Atrioesophageal fistula (AEF) is an important complication of radiofrequency ablation (RFA). Delayed diagnosis is associated with increased morbidity and mortality. Despite the name “atrioesophageal fistula,” fistulas functionally act esophageal to atrial, which accounts for the neurologic and infectious complications. This report presents the management of a 60-year-old male patient who was admitted to the emergency department (ED) with AEF-caused gastrointestinal bleeding. The patient was operated urgently, but he had serious comorbidities and died after the operation. The aim of this case was to evaluate patients who underwent RFA, within 10 days to two months, carefully in the ED and to know the possible complications.

Up until now, there is much debate about the role of asymptomatic patients and pauci-symptomatic patients in severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2) transmission, and little is known about the kinetics of viral ribonucleic acid (RNA) shedding in these populations. This article aims to describe key features and the nature of asymptomatic and pauci-symptomatic SARS-CoV-2 infected patients. The cohort consisted of six participants, three pairs, which were infected with SARS-CoV-2 during February 2020 on board the Diamond Princess. Of the six confirmed (reverse transcription polymerase chain reaction [RT-PCR]) cases, four were initially diagnosed in Japan and two upon their arrival to Israel. Duration of infection was between four days and up to 26 days. Of the six patients, three were completely asymptomatic and the others were pauci-symptomatic. All five patients in whom a computerized tomography (CT) scan was performed had lung pathology. In one patient, infectivity was tested using cell culture and a cytopathic effect was demonstrated. A serology test was performed in three of the patients and all three had a positive immunoglobulin G (IgG) four to eight weeks after disease onset. This case series demonstrates that asymptomatic and pauci-symptomatic patients may play a role in infection transmission by demonstrating probable transmission among asymptomatic spouses and by demonstrating a viable virus via a cell culture. Additionally, asymptomatic and pauci-symptomatic patients can have lung pathology and developing IgG antibodies.

Coronavirus Disease 2019 (COVID-19), a new respiratory disease, is spreading globally. In France, Emergency Medical Service (EMS) teams are mobile medicalized resuscitation teams composed of emergency physician, nurse or anesthesiologist nurse, ambulance driver, and resident. Four types of clinical cases are presented here because they have led these EMS teams to change practices in their management of patients suspected of COVID-19 infection: cardiac arrest, hypoxia on an acute pneumonia, acute chronic obstructive pulmonary disease (COPD) exacerbation with respiratory and hemodynamic disorders, and upper function disorders in a patient in a long-term care facility. The last case raised the question of COVID-19 cases with atypical forms in elderly subjects. Providers were contaminated during the management of these patients. These cases highlighted the need to review the way these EMS teams are responding to the COVID-19 pandemic, in view of heightening potential for early identification of suspicious cases, and of reinforcing the application of staff protection equipment to limit risk of contamination.

Introduction: CT scan is the most common imaging modality for suspected renal colic and is used for about 80% of presentations. Cumulative ionizing radiation exposure from repeat CT scans increases long-term cancer risk. Despite a 10-fold increase in CT use to detect kidney stones in the ED in just over a decade, there has been no increase in the proportion of kidney stones diagnosed, number of significant alternate diagnoses or admissions to hospital. Choosing Wisely recommends to avoid ordering CT of the abdomen/pelvis in otherwise healthy patients<age 50 presenting to the ED with known history of kidney stones and with symptoms consistent with uncomplicated renal colic. The aim is that >90% of patients < age 50 with a history of renal stones arriving in Sunnybrook ED with symptoms consistent with renal colic will be managed without a CT abdomen/pelvis. Methods: Emergency physicians were engaged in the process at various stages, including a brainstorming session to perform a root cause analysis. A Driver diagram was created to generate change ideas. Outcome Measure Number of CT scans ordered for target population (Results: Results to date indicate that there is a non-sustained decrease in the number of CT scans performed on ED patients < age 50 with recurrent renal colic. The STONE score was infrequently used, thus making it difficult to standardize CT ordering for presumed renal colic. Conclusion: As a result of this QI initiative, there is awareness amongst emergency physicians of a patient population that is over imaged with CT scan, often with no change in management. Introduction of a low dose CT scan order was the greatest gain from this QI initiative. In order to decrease CT utilization, physicians need to be shown the lack of benefit of CT use and a safe alternative diagnostic approach.

