Eric Savitsky

Current controversies in the management of minor pediatric head injuries

Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.

Emergency department presentations of pediatric congenital heart disease.

Numerous studies have described the pathophysiology, clinical manifestations, and treatment of the many forms of congenital heart disease (CHD), but none has specifically addressed the reasons CHD patients present to the Emergency Department (ED). The objective of this study was to provide a descriptive analysis of the ED presentations of acute and seriously ill pediatric CHD patients. We intended to capture a subset of acutely ill CHD patients who had presenting signs and symptoms that were potentially attributable to their underlying CHD. Recognizing the more common presentation patterns for patients with CHD may be of benefit. Adhering to the basic principles of airway, breathing and circulatory (ABC) management is essential when caring for critically ill CHD patients. Patients with complex CHD are often very difficult to correctly diagnose and manage in the ED. They often require extensive inpatient observation and evaluation. A low threshold for inpatient management of these high-risk patients is warranted.

A Novel Method for Enhanced Needle Localization Using Ultrasound-Guidance

In this paper, we propose a novel and fast method to localize and track needles during image-guided interventions. Our proposed method is comprised of framework of needle detection and tracking in highly noisy ultrasound images via level set and PDE (partial differential equation) based methods. Major advantages of the method are: (1) efficiency, the entire numerical procedure can be finished in real-time: (2) robustness, insensitive to noise in the ultrasound images and: (3) flexibility, the motion of the needle can be arbitrary. Our method will enhance the ability of medical care-providers to track and localize needles in relation to objects of interest during image-guided interventions.

Evaluation of Orthotopic Liver Transplant Recipients Presenting to the Emergency Department

Improved survival rates and more centers performing liver transplantation have resulted in increasing numbers of liver transplant recipients presenting to emergency departments. This article familiarizes emergency physicians with orthotopic liver transplantation and complications that cause liver transplant recipients to visit EDs. Savitsky EA, Üner AB, Votey SR: Evaluation of orthotopic liver transplant recipients presenting to the emergency department. Ann Emerg Med April 1998;31:507-517.].

Emergency medical services development in the Seychelles islands

The Republic of the Seychelles enjoys a sophisticated health care system by developing country standards. Basic food, water, sanitation, and preventative health care needs have been addressed and the Seychelles Ministry of Health has recently focused on the need to improve the countrys emergency medical services (EMS). In response to this need, a joint international collaborative effort designed to improve the islands EMS was launched. This report profiles the current health care system in the Seychelles, with special emphasis on EMS. It also describes an international collaborative effort between the Seychelles Ministry of Health and the UCLA Center for International Emergency Medicine designed to improve existing EMS.

Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology

&NA; The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology: Beyond Ultrasound First Forum

