ 250 doctors per 100,000 population). The Gini coefficient showed an increase to 0.226 in 2018 compared with only 0.160 during the control period. CONCLUSIONS: After the implementation of the new training system, there was an increase in the number of doctors enrolling in specialty programs, and the specialties other than internal medicine and surgery have attracted more trainees. Inequality in the distribution of doctors between urban and rural prefectures worsened. This indicates the need to explore new ways of balancing distribution while maintaining optimal opportunities for specialist training.

Evaluation of Spodick's Sign and Other Electrocardiographic Findings as Indicators of STEMI and Pericarditis.

BACKGROUND: Patients with ST elevation on electrocardiogram (ECG) could have ST elevation myocardial infarction (STEMI) or pericarditis. Spodick's sign, a downsloping of the ECG baseline (the T-P segment), has been described, but not validated, as a sign of pericarditis. OBJECTIVE: This study estimates the frequency of Spodick's sign and other findings in patients diagnosed with STEMI and those with pericarditis. METHODS: In this retrospective review, we selected charts that met prospective definitions of STEMI (cases) and pericarditis (controls). We excluded patients whose ECGs lacked ST elevation. An authority on electrocardiography reviewed all ECGs, noting the presence or absence of Spodick's sign, ST depression (in leads besides V1 and aVR), PR depression, greater ST elevation in lead III than in lead II (III > II), abrupt take-off of ST segment (the RT checkmark sign), and upward or horizontal ST convexity. We quantified strength of association using odds ratio (OR) with 95% confidence interval (CI). RESULTS: One hundred and sixty-five patients met criteria for STEMI and 42 met those for pericarditis. Spodick's sign occurred in 5% of patients with STEMI (95% CI 3-10%) and 29% of patients with pericarditis (95% CI 16-45%). All other findings statistically distinguished STEMI from pericarditis, but ST depression (OR 31), III > II (OR 21), and absence of PR depression (OR 12) had the greatest OR values. CONCLUSIONS: Spodick's sign is statistically associated with pericarditis, but it is seen in 5% of patients with STEMI. Among other findings, ST depression, III > II, and absence of PR depression were the most discriminating.

A Diagnosis of Adult-Onset Still's Disease after Multiple Urgent Care Visits.

A 34-year-old man with recent treatment and resolution of community-acquired pneumonia presents to the emergency department with protracted fever, rash, and sore throat. Sustained fever and greater than two-fold increase in leukocytosis despite appropriate antibiotic therapy prompted hospital admission for infectious disease and rheumatologic evaluations which ultimately revealed adult-onset Still's disease, a rare autoinflammatory disorder with potentially life-threatening complications.

Female Nonobstetric Genitourinary Emergencies.

The emergency medicine provider sees a broad range of pathology involving the female genitourinary system on a daily basis. Must-not-miss diagnoses include pelvic inflammatory disease and ovarian torsion, because these diagnoses can have severe complications and affect future fertility. Although most patients with abnormal uterine bleeding are hemodynamically stable, it can present as a life-threatening emergency and providers should be adept managing severe hemorrhage. Bartholin gland cysts are common complaints that often require procedural intervention. This article discusses these diagnoses and appropriate evaluation and management in the emergency department.

Trend in unequal geographical distribution of doctors by age and sex in Japan from 2004 to 2014.

OBJECTIVES: In Japan, the proportion of female doctors and elderly doctors is increasing as in other countries. We investigated the relationship between doctors' demographic changes and their geographical distribution. STUDY DESIGN: A national database study. METHODS: We assessed trends in unequal geographical distribution of the number of doctors by sex and age from 2004 to 2014 in Japan. RESULTS: The Gini coefficient values for the number of female doctors (0.18) were larger than those for male doctors across all generations (0.13-0.14). The Gini coefficient values for the number of elderly doctors aged 60 years and older (male: 0.12, female: 0.18-0.23) were larger than those for majority age groups aged 40-59 years (male: 0.10, female: 0.16-0.17). CONCLUSION: The persisting geographical maldistribution of doctors may be associated with demographic changes, such as increase in the number of female doctors.

High initial tidal volumes in emergency department patients at risk for acute respiratory distress syndrome.

