Emergency department activities at the Athletes' Village during the Tokyo 2020 Olympic and Paralympic Games.

Aim: More than 15,000 elite athletes participated in the Tokyo 2020 Olympic and Paralympic Games. Providing adequate medical services to these elite athletes was a priority. Hence, a polyclinic was established in the Athletes' Village. Visitors were triaged at the emergency department of the polyclinic to enable early treatment of critical illnesses or injuries in the emergency room (ER) and to identify patients suspected of having coronavirus disease as early as possible. No reports of emergency department activities at large sporting events in the pandemic era are available. Here, we aim to summarize the activities at the emergency department of the polyclinic. Methods: Data were collected using an electronic medical record system, nursing records, and questionnaires administered during triage from July 13 to September 8, 2021. Polyclinic data involving accredited athletes and team members were summarized. Results: During the Olympic Games, 12,318 triage cases were reported, of which 75 were treated in the ER. During the Paralympic Games, 8398 triage cases were reported, of which 94 were treated in the ER. During the Olympic Games, musculoskeletal issues (26 patients) were the most common. During the Paralympic Games, ear, nose, and throat issues were the most common (21 patients). Two patients experienced cardiopulmonary arrest in the Athletes' Village and were transported to the hospital postresuscitation. Conclusion: During the study period, many critically ill patients were triaged and treated at the emergency department. Our data can be used to improve medical care and infection prevention at future international sporting events.

Breath-by-breath P0.1 measured on quasi-occlusion via Hamilton C6 may result in underestimation of respiratory drive and inspiratory effort.

We aimed to identify the threshold for P0.1 in a breath-by-breath manner measured by the Hamilton C6 on quasi-occlusion for high respiratory drive and inspiratory effort. In this prospective observational study, we analyzed the relationships between airway P0.1 on quasi-occlusion and esophageal pressure (esophageal P0.1 and esophageal pressure swing). We also conducted a linear regression analysis and derived the threshold of airway P0.1 on quasi-occlusion for high respiratory drive and inspiratory effort. We found that airway P0.1 measured on quasi-occlusion had a strong positive correlation with esophageal P0.1 measured on quasi-occlusion and esophageal pressure swing, respectively. Additionally, the P0.1 threshold for high respiratory drive and inspiratory effort were calculated at approximately 1.0 cmH2O from the regression equations. Our calculations suggest a lower threshold of airway P0.1 measured by the Hamilton C6 on quasi-occlusion than that which has been previously reported.

Prevalence of COVID-19 Mimics in the Emergency Department.

Objective Due to the lack of specific clinical manifestations and symptoms, it is difficult to distinguish COVID-19 from mimics. A common pitfall is to rush to make a diagnosis when encountering a patient with COVID-19-like symptoms. The present study describes a series of COVID-19 mimics using an outpatient database collected from a designated COVID-19 healthcare facility in Tokyo, Japan. Methods We established an emergency room (ER) tailored specifically for patients with suspected or confirmed COVID-19 called the "COVID-ER." In this single-center retrospective cohort study, we enrolled patients who visited the COVID-ER from February 1 to September 5, 2020. The outcomes included the prevalence of COVID-19, admission, potentially fatal diseases and final diagnosis. Results We identified 2,555 eligible patients. The median age was 38 (interquartile range, 26-57) years old. During the study period, the prevalence of COVID-19 was 17.9% (457/2,555). Non-COVID-19 diagnoses accounted for 82.1% of all cases. The common cold had the highest prevalence and accounted for 33.0% of all final diagnoses, followed by gastroenteritis (9.4%), urinary tract infections (3.8%), tonsillitis (2.9%), heat stroke (2.6%) and bacterial pneumonia (2.1%). The prevalence of potentially fatal diseases was 14.2% (298/2,098) among non-COVID-19 patients. Conclusion Several potentially fatal diseases remain masked among the wave of COVID-19 mimics. It is imperative that a thorough differential diagnostic panel be considered prior to the rendering of a COVID-19 diagnosis.

Abnormal pulmonary function and imaging studies in critical COVID-19 survivors at 100 days after the onset of symptoms.

BACKGROUND: The long-term repercussions of critical COVID-19 on pulmonary function and imaging studies remains unexplored. In this study, we investigated the pulmonary function and computed tomography (CT) findings of critical COVID-19 patients approximately 100 days after symptom onset. METHODS: We retrospectively extracted data on critical COVID-19 patients who received invasive mechanical ventilation during hospitalization from April to December 2020 and evaluated their pulmonary function, residual respiratory symptoms and radiographic abnormalities on CT. RESULTS: We extracted 17 patients whose median age was 63 (interquartile range [IQR], 59-67) years. The median lengths of hospitalization and mechanical ventilation were 23 (IQR, 18-38) and 9 (IQR, 6-13) days, respectively. At 100 days after symptom onset, the following pulmonary function abnormalities were noted in 8 (47%) patients: a diffusion capacity of the lung for carbon monoxide (%DLCO) of <80% for 6 patients (35%); a percent vital capacity (%VC) of <80% for 4 patients (24%); and a forced expiratory volume in one second/forced vital capacity (FEV1%) of <70% for 1 patient (6%) who also presented with %DLCO and %VC abnormalities. Twelve (71%) patients reported residual respiratory symptoms and 16 (94%) showed abnormalities on CT. CONCLUSIONS: Over 90% of the critical COVID-19 patients who underwent invasive mechanical ventilation continued presenting with abnormal imaging studies and 47% of the patients presented with abnormal pulmonary function 100 days after symptom onset. The extent of the residual CT findings might be associated with the degree of abnormal pulmonary function in critical COVID-19 survivors.

