Michael P. Hirsh

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

MR imaging of benign fatty tumors in children: report of four cases and review of the literature

This study correlates the magnetic resonance imaging characteristics with the pathologic findings in rare benign fatty soft tissue tumors in four children. A review of the literature is presented. Two cases of infiltrating lipoma displayed bright signal on both T1- and T2-weighted images, similar to that observed in subcutaneous fat. Histological study revealed extensive muscle infiltration by mature fat, with some areas of total fatty replacement. The case of facial lipomatosis revealed an extensive process of fatty invasion of adjacent soft tissue and osseous deformity by mass effect of the tumor. This lesion was bright on T1- and T2-weighted images. Histopathologic examination showed widespread invasion of squamous mucosa and skeletal muscle. The single case of lipoblastoma involved the presacral region and right buttock. This lesion, although bright on both T1 and T2 weighting, was relatively hypointense to subcutaneous fat on T1. Microscopic examination revealed a well-encapsulated fatty mass made up of cells ranging from lipoblasts to mature lipocytes. In childhood, when fatty lesions are almost always benign, a morphologic characterization by magnetic resonance may be sufficient basis on which to make critical therapeutic judgements.

Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children

BACKGROUND/PURPOSE Although ultrasound is often the preferred pediatric imaging study, many institutions lack ultrasound access at night; and computerized tomography (CT) becomes the only radiological method available for evaluation of appendicitis in children. The purpose of this study was to characterize patterns of daytime and nighttime use of ultrasound or CT for evaluation of pediatric appendicitis and to measure consequent differences in radiation exposure and cost. METHODS A retrospective chart review of patients evaluated for appendicitis from October 2004 to October 2009 (N = 535) was performed to evaluate daytime and nighttime use of ultrasound and CT for pediatric patients. RESULTS Average age was 10.2 years (range, 3-17 years). During the day, 6 times as many ultrasounds were performed as CTs (230 vs 35). At night, half as many ultrasounds were performed (50 vs 110). Average radiation dose per child during the day was significantly lower than at night (day, 0.52 mSv per patient; night, 2.75 mSv per patient). Average radiology costs were lower for daytime patients (

Necrotizing enterocolitis in a neonatal piglet model

2491.06 day vs

A Human Factors Curriculum for Surgical Clerkship Students

4045.00 night; P < .05). CONCLUSIONS Dependence on CT at night results in higher average radiation exposure and cost. Twenty-four-hour ultrasound availability would decrease radiation exposure and cost of evaluation of children presenting with appendicitis.

Sonography of Nager acrofacial dysostosis syndrome in utero.

The aim of this study was to develop an animal model for necrotizing enterocolitis (NEC). Twenty-five neonatal Hanford minipigs had carotid artery and external jugular vein catheters and rectal Clinical Tonomitors placed under anesthesia. Experimental animals were subjected to a hypoxic insult (50% reduction in baseline PaO2 for 30 minutes) and hypothermic stress (core temperature reduced to 35 degrees C for 30 minutes). Regular oral diet was resumed and the survivors were euthanized 3 to 4 days later. All animals underwent necropsy with gross and histopathological evaluation of the entire bowel. Of 22 experimental animals, 14 survived (64%) and 8 (36%) died of pulmonary hemorrhage. Of the 14 survivors, 8 (57%) had gross and microscopic evidence of NEC. Six of the total 25 animals (24%) sustained rectal perforations from the tonometer. Of 3 control animals, one died of pulmonary hemorrhage and the two survivors had normal intestine. This model successfully produced gross and histological evidence of NEC. The tonometer shows promise as a predictor of NEC provided technical modifications can reduce the complication rate.