PURPOSE: Emergency department (ED) patients are at high risk for the acute respiratory distress syndrome (ARDS). Settings only 1 mL/kg above recommended tidal volumes confers harm for these patients. The purpose of this study was to determine whether ED physicians routinely initiate mechanical ventilation with low tidal volumes in patients at risk for ARDS. MATERIALS AND METHODS: We retrospectively reviewed the charts of all adult patients who were intubated in an urban, academic ED. The charts were analyzed to identify patients in whom ARDS developed within 48 hours after ED admission. Patients were eligible for inclusion if they had bilateral infiltrates on imaging, had a Pao2/Fio2 ratio less than 300 mm Hg and did not have heart failure contributing to their presentation. The tidal volumes set in the ED were then compared with the recommended tidal volume of 6 mL/kg of predicted body weight. RESULTS: The initial tidal volumes set in the ED were higher than recommended by an average of 80 mL (95% confidence interval, 60-110, P < .0001) or 1.5 mL/kg (95% confidence interval, 1.0-1.9). Only 5 of the 34 patients received the recommended tidal volume ventilation setting. CONCLUSIONS: In an academic, tertiary hospital, newly intubated ED patients in whom ARDS developed within 48 hours after intubation were ventilated with tidal volumes that exceeded recommendations by an average of 1.5 mL/kg.

Expanding the role of percutaneous coronary intervention in patients resuscitated from cardiac arrest.

Special attention to post-cardiac arrest management is important to long-term survival and favorable neurological outcome in patients resuscitated from cardiac arrest. The use of emergent percutaneous coronary intervention in resuscitated patients presenting with ST-segment elevation myocardial infarction has long been considered an appropriate approach for coronary revascularization. Recent evidence suggests that other subsets of patients, namely, post-cardiac arrest patients without ST-segment elevation myocardial infarction, may benefit from immediate percutaneous coronary intervention following resuscitation. These findings could eventually have important implications for the care of resuscitated patients, including transportation of resuscitated patients to appropriate cardiac interventional facilities, access to treatment modalities such as therapeutic hypothermia, and coordinated care with cardiac catheterization laboratories.

Allogeneic cord blood transplantation for adult acute lymphoblastic leukemia: retrospective survey involving 256 patients in Japan.

We investigated the efficacy of cord blood transplantation (CBT) for adult acute lymphoblastic leukemia (ALL) by reviewing medical records of 256 patients reported to the Japan Cord Blood Bank Network between June 1997 and August 2006. Cumulative incidence of neutrophil engraftment at day 100 was 78%. Infused CD34-positive cell dose (>1 × 10(5) cells/kg) was associated with successful neutrophil engraftment. Cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) at day 100 was 37%. A 2-year disease-free and overall survival (OS) rates were 36% and 42%, respectively. Multivariate analysis showed that age (51 or older vs younger than 50) (hazard ratio 1.9, 95% confidence interval (CI), 1.3-2.8, P=0.001), disease status (non-remission vs remission) (hazard ratio 2.2, 95% CI, 1.5-3.2, P<0.0001), grade III-IV acute GVHD (hazard ratio 2.0, 95% CI, 1.2-3.2, P=0.006) and absence of chronic GVHD (hazard ratio 2.4, 95% CI, 1.1-5.1, P=0.02) were negatively associated with OS. CBT is effective for some patients with advanced ALL. It is worth considering for further evaluation.

Usefulness of a bidirectional e-learning material for explaining surgical anesthesia to cancer patients.

BACKGROUND: We developed an e-learning system, which is based on an interactive animation video that assists anesthesiologists in preanesthetic interviews. MATERIALS AND METHODS: First, the feasibility of the system was investigated in 18 anesthesiologists and 95 volunteers from the general public. Content/quantity, operability, and satisfaction were assessed with a five-point scale. Secondly, a randomized controlled trial was conducted on 211 cancer patients who were scheduled to undergo general anesthesia. They were divided into an e-learning group (n = 106) and a control group (n = 105). The patients in the e-learning group watched the interactive animation before a preanesthetic interview by an anesthesiologist. RESULTS: In 10 of the 11 items for content/quantity, operability, and satisfaction, the average score for both anesthesiologists and volunteers was ≥3.0 in feasibility study. Then, the level of patient comprehension of preoperative rounds and postoperative complications in the e-learning group was significantly higher than that in the control group (mean: 4.4 ± 0.5 versus 4.1 ± 0.7, P = 0.003, and 4.3 ± 0.5 versus 4.2 ± 0.5, P = 0.02); however, no significant difference in anxiety was seen between the two groups. Patient satisfaction in the e-learning group was significantly higher (mean: 4.3 ± 0.5 versus 4.0 ± 0.6, P = 0.002). CONCLUSION: The e-learning system is an effective supplementary tool for preanesthetic interviews in cancer patients.