Subtle visual impairment caused by temporoparietal infarction: a case report.

Cerebral infarction is associated with various symptoms. Considering its high volume of patients who present with various symptoms, the emergency department is an unfavorable environment for detecting atypical symptoms. A man in his 50 s visited the emergency department because he had experienced subtle discomfort when changing lanes while driving. Several coincidental events could have led to a misdiagnosis, such as the patient's first-ever use of diabetes medication on the day before symptom onset and the patient's first attempt at driving after a 2-week hiatus. A detailed neurological examination and magnetic resonance imaging revealed right temporoparietal infarction; accordingly, the patient received antiplatelet therapy and was discharged. Clinicians increasingly rely on high-tech imaging equipment, rather than history-taking and physical examination approaches. However, clinicians must decide which tests to perform. This report illustrates that when patients present with mild or ambiguous symptoms, clinicians should place greater emphasis on history-taking and physical examination to avoid misdiagnosis.

Prolonged oral sildenafil use-induced Mondor disease: a case report.

Penile Mondor disease (MD) is a palpable, painful, subcutaneous induration caused by superficial dorsal penile vein thrombosis. We report a case of penile MD that was suspected to be related to prolonged oral sildenafil use. A 46-year-old man visited our emergency department with sustained penile pain and swelling that began 7 hours after sexual intercourse. He had used oral sildenafil intermittently for 11 years and engaged in sexual intercourse the previous night after taking sildenafil. Examination revealed no evidence of intercourse-related trauma to the genital area or an increase in penile skin temperature. However, penile swelling and tenderness over the protruding dorsal penile vein were noted. A color Doppler ultrasound examination was performed immediately, which showed hyperechoic thrombosis in the right superficial dorsal penile vein that was dilated, with soft tissue swelling and no detectable flow signal in the thrombotic lesion. The patient was diagnosed as having penile MD. The patient was treated conservatively. Some reports have indicated the involvement of sildenafil in thrombogenesis. Physicians should be aware that prolonged oral sildenafil use may be associated with penile MD.

Chief complaints of patients with cancer who visit the emergency department over their oncologist's outpatient clinic in South Korea.

BACKGROUND: There have been several reports of patients with cancer visiting the Emergency Department (ED) rather than the outpatient department of their oncologist. In this study, we aimed to analyze the chief complaints, visit time, and time spent in the ED between study groups of patients with cancer visiting the ED. This finding will help medical staff provide better care for patients with cancer and reduce time spent in the ED. METHODS: A total of 787 patients with cancer visited the Regional Emergency Medical Center between January 1, 2020, and December 31, 2020. After the exclusion criterion such as patients who were transferred to the ED with a referral issued slip, patients who were pregnant women or minors under the age of 18 were applied, data from 607 patients with cancer were collected retrospectively from electronic medical records at the hospital. The participating patients with cancer were divided into two groups: 1) ED group-those who were cared for by the ED physician and 2) Referral group-those who were referred to their oncologist for hospitalization. RESULTS: We found that 40% of the total patients with cancer included in the study visited the ED with a chief complaint of pain. It was observed that the highest frequency of visits to the ED was around noon during clinic hours. The length of ED stay was 169 and 566 min for the ED and referral groups, respectively. CONCLUSION: It would be more beneficial for patients with cancer visiting the ED to be quickly discharged from the ED physician's active care for their symptoms. This usage of ED services will reduce unnecessary waiting time.

Acute esophageal obstruction after ingestion of psyllium seed husk powder: A case report.

BACKGROUND: Bezoar is a mass of hardened external material found in the gastrointestinal (GI) tract. It may form anywhere in the GI tract, but esophageal bezoar is rare because of the short esophageal transit time. Psyllium seed husk is an indigestible natural derivative that is widely used as an herbal laxative. Herein, we report a case of acute esophageal obstruction caused by a bezoar after ingestion of psyllium seed husk powder. CASE SUMMARY: A 76-year-old male with Parkinson's disease visited the emergency department with swallowing difficulty approximately 10 h after ingesting psyllium seed husk powder. Symptoms began a few hours after ingestion and progressed to severe dysphagia. There were no abnormal findings on simple radiography. However, a computed tomography scan revealed an approximately 2.0 cm × 2.5 cm mass located near the gastro-esophageal junction. After grinding, the mass was removed using an endoscopic capture net. Esophageal bezoars may cause life-threatening complications. Patients with Parkinson's disease may have esophageal motility dysfunction, which may increase esophageal transit time. Since our patient had Parkinson's disease, this effect may have contributed to the formation of the bezoar. CONCLUSION: Attention should be paid to using bulk-laxatives, and an appropriate specified regimen will be needed when marketed as a dietary supplement.

