Aortic Saddle Embolism: A Common Complaint With Multifaceted Catastrophe Disease.

Non-traumatic lower back pain is a common complaint seen in all emergency department (ED) visits. For many individuals, episodes of back pain are self-limited, but rarely, back pain is a signal of serious medical illness. A 58-year-old male was admitted to our ED suffering from lower back pain with radiation to the lower legs. Examination found bilateral lower limbs weakness with numbness and weak dorsalis pedis pulse. This is the point which peripheral arterial disease was considered and contrast computed tomography scan of abdomen and pelvis was arranged. Enormous aortic bifurcation clots were seen. This patient was soon to recover from the illness after receiving transfemoral catheterization thrombolysis and stenting. Aortic saddle embolism is a rare case of spontaneous acute aortic occlusion which the embolus terminated and straddled at the aortic bifurcation, producing bilateral lower extremity arterial obstruction and led to serious hemodynamic and metabolic consequences. The objective in this report is to raise awareness about this potentially fatal condition. In addition, to emphasize the importance of a thorough assessment and expeditious treatment in order to prevent serious complications including limb loss and potential mortality.

Thyroid Cancer With Cardiac Metastasis Presented With New Onset of Atrial Fibrillation.

Atrial fibrillation (Af) is frequently seen in the emergency department (ED), and the main concern of which is the potential to lead to blockage of blood flow. Cardiac tumors can also present with Af, which are often overlooked due to the rarity but clinically significant. A 70-year-old woman presented at our ED with intermittent palpitation and dizziness for several weeks. She has an underlying disease of right thyroid follicular carcinoma status-post surgery many years ago, but no history of heart disease. Her electrocardiogram (ECG) showed Af, and the transthoracic echocardiography showed a huge mass occupying the left atrium. The patient underwent an open-heart surgery with tumor excision. The pathology revealed metastatic thyroid follicular carcinoma. The patient recovered smoothly, and her ECG showed normal sinus rhythm after the operation. Most cardiac secondary tumors remain clinically silent and are often diagnosed postmortem. These conditions are rare but clinically significant; therefore, the physician should always raise suspicion of metastatic cardiac tumor as the differential diagnosis when patient presents with an unexplained Af.

Depressed sympathovagal modulation indicates sepsis in patients with suspected infection.

This study explored whether sympathovagal modulation assessed through frequency domains of heart rate variability (HRV) can indicate sepsis in patients with suspected infection.In total, 370 consecutive adult patients with suspected infection admitted to the emergency department were enrolled in this single-center cohort study. A continuous 10-minute electrocardiography for HRV analysis was recorded immediately for these patients after inclusion. Patients were stratified into non-sepsis and sepsis groups based on a sepsis-related organ failure assessment score of ≥2 that met the Third International Consensus Definitions for Sepsis. Seven frequency domains of HRV were compared between these 2 groups.Compared with the non-sepsis group (n = 98), the sepsis group (n = 272) had a significantly lower incidence of respiratory tract infection, higher total power, higher very-low-frequency component, higher high-frequency (HF) component, higher normalized HF component, lower normalized low-frequency (LF) component, and lower LF component/HF component ratio (LF/HF). Multiple logistic regression model identified HF component (odds ratio [OR] = 0.994; 95% confidence interval [CI], 0.990-0.999) and LF/HF (OR = 0.494; 95% CI, 0.423-0.578) as significant variables associated with sepsis. The area under receiver operating characteristic curves of HF component and LF/HF was 0.741 (95% CI, 0.685-0.797) and 0.930 (95% CI, 0.900-0.960), respectively, in identifying sepsis in patients with suspected infection.Tilted sympathovagal balance toward increased vagal activity and depressed sympathetic modulation, assessed by the HF component and LF/HF, may indicate sepsis in patients with suspected infection.

Utilization of systemic inflammatory response syndrome criteria in predicting mortality among geriatric patients with influenza in the emergency department.