Two Cases of Post-intubation Laryngotracheal Stenosis Occurring after Severe COVID-19.

We experienced two cases of post-intubation laryngotracheal stenosis (PILS) occurring in patients after acute coronavirus disease (COVID)-19 in a relatively narrow time period. The patients required mechanical ventilation for 9 days in one and 28 days in the other. In both cases, the patients were discharged but later developed symptoms of cough and dyspnea, which were later diagnosed as PILS. Persistent cough and dyspnea are common symptoms in both PILS and the recovery phase of severe COVID-19. For this reason, PILS should be considered in the differential diagnosis post-COVID-19 patients. In addition, the prevalence of PILS may be greater than that of other critical diseases in severe COVID-19 patients.

Delayed bleeding complication due to internal mammary artery injury after ultrasound-guided percutaneous catheter drainage for liver cyst infection.

BACKGROUND: Ultrasound-guided percutaneous catheter drainage (PCD) is widely accepted as a primary treatment for pyogenic liver abscess. Severe PCD-related complications have been reported; however, delayed bleeding complications due to internal mammary artery injury are unknown. CASE PRESENTATION: An 84-year-old man undergoing hemodialysis owing to chronic kidney disease due to focal segmental glomerulosclerosis was admitted to our hospital for liver cyst infection. Ultrasound-guided PCD was carried out through the normal liver at the upper abdominal midline at the level of the sixth intercostal space. Two days later, an abdominal hematoma occurred at the puncture site. Contrast-enhanced computed tomography revealed extravasation of the distal right internal mammary artery, which was successfully treated with percutaneous coil embolization. CONCLUSION: Internal mammary artery injury should be considered as a differential diagnosis when a progressing hematoma develops after PCD.

[Diaphragmatic Injury Due to Blunt Trauma Diagnosed by a Diagnostic Thoracoscopy;Report of a Case].

We performed an exploratory thoracoscopy for a suspected diaphragm injury caused by a blunt-force chest trauma. A male patient in his fifties involved in a traffic accident and was transported by ambulance to our hospital. Upon arrival, his vital signs were stable, however, he was diagnosed as having fractures of the right tibia and fibula, multiple rib fractures and a slight right hemothorax. The limb fracture was treated by emergency surgery and the chest trauma was managed by chest drainage. Since injury of the diaphragm by fragment of the right 10th rib was suspected with chest computed tomography(CT), an exploratory thoracoscopy was performed after orthopedic surgery, and a laceration of the diaphragm without herniation was successfully closed.

Body temperature change and outcomes in patients undergoing long-distance air medical transport.

BACKGROUND: Short-distance air medical transport for adult emergency patients does not significantly affect patients' body temperature and outcomes. This study aimed to examine the influence of long-distance air medical transport on patients' body temperatures and the relationship between body temperature change and mortality. METHODS: We retrospectively enrolled consecutive patients transferred via helicopter or plane from isolated islands to an emergency medical center in Tokyo, Japan between April 2010 and December 2016. Patients' average body temperature was compared before and after air transport using a paired t-test, and corrections between body temperature change and flight duration were calculated using Pearson's correlation coefficient. Multivariable logistic regression models were then used to examine the association between body temperature change and in-hospital mortality. RESULTS: Of 1253 patients, the median age was 72 years (interquartile range, 60-82 years) and median flight duration was 71 min (interquartile range, 54-93 min). In-hospital mortality was 8.5%, and average body temperature was significantly different before and after air transport (36.7 °C versus 36.3 °C; difference: -0.36 °C; 95% confidence interval, -0.30 to -0.42; p < 0.001). There was no correlation between body temperature change and flight duration (r = 0.025, p = 0.371). In-hospital death was significantly associated with (i) hyperthermia (>38.0 °C) or normothermia (36.0-37.9 °C) before air transport and hypothermia after air transport (odds ratio, 2.08; 95% confidence interval, 1.20-3.63; p = 0.009), and (ii) winter season (odds ratio, 2.15; 95% confidence interval, 1.08-4.27; p = 0.030). CONCLUSION: Physicians should consider body temperature change during long-distance air transport in patients with not only hypothermia but also normothermia or hyperthermia before air transport, especially in winter.

Persistent Vegetative State after Diabetic Ketoacidosis Triggered by an Overdose of Psychotropic Agents.