Introduction: Computerized tomography for pulmonary embolism (CTPE) has come under increased scrutiny with recommendations for evidence-based use found on Choosing Wisely lists in both Canada and the US. However practice variation in ordering patterns and diagnostic yield have not been well-reported for the Canadian context. Our objective was to investigate practice variation in CTPE ordering and rule-in rates within a large group of specialty-trained emergency physicians. Methods: We undertook an analysis of a computerized physician order entry database from four tertiary care EDs covering a 12-month period from August 1, 2016 to July 30, 2016 with 31 419 visits for potential pulmonary embolism (PE) as determined by a previously validated algorithm based on presenting complaints. CTPE utilization and diagnostic yield were determined for 149 physicians who ordered at least 10 studies over that time period. Outcomes of interest included CT utilization as determined by electronic order entry and a confirmed diagnosis of PE based on ICD-10 coding of the emergency visit. Descriptive statistics using medians, IQR and 95% confidence intervals are reported. This study is approved through REB14-0650 and is a component of a larger cluster RCT to improve CTPE utilization. Results: During the study period 2670 CTPE studies were ordered for potential PE patients representing 8.5% of the total with relevant complaints. We observed a 10-fold variation in CTPE ordering among physicians with rates as low as 2.7% and as high as 25%. The median rate of CTPE ordering for potential PE was 8.8% with an IQR of 6.0% to 11.7%. A total of 4146 CTPE studies were ordered during the study period with physicians ordering an average of 28 CTPE studies each; range 10-90. In terms of diagnostic yield, 591/4146 studies, or 14.3% (95% CI 13.2-15.3%) were associated with a diagnosis of PE. Diagnostic yield per physician ranged from 0 to 50%, with a median of 13.5% and an IQR of 7.6% to 21.4%. Conclusion: In this large, robust administrative dataset from four Canadian urban EDs, threshold for CTPE ordering varies widely among physicians as does diagnostic yield. Efforts to improve appropriate utilization are justified with an eye to reducing unnecessary radiation, costs and incidental findings.

The optimal method for securing the airway in injured patients is controversial. Maxillofacial injury has been shown to be a marker for difficult airway management; however, a delay in intubation may result in deterioration of intubating conditions due to further airway bleeding and swelling. Decisions on the timing and method of airway management depend on multiple factors, including patient characteristics, the skill set of the clinicians, and logistical considerations. This report describes the case of a multi-agency response to a motor-vehicle collision in a rural area in Ireland. One young male patient had sustained significant maxillofacial injuries, multiple limb injuries, and had a decreased level of consciousness. Further airway compromise occurred following extrication. Difficult intubation was predicted; however, abnormal jaw mobility from bilateral mandibular fractures enabled easy laryngoscopy and intubation. Although preparation must be made for difficult airway management in the setting of maxillofacial injury, appropriately trained and experienced practitioners should not be deterred from performing early intubation when indicated.

Glasheen J, Hennelly D, Cusack S. Maxillofacial Injury—Not Always a Difficult Airway. Prehosp Disaster Med. 2015;30(4):1 –4.

A 25-year-old male developed a traumatic intimo-medial dissection and saccular pseudoaneurysm at the origin of the innominate artery following a motorcycle accident. On physical examination there was no perceivable trauma to the chest. In addition, there were no clinical symptoms that suggested this serious injury. The patient was managed with successful stent-graft placement on an elective basis.

AzarconF, GhalebM. Early Diagnosis and Treatment of a Posttraumatic Pseudoaneurysm/Dissection of the Innominate Artery. Prehosp Disaster Med. 2014;29(1):1-3.