The effects of enteral stimulation on gallbladder bile during total parenteral nutrition in the neonatal piglet

HYPOTHESIS Early introduction of a full-day human factors training experience into the surgical clerkship curriculum will teach effective communication skills and strategies to gain professional satisfaction from a career in surgery. DESIGN In pilot 1, which took place between July 1, 2007, and December 31, 2008, 50 students received training and 50 did not; all received testing at the end of the rotation for comparison of control vs intervention group performance. In pilot 2, a total of 50 students were trained and received testing before and after rotation to examine individual change over time. SETTING University of Massachusetts Medical School. PARTICIPANTS A total of 148 third-year medical students in required 12-week surgical clerkship rotations. INTERVENTIONS Full-day training with lecture and small-group exercises, cotaught by surgeons and educators, with focus on empathetic communication, time management, and teamwork skills. MAIN OUTCOME MEASURES Empathetic communication skill, teamwork, and patient safety attitudes and self-reported use of time management strategies. RESULTS Empathy scores were not higher for trained vs untrained groups in pilot 1 but improved from 2.32 to 3.45 on a 5-point scale (P < .001) in pilot 2. Students also were more likely to ask for the nurses perspective and to seek agreement on an action plan after team communication training (pilot 1, f = 7.52, P = .007; pilot 2, t = 2.65, P = .01). Results were mixed for work-life balance, with some trained groups scoring significantly lower than untrained groups in pilot 1 and no significant improvement shown in pilot 2. CONCLUSIONS The significant increase in student-patient communication scores suggests that a brief focused presentation followed by simulation of difficult patient encounters can be successful. A video demonstration can improve interdisciplinary teamwork.

Prevention of firearm-related injuries with restrictive licensing and concealed carry laws: an Eastern Association for the Surgery of Trauma systematic review

Sonographic detection of fetal facial abnormalities, including cleft lip and palate,13 hypotelorism, and holoprosencephaly-associated cyclopia4 has been reported. Prenatal diagnosis of mandibulofacial dysostosis (Treacher Collins Syndrome) with mandibular and ear abnormalities has been possible.5 Isolated fetal limb defects, such as clubfoot and clinodactyly, as well as complex limb defects occurring secondary to skeletal dysplasias, have also been reported.-u Less attention, however, has been paid to the detection of limb reduction defects.1U 5 We report a case of prenatal sonography of Nager Syndrome (Acrofacial Dysostosis-AFD), 16 including mandibulofacial changes of hypoplastic mandible and abnormal external ear, as well as shortened upper extremities. We discuss the differential diagnosis of this combination of defects.

Goods for guns-the use of a gun buyback as an injury prevention/community education tool

The neonatal piglet is a satisfactory model for the human neonate requiring total parenteral nutrition (TPN). Bile status and subsequent liver and gallbladder dysfunction have long been documented as serious complications of long-term TPN. The purpose of this study was to determine whether small amounts of enteral formula during TPN will maintain normal bile appearance and composition. Thirty-one Hanford miniswine, 3 to 6 days old underwent surgery for the placement of central venous catheters. Two days postoperatively, the animals were separated into three groups, according to dietary regimens. Group 1 (n = 10), the control group, received pig formula (SPF-lac) orally (200 cal/kg/d); group 2 (n = 11), was maintained on TPN (180 cal/kg/d) with an enteral supplement of SPF-lac (20 cal/kg/d); group 3 (n = 10), was maintained on TPN only (200 cal/kg/d). The TPN formula consisted of 35 g/kg/d of glucose, 10 g/kg/d of protein, and 3 g/kg/d of lipid. The animals were maintained on these diets for 6 weeks. At necropsy, gallbladder with bile was weighed and bile volume and appearance was recorded. Chemical analyses was performed on 26 bile samples. Gallbladder weight was significantly decreased in groups 2 and 3 compared with group 1 (P less than .0003, P less than .033, respectively, using Students t test with Bonferoni adjustment). Volume was significantly decreased only in group 2 (P less than .003). Group differentiation in relation to bile appearance was determined by the presence or absence of either bile sludge or crystals.(ABSTRACT TRUNCATED AT 250 WORDS)

Gun buyback programs: a venue to eliminate unwanted guns in the community

BACKGROUND In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the US Restrictive Licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons. METHODS A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions. RESULTS A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3,623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3,379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2. CONCLUSION PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries. PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries. This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7% to 40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines. LEVEL OF EVIDENCE Systematic review, level III.