BACKGROUND: Systemic Inflammatory Response Syndrome (SIRS) criteria are often used to evaluate the risk of sepsis and to identify in-hospital mortality among patients with suspected infection. However, utilization of the SIRS criteria in mortality prediction among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, we conducted a research to delineate this issue. METHODS: This is a retrospective case-control study including geriatric patients (age ≥ 65 years) with influenza, who presented to the ED of a medical center between January 1, 2010 and December 31, 2015. Vital signs, past history, subtype of influenza, demographic data, and outcomes were collected from all patients and analyzed. We calculated the accuracy for predicting 30-days mortality using the SIRS criteria. We also performed covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling. RESULTS: We recruited a total of 409 geriatric patients in the ED, with mean age 79.5 years and an equal sex ratio. The mean SIRS criteria score was 1.9 ± 1.1. The result of a Hosmer-Lemeshow goodness-of-fit test was 0.34 for SIRS criteria. SIRS criteria score ≥ 3 showed better mortality prediction, with odds ratio (OR) 3.37 (95% confidence interval (CI), 1.05-10.73); SIRS score ≥ 2 showed no statistical significance, with p = 0.85 (OR, 1.15; 95% CI, 0.28-4.69). SIRS score ≥ 3 had acceptable 30-days mortality discrimination, with AUROC 0.77 (95% CI, 0.68-0.87) after adjustment. SIRS score ≥ 3 also had a notable negative predictive value of 0.97 (95% CI, 0.94-0.99). CONCLUSION: The presence of a higher number of SIRS criteria (≥ 3) showed greater accuracy for predicting mortality among geriatric patients with influenza.

Heart Rate Variability Predicts Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage.

BACKGROUND: An alternation of sympathetic and vagal nervous activity has been suggested to be one possible mechanism of neurogenic pulmonary edema (NPE) in patients with subarachnoid hemorrhage (SAH). The study aimed to explore if sympathovagal modulation assessed by frequency domains of heart rate variability (HRV) is associated with impending NPE in patients with SAH. METHODS: Two hundred forty-eight consecutive spontaneous SAH adult patients were included in this single-center cohort study. A continuous 10-min electrocardiography for HRV analysis was recorded. The patients were stratified into NPE and non-NPE based on serially clinical and radiologic findings within 24 h. Seven frequency domains of HRV were compared between these 2 groups. RESULTS: Compared to the non-NPE (n = 212), the NPE (n = 36) had significantly higher mean arterial pressure, higher World Federation of Neurological Surgeons (WFNS) class, higher Hunt-Hess scale, lower total power (TP), lower very low-frequency component, lower low-frequency component, lower normalized low-frequency component (LF %), higher normalized high-frequency component, and lower low-frequency component/high-frequency component ratio. Multiple logistic regression model identified WFNS class (OR 4.048; 95 % CI 1.589-10.311), LF % (OR 0.933; 95 % CI 0.910-0.958), and TP (OR 0.995; 95 % CI 0.992-0.998) as the significant variables associated with occurrence of NPE. The area under receiver operating characteristic curves of LF % and TP were found to be 0.838 (95 % CI 0.774-0.901) and 0.653 (95 % CI 0.557-0.749), respectively. CONCLUSION: Loss of cardiac variability and depressed sympathovagal modulation, represented by TP and LF %, may predict the development of NPE in the early stage in patients with SAH.

ECG abnormalities predict neurogenic pulmonary edema in patients with subarachnoid hemorrhage.