Three dimensional images derived from X-Rays, scans or Digital Cone Beam Computed Tomography (CBCT) are components of supplementary diagnostic procedures. Using them, practitioners can visualize the anatomic relationships of teeth with each other and with adjacent structures and can discern the presence or absence of root resorption.

These radiographic films can assist in the diagnostic evaluation of impacted, transposed, or duplicated teeth or those situated on the edges of facial clefts. They are indispensable in helping diagnosticians to rule out contraindications as they establish treatment plans and continue to be useful as guides when mechano- therapy starts.

Recently, CBCT has become accessible for use in dental offices even though it has been an expensive and bulky instrument with a relatively high radiation output. Today, with a more acceptable radiation dosage, it is well accepted as an alternative diagnostic procedure in the field of oro-facial implants, but overall, it cannot yet be considered as a technique that should be systematically employed in every supplementary examination.

The coronary arteries, the vessels through which both substrate and oxygen are provided to the cardiac muscle, normally arise from paired stems, right and left, each arising from a separate and distinct sinus of the aortic valve. The right coronary artery runs through the right atrioventricular groove, terminating in the majority of instances in the inferior interventricular groove. The main stem of the left coronary artery bifurcates into the anterior descending, or interventricular, and the circumflex branches. Origin of the anterior descending and circumflex arteries from separate orifices from the left sinus of Valsalva occurs in about 1% of the population, while it is also frequent to find the infundibular artery arising as a separate branch from the right sinus of Valsalva.

Anomalies of the coronary arteries can result from rudimentary persistence of an embryologic coronary arterial structure, failure of normal development or normal atrophy as part of development, or misplacement of connection of a an otherwise normal coronary artery. Anomalies, therefore, can be summarized in terms of abnormal origin or course, abnormal number of coronary arteries, lack of patency of the orifice of coronary artery, or abnormal connections of the arteries.

Anomalous origin of the left coronary artery from the pulmonary trunk occurs with an incidence of approximately 1 in 300,000 children. The degree of left ventricular dysfunction produced likely relates to the development of collateral vessels that arise from the right coronary artery, and provide flow into the left system. Anomalous origin of either the right or the left coronary artery from the opposite sinus of Valsalva can be relatively innocuous, but if the anomalous artery takes an interarterial course between the pulmonary trunk and the aorta, this can underlie sudden death, almost invariably during or immediately following strenuous exercise or competitive sporting events. Distal anomalies of the coronary arteries most commonly involve abnormal connections, or fistulas, between the right or left coronary arterial systems and a chamber or vessel.

We discuss the current techniques available for imaging these various lesions, along with their functional assessment, concluding with a summary of current strategies for management.

Objectives: Magnetic resonance imaging (MRI) and computerized tomography (CT) scanners are high-tech equipment with the highest utilizations and expenditures in Taiwan. This study investigates the factors that affect MRI and CT utilization, such as whether supply-side factors have more impact than demand-side factors, and the effect of utilization control policies.

Methods: This study used the nationwide CT and MRI claim data for the years 1998 to 2001 from the Bureau of National Health Insurance (BNHI) in Taiwan. Multiple regression analysis was the statistical method used to determine the relative factors that influence CT and MRI utilization.

Results: CT : population ratio, hospital-based physician : population ratio, female ratio, pediatric (≤14 years) : population ratio, and family income significantly influenced CT utilization. MRI : population ratio and hospital-based physician : population ratio, female ratio, and family income significantly influenced MRI utilization. However, the proportion of the aged (≥65 years of age) did not significantly influence CT or MRI utilization after controlling for other factors. The rates of CT and MRI utilization for the outpatient and inpatient settings and the repeated uses of CT or MRI have decreased significantly after a utilization review was implemented by BNHI, which suggests that CT and MRI have been overused.

Conclusions: Increases in supply-side factors significantly increase CT/MRI utilization, and supply-side factors impact CT/MRI utilization more than demand-side factors. The results show that the utilization instant report policy effectively decreases repeated uses of CT/MRI.