External validation of multimodal termination of resuscitation rules for out-of-hospital cardiac arrest patients in the COVID-19 era.

BACKGROUND: Futile resuscitation for out-of-hospital cardiac arrest (OHCA) patients in the coronavirus disease (COVID)-19 era can lead to risk of disease transmission and unnecessary transport. Various existing basic or advanced life support (BLS or ALS, respectively) rules for the termination of resuscitation (TOR) have been derived and validated in North America and Asian countries. This study aimed to evaluate the external validation of these rules in predicting the survival outcomes of OHCA patients in the COVID-19 era. METHODS: This was a multicenter observational study using the WinCOVID-19 Daegu registry data collected during February 18-March 31, 2020. The subjects were patients who showed cardiac arrest of presumed cardiac etiology. The outcomes of each rule were compared to the actual patient survival outcomes. The sensitivity, specificity, false positive value (FPV), and positive predictive value (PPV) of each TOR rule were evaluated. RESULTS: In total, 170 of the 184 OHCA patients were eligible and evaluated. TOR was recommended for 122 patients based on the international basic life support termination of resuscitation (BLS-TOR) rule, which showed 85% specificity, 74% sensitivity, 0.8% FPV, and 99% PPV for predicting unfavorable survival outcomes. When the traditional BLS-TOR rules and KoCARC TOR rule II were applied to our registry, one patient met the TOR criteria but survived at hospital discharge. With regard to the FPV (upper limit of 95% confidence interval < 5%), specificity (100%), and PPV (> 99%) criteria, only the KoCARC TOR rule I, which included a combination of three factors including not being witnessed by emergency medical technicians, presenting with an asystole at the scene, and not experiencing prehospital shock delivery or return of spontaneous circulation, was found to be superior to all other TOR rules. CONCLUSION: Among the previous nine BLS and ALS TOR rules, KoCARC TOR rule I was most suitable for predicting poor survival outcomes and showed improved diagnostic performance. Further research on variations in resources and treatment protocols among facilities, regions, and cultures will be useful in determining the feasibility of TOR rules for COVID-19 patients worldwide.

Confirmation of COVID-19 in Out-of-Hospital Cardiac Arrest Patients and Postmortem Management in the Emergency Department during the COVID-19 Outbreak.

BACKGROUND: There is currently a lack of evidence-based postresuscitation or postmortem guidelines for patients with out-of-hospital cardiac arrest (OHCA) in the setting of an emerging infectious disease. This study aimed to develop and validate a multimodal screening tool that aids in predicting the disease confirmation in emergency situations and patients with OHCA during a coronavirus disease 2019 (COVID-19) outbreak. MATERIALS AND METHODS: We conducted a retrospective, multicenter observational study of adult patients with OHCA in Daegu, Korea. To identify the potential predictors that could be used in screening tools in the emergency department, we applied logistic regression to data collected from March 1 to March 14. The prediction performance of the screening variables was then assessed and validated on the data of patients with OHCA who were treated between February 19 and March 31, 2020. General patient characteristics and hematological findings of the COVID-19-negative and COVID-19-positive groups were compared. We also evaluated confirmation test criteria as predictors for COVID-19 positivity in patients with OHCA. RESULTS: Advanced age, body temperature, and abnormal chest X-ray (CXR) revealed significant predictive ability in the derivation cohort. Of the 184 adult patients with OHCA identified in the validation cohort, 80 patients were included in the analysis. Notably, 9 patients were positive and 71 were negative on the COVID-19 reverse transcription polymerase chain reaction test. Five patients (55.6%) in the COVID-19-positive group had a fever before OHCA, and 12 (16.9%) of the COVID-19-negative group had a fever before OHCA (P = 0.018). Eight patients (88.9%) in the COVID-19-positive group had a CXR indicating pneumonic infiltration. Of the criteria for predicting COVID-19, fever or an abnormal CXR had a sensitivity of 100% (95% confidence interval [CI]: 65.4 - 100) and a specificity of 22.5% (95% CI: 13.5 - 34.0). CONCLUSION: The screening tools that combined fever or abnormal CXR had a good discriminatory ability for COVID-19 infection in adult patients with OHCA. Therefore, during the COVID-19 outbreak period, it is recommended to suspect COVID-19 infection and perform COVID-19 test if patients present with a history of fever or show abnormal findings in postmortem CXR.

Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City.