OBJECTIVE: The study aims to assess if electrocardiographic (ECG) abnormalities could predict the development of neurogenic pulmonary edema (NPE) within 24 hours in cases of spontaneous subarachnoid hemorrhage (SAH). METHODS: We studied prospectively a cohort of 269 adult patients with nontraumatic SAH in an emergency department of a university-affiliated medical center. A 12-lead ECG was taken for these patients. The patients were stratified into NPE and non-NPE based on serially clinical and radiologic findings. The ECG abnormalities were compared between these 2 groups of patients. RESULTS: Compared with the non-NPE (n = 229), the NPE (n = 40) had significantly higher World Federation of Neurological Surgeons class (P < .001), higher Hunt-Hess scale (P < .001), and higher prevalence of diabetes mellitus (P = .033). In addition, the percentage of ECG morphological abnormality was significantly higher in NPE, in which nonspecific ST- or T-wave changes (NSSTTCs) are significantly higher. Multiple logistic regression model identified World Federation of Neurological Surgeons class (95% confidence interval [CI], 2.6-13.3; P < .001), abnormal Q or QS wave (95% CI, 1.1-9.1; P = .038), and NSSTTCs (95% CI, 1.2-7.5; P = .016) as the significant variables associated with NPE. CONCLUSIONS: Electrocardiographic abnormalities, especially abnormal Q or QS wave and NSSTTCs, may predict the development of NPE within 24 hours in adult patients with spontaneous SAH.

Inaccurate or delayed diagnosis of hollow organ perforation by emergency physicians: using a qualitative approach to identify the causes.

BACKGROUND: Mistakes or delays in the diagnosis of hollow organ perforation may be detrimental to prognosis. Nonetheless, emergency physicians (EPs) are prone to misdiagnosing this condition in specific scenarios. The factors leading to errors in their cognitive processes, however, have received little attention. METHODS: Using a qualitative approach, we conducted in-depth semi-structured interviews with EPs in the emergency departments (EDs) of three hospitals in Taiwan. We purposively selected participants to obtain a sample that can contribute essential information about the diagnostic process. Sampling continued until new information was no longer being gathered. All interviews were audio-recorded, transcribed verbatim, and then analyzed by two investigators according to grounded theory. RESULTS: Based on 23 cases from 20 EPs, four themes emerged from the analysis regarding the reasons for diagnostic errors: (1) atypical disease presentations (6/23; 26%), (2) cognitive process of the physicians (21/23; 91%), (3) systemic factors (14/23; 61%), and (4) composite factors (14/23; 61%). CONCLUSIONS: These findings provide valuable insight into the factors that contribute to diagnostic error in cases of abdominal hollow organ perforation. The results offer a basis on which to build a framework for teaching physicians how to avoid misdiagnosing hollow organ perforation in the future.

Lower leg weakness as the presentation of infective endocarditis with septic emboli.

Lower leg weakness is a common and nonspecific complaint that encompasses a broad differential diagnosis at emergency department, which includes neurologic aspect and a wide range of nonneurologic conditions. Infective endocarditis usually presented with variable symptoms emphasizing constitutional complaints, or complaints that focus on primary cardiac effects or secondary embolic phenomena. Underdiagnosis of the disease can lead to clinical catastrophe and even death. By far, it is rarely considered in the differential diagnosis of lower leg weakness. Herein, we present a case of a 56-year-old man who came to our emergency department with a chief concern of lower leg weakness, which was actually the result of L-spine osteomyelitis and spondylodiscitis as complications of infective endocarditis with septic emboli.

Spontaneous septic diskitis: a common complaint with a serious pathologic cause that should not been overlooked.

Many people who have low back pain are likely to be out of work and taking medication and probably make demands on both primary and secondary health care as well as the private sector. Septic diskitis is a rare cause of back pain, accounting for less than 0.01% of cases in the primary care setting (Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am. 1997;79:874-80). It has been associated with a high morbidity and mortality in the past. Although it is an unusual complication in a postoperative patient, it is even more rare in a nonoperative patient. It accounts for 2% of all osteomyelitis (Maiuri F, Iaconetta G, Gallicchio B, Manto A, Briganti F. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine. 1997;22:1741-6) and may occur spontaneously, after surgery (especially after epidural anesthesia), in the immunosuppressed, and systemic infections. It has the potential to be an orthopedic pitfall in the emergency department because it can be presented with nonspecific symptoms, nonspecific laboratory abnormalities, and nondiagnostic radiographic studies. We present a case of low back pain in a previously healthy individual as a result of spontaneous septic diskitis, which had been initially misdiagnosed in the private sector as herniation of an intervertebral disk.