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

The Evolving Epidemiology and Management of Spontaneous Pneumothorax

Spontaneous pneumothorax represents air trapped within the pleural space that develops without antecedent trauma. Current understandingregardingtheepidemiologyofspontaneouspneumothoraxhasbeeninformedbysmallstudiesperformedatsingle medical centers or retrospective reviews of national data registries.1,2 The overall incidence of spontaneous pneumothorax has been estimated at 17 to 24/100 000 in the male population and 1 to 6/100 000 in the female population.1-4 Spontaneous pneumothorax recurrence rates have primarily been extrapolated from retrospective case series, with 1to 6-year recurrence rates ranging from 17% to 54%.5,6 In this issue of JAMA, Hallifax et al7 characterize the epidemiology of this condition over 5 decades with an analysis of inpatient-treated spontaneous pneumothorax in England. They report national estimates of incidence and recurrence by age group, sex, and presence or absence of chronic lung disease. The authors used the historical definition of primary spontaneous pneumothorax, which is a spontaneous pneumothorax diagnosed in a patient with no previously identified underlying lung disease or chest trauma.8 Secondary spontaneous pneumothorax was defined as a spontaneous pneumothorax occurring in a patient with an established underlying pathologic lung disorder.8 Hallifax et al analyzed 170 929 hospital admissions in England for spontaneous pneumothorax during the study period and determined that from 1968 to 2016, the annual hospitalization rate increased from 9.1 to 14.1 admissions per 100 000 population aged 15 years or older.7 The authors describe an initial peak in incidence of spontaneous pneumothorax occurring among patients aged 15 to 34 years, the majority of whom had no previously identified lung disorders (primary spontaneous pneumothorax). The subsequent peak in incidence occurred among men and women older than 60 years, many of whom had a previously identified underlying lung disorder (secondary spontaneous pneumothorax). Expectedly, interstitial lung disease and malignancy were significantly more common among patients aged 65 years or older compared with younger patients. Spontaneous pneumothorax recurrence rates were similar for both men and women, with approximately 26% of patients experiencing a recurrence within 5 years of initial pneumothorax diagnosis. Approximately 75% of recurrent pneumothoraces occurred in the first year following the initial pneumothorax. The probability of recurrence varied, depending on age group and presence of underlying lung disease. For example, male patients aged 15 to 34 years with underlying chronic lung disorders had the highest probability of recurrent pneumothorax within 5 years of initial pneumothorax (39.2% recurrence rate). This study by Hallifax et al provides an updated perspective on the epidemiology of spontaneous pneumothorax among hospitalized patients.7 However, the study likely underestimates the true overall incidence of spontaneous pneumothorax by limiting the analysis to inpatient care. The study inclusion criteria would not have accounted for the increasing number of patients with primary spontaneous pneumothorax who are successfully managed as outpatients with simple observation, needle aspiration, or outpatient smallbore catheter thoracostomy management.5,9,10 In addition, the authors’ reliance on precision of coding diagnoses may introduce inaccuracies into differentiation of primary vs secondary spontaneous pneumothorax and recurrence risk factors. This review of historical medical records largely assumed documentation was performed correctly and in sufficient detail for billing coders to discern proper diagnoses. A better understanding of the underlying etiology of spontaneous primary pneumothorax has been developing. Improved imaging modalities and diagnostic approaches have detected evidence of underlying pathologic lung conditions (eg, blebs, emphysematous-like changes, and pleural porosity) among patients traditionally classified as having primary spontaneous pneumothorax.11 Subpleural blebs and bullae have been documented in lung apices during thoracoscopy and with computed tomographic (CT) imaging in a majority of patients with primary spontaneous pneumothorax.12-14 The current widely used definition of primary spontaneous pneumothorax is imprecise and should be revised. From an initial diagnostic evaluation perspective, pneumothorax is typically detected using plain radiographs and, increasingly, bedside ultrasound.15 CT imaging is used to screen for underlying lung disorders in patients with pneumothorax, to better delineate concurrent pathologic findings in select patients, or both. Chest CT is ideally performed after full or near-full lung reexpansion to better assess the lung parenchyma. The extent to which patients with spontaneous pneumothorax benefit from CT imaging following initial presentation requires study. A diverse spectrum of practice patterns currently exists for medical management, surgical intervention, and follow-up care of patients diagnosed with spontaneous pneumothorax, owing to the paucity of evidence-based literature. Related article page 1471 Opinion

Patient-Specific Interactive Simulation of Compression Ultrasonography

We are developing an ultrasonography training system that promises to accelerate the broader use of ultrasound imaging in healthcare. Aiming at cheaper, more efficient, and more effective ultrasound training, a key feature of our system is the real-time, interactive simulation of a 3D virtual patient that, unlike conventional, purely geometric models of the human body, includes deformable soft tissues. Since soft-tissue deformation is an important factor in the clinical practice of ultrasound imaging, our objective in this paper is to incorporate real-time interactive soft tissue mechanics simulation into our 3D patient model. To this end, we adapt and evaluate two well-known deformable model simulation methods-mass-spring-damper systems and the finite element method-and we apply these methods to the simulation of ultrasound imaging in soft tissues, obtaining promising results on a multicore laptop computer.