BACKGROUND: When an emergency-care patient is diagnosed with an emerging infectious disease, hospitals in Korea may temporarily close their emergency departments (EDs) to prevent nosocomial transmission. Since February 2020, multiple, consecutive ED closures have occurred due to the coronavirus disease 2019 (COVID-19) crisis in Daegu. However, sudden ED closures are in contravention of laws for the provision of emergency medical care that enable the public to avail prompt, appropriate, and 24-hour emergency medical care. Therefore, this study ascertained the vulnerability of the ED at tertiary hospitals in Daegu with regard to the current standards. A revised triage and surveillance protocol has been proposed to tackle the current crisis. METHODS: This study was retrospectively conducted at 6 level 1 or 2 EDs in a metropolitan city where ED closure due to COVID-19 occurred from February 18 to March 26, 2020. The present status of ED closure and patient characteristics and findings from chest radiography and laboratory investigations were assessed. Based on the experience from repeated ED closures and the modified systems that are currently used in EDs, revised triage and surveillance protocols have been developed and proposed. RESULTS: During the study period, 6 level 1 or 2 emergency rooms included in the study were shut down 27 times for 769 hours. Thirty-one confirmed COVID-19 cases, of whom 7 died, were associated with the incidence of ED closure. Typical patient presentation with respiratory symptoms of COVID-19 was seen in less than 50% of patients, whereas abnormal findings on chest imaging investigations were detected in 93.5% of the study population. The chest radiography facility, resuscitation rooms, and triage area were moved to locations outside the ED, and a new surveillance protocol was applied to determine the factors warranting quarantine, including symptoms, chest radiographic findings, and exposure to a source of infection. The incidence of ED closures decreased after the implementation of the revised triage and surveillance protocols. CONCLUSION: Triage screening by emergency physicians and surveillance protocols with an externally located chest imaging facility were effective in the early isolation of COVID-19 patients. In future outbreaks of emerging infectious diseases, efforts should be focused toward the provision of continued ED treatment with the implementation of revised triage and surveillance protocols.

Preparedness of personal protective equipment and implementation of new CPR strategies for patients with out-of-hospital cardiac arrest in the COVID-19 era.

BACKGROUND: In February and March 2020, healthcare providers and citizens in Daegu, South Korea, experienced the onslaught of a large-scale community epidemic of COVID-19. This had a profound impact on patients who experienced out-of-hospital cardiac arrest (OHCA). METHODS: We conducted a retrospective observational study of 171 OHCA patients based on the multicenter WinCOVID registry. Demographic and clinical characteristics, overall survival, COVID-19 related data, as well as personal protective equipment (PPE) and resuscitation techniques used during the COVID-19 outbreak were evaluated and compared with outcomes from a 2018 historical cohort (n â€‹= â€‹158). RESULTS: Among the interventions, high-level PPE was introduced and standard cardiopulmonary resuscitation was changed to chest compressions using mechanical devices. All OHCA patients were treated as confirmed or suspicious for COVID-19 regardless of symptoms. Furthermore, complete or partial closures of emergency centers and the number of medical personnel requiring self-isolation decreased in response to the introduction of isolated resuscitation units. However, the adjusted odds ratio and 95% confidence intervals for survival discharge and favorable neurologic outcome were 0.51 (0.25-0.97) and 0.45 (0.21-1.07) compared with those in the 2018 historical cohort. CONCLUSIONS: Responses to the COVID-19 pandemic included changes to current PPE strategies and introduction of isolated resuscitation units; the latter intervention reduced the number of unexpected closures and quarantines of emergency resources early on during the COVID-19 outbreak. Given the possibility of future outbreaks, we need to have revised resuscitation strategies and the capacity to commandeer emergency resources for OHCA patients.

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy.

Purpose: We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA). Methods: This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups. Results: The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups. Conclusion: SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Splenic artery aneurysm with the double-rupture phenomenon.

Splenic artery aneurysm is the third most common type of intra-abdominal aneurysm, with a prevalence rate of 0.01% to 10.4% in the general population. Splenic artery aneurysm is usually asymptomatic and is typically detected by chance and does not require surgical management; however, if rupture occurs, although rare, the patient's situation can become critical. We report our experience with a man who presented with left flank and left shoulder pain. His symptoms were caused by multiple hematomas confined to the spleen, but 2 days after admission, he developed delayed hemoperitoneum and required surgical management. We believe that his condition was due to delayed intraperitoneal bleeding called the double-rupture phenomenon; emergency physicians must consider this phenomenon when taking care of splenic artery aneurysm patients.