A 28-year-old man with type 1 diabetes mellitus was admitted for shock and coma due to diabetic ketoacidosis. Despite aggressive treatment and management of the patient's underlying clinical issues, the patient remained in a comatose state. Further investigations revealed an excess consumption of psychotropic agents; however, there was no evidence of an insulin overdose. Physicians should be aware that, in patients who are highly dependent upon insulin, an overdose of psychotropic agents can lead to hypoxic-ischemic brain injury.

Fulminant type 1 diabetes mellitus with remarkable elevation of serum pancreatic enzymes.

Fulminant type 1 diabetes mellitus progresses extremely rapidly and is accompanied by ketoacidosis. Patients with the disease present at emergency departments with non-specific symptoms, including fever, nausea, vomiting, and abdominal pain. Here, we present a case of fulminant type 1 diabetes mellitus where the patient was initially misdiagnosed with gastroenteritis and acute pancreatitis. A 50-year-old Japanese woman was referred to our hospital with coma and shock. She had presented with nausea, vomiting, abdominal pain and thirst from 5 days before admission, and had been misdiagnosed with gastroenteritis by her primary care physician. Upon examination, metabolic acidosis and remarkable elevation of pancreatic exocrine enzymes were found (amylase 4322 IU/L, lipase 1046 IU/L). Acute pancreatitis was initially suspected because of the high pancreatic enzyme levels and abdominal pain. However, her plasma glucose level was markedly elevated at 1357 mg/dL. The patient was diagnosed with fulminant type 1 diabetes mellitus. Computed tomography showed no radiological evidence of acute pancreatitis. In conclusion, fulminant type 1 diabetes mellitus is often referred to hospital with flu-like or gastrointestinal symptoms and elevation of serum pancreatic enzymes. Physicians must be sure not to misdiagnose it as gastroenteritis or acute pancreatitis.

Giant Iliopsoas Abscess Caused by Morganella Morganii.

BACKGROUND While uncommon, iliopsoas abscesses can become the underlying cause of a fever of unknown origin. Even in such cases, it is considered rare for an iliopsoas abscess to extend into the subcutaneous space. CASE REPORT A 74-year-old woman with a history of schizophrenia was referred to our hospital with a high-grade fever. The patient was unaware of her febrile status prior to admission. There was no previous hospital admission. Examination revealed a non-tender mass in the lower right back that the patient had been aware of for approximately 1 month. Initially, we considered a subcutaneous abscess; however, computed tomography (CT) detected a large mass in the right retroperitoneum, which extended into the adjacent subcutaneous space. Surgical drainage was performed. M. morganii was detected in fluid evacuated from the abscess and in a urine culture. Blood cultures were negative. A repeat enhanced CT revealed a right renal abscess with staghorn calculus. This iliopsoas abscess was considered to be due to a renal abscess. The combination of a minimally aggressive bacterial species and the absence of disease awareness resulted in uncontrolled abscess growth in this case. Surgical drainage and salvage nephrectomy was subsequently performed, and she was discharged to a nursing home. CONCLUSIONS M. morganii can lead to massive abscess formation without an underlying immunocompromised status. Iliopsoas abscesses can surreptitiously extend into the subcutaneous space; therefore, not all abscesses observable from the surface are necessarily subcutaneous in origin.

Hemorrhagic giant cystic lymphangioma of the liver in an adult female.

An 18-year-old woman who presented with epigastric pain was diagnosed with rupture of a hepatic tumor and transported to our hospital. Contrast-enhanced computed tomography revealed a 13-cm, low-density giant mass in the left hepatic lobe and high-density ascites, indicating abdominal bleeding from the liver tumor. The patient underwent emergent celiac angiography, and the left hepatic artery, which was believed to feed the tumor, was embolized. After the patient's condition stabilized, she underwent left hepatic lobectomy. In addition, the enlarged lymph nodes of the hepatoduodenal ligament were dissected. On microscopic examination, immunohistochemical staining revealed that both the liver cyst and the enlarged lymph node were positive for the endothelial marker CD31 and lymphangial marker D2-40. The patient was pathologically diagnosed with cystic lymphangioma of the liver. She has now been followed up for almost 4 years after surgery without any sign of recurrence.

[Clinical analysis of delayed hemothorax due to diaphragmatic injury treated by emergent video-assisted thoracic surgery].

We encountered 5 cases of delayed massive hemothorax due to diaphragmatic injury. Delayed hemothorax presented 2∼11 days after injury, with lower rib fractures seen all cases. We performed emergent video-assisted thoracic surgery with mini-thoracotomy for all patients. Lacerations could be clearly visualized in the diaphragm after evacuation of blood clots, which were then sutured. In four cases, the sharp edges of the broken ribs were thought to have caused the diaphragmatic lacerations. The mean blood loss volume was 2,905 ml, and all patients required blood transfusions. However, homeostasis was achieved after surgery, and all patients had an uneventful postoperative course. Although, delayed hemothorax is relatively uncommon, it needs to be considered a lethal condition.