STRANGULATION-INDUCED ATLANTOAXIAL ROTATORY SUBLUXATION TREATED WITH CLOSED REDUCTION.

BACKGROUND: Cervical subluxation is a broad class of injuries in which there are degrees of misalignment of vertebral bodies in relationship to adjacent vertebra. Atlantoaxial rotatory subluxation (AARS) is a subtype of cervical subluxation resulting from exaggerated rotation of the C1-C2 complex. Inflammatory, infectious, post-surgical, and traumatic etiologies are recognized and well-described. AARS is predominantly seen in children and occurs rarely in adults. CASE REPORT: We submit the case of an otherwise healthy adult male patient presenting to the emergency department with strangulation-induced C1-C2 subluxation with a rotational component that was treated at the bedside by neurosurgery with closed reduction. Why Should an Emergency Physician Be Aware of This? Clinicians must consider a broad range of serious pathologies in a patient presenting with torticollis, especially in the setting of strangulation. Although extremely rare in adults, AARS must be considered in the differential diagnosis, as early identification increases the likelihood of successful nonoperative treatment.

Diagnosing and treating pericarditis and myocarditis in the emergency department.

Pericarditis and myocarditis represent a challenging set of diseases to diagnose and treat. These diseases typically present with chest pain and dyspnea in previously healthy young people, often in the weeks following a viral illness, including COVID-19. Nonetheless, the etiologies can be very diverse, including infectious, noninfectious, drug-induced, and autoimmune causes. This review focuses on the evaluation, diagnosis, and management of emergency department patients presenting with pericarditis and myocarditis and summarizes current guidelines and best-practice medical management strategies in order to avoid potential life-threatening cardiac complications.

Performance comparison of intraosseous devices and setups for infusion of whole blood in a cadaveric swine bone model.

OBJECTIVES: Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable. Successful pressurized IO infusion requires flow rates sufficient to preserve life, but with infusion pressures low enough to avoid clinical complications (e.g., hemolysis, bone damage, fat emboli). However, the optimal method for pressured IO delivery of blood was unknown. METHODS: Three trained physicians infused 500 mL of whole blood through a 15-gauge, 45 mm IO catheter into fresh, high bone density cadaveric swine proximal humeri. Participants applied eight different pressure infusion strategies: (1) gravity, (2) pressure bag, (3) pressure bag actively maintained at or above 300 mmHg, (4) hand pump, (5) hand pump with pressure bag, (6) push-pull with 10 mL syringe, (7) push-pull with 60 mL syringe, and a (8) Manual Rapid Infuser in a randomized within-subjects design (30 trials per method, 240 trials total). The primary outcomes of flow rates, mean and peak pressures, and user ratings were contrasted using ANOVA at p < 0.05. RESULTS: The Manual Rapid Infuser conferred the highest flow rates (199 ± 3 mL/min) and most favorable user ratings, but also the highest mean and peak pressures. Push-pull conferred the next highest flow rates (67 ± 5 mL/min for 60 mL, 56 ± 2 mL/min for 10 mL) and pressures, with intermediate-to-high user ratings. Hand pump flow rates were essentially identical with (45 ± 4 mL/min) or without (44 ± 3 mL/min) pressure bag, with high user ratings without a pressure bag. Pressure bag and gravity methods conferred low flow rates and user ratings. CONCLUSIONS: Some pressured IO infusion methods can achieve flow rates adequate to serve as a resuscitative bridge in the massively hemorrhaged trauma victim, but flow rates and pressures vary greatly across IO pressurized infusion methods. Manual Rapid Infuser and push-pull methods conferred high flow rates but also relatively high pressures, highlighting the importance of using in vivo models in future research to assess the possible clinical complications of using these promising methods. Combined, present findings highlight the importance of studying pressurized IO methods towards preserving the life of the critically injured trauma victim.

Supraventricular tachydysrhythmias in the emergency department.

Diagnosing and treating supraventricular tachycardias is routine in emergency medicine, and new strategies can improve efficiency and outcomes. This review provides an overview of supraventricular tachycardias, their pathophysiology, differential diagnosis, and electrocardiographic features. Clinical evidence guiding contemporary practice is determined largely by multiple observational studies, with few randomized controlled trials. Current prehospital and emergency department management strategies beyond the use of adenosine and calcium channel blockers are addressed. Diagnostic and therapeutic recommendations are provided, based on the best available evidence.

An Assessment of The New York State Behavioral Health System's Readiness to Transition to Medicaid Managed Care.

New York State has one of the most richly funded Medicaid programs in the United States. In an effort to achieve the triple aim New York State is undergoing a significant redesign of its Medicaid program including transitioning nearly all Medicaid funded behavioral health services into Medicaid managed care. In preparation for this transition, a state funded technical assistance center assessed the behavioral health care system's readiness to undergo this reform across 11 domains. Between September and November, 2014, the TA center electronically distributed a readiness survey to 897 mental health and substance abuse agencies: 313 (n = 269, 33%) organizations completed the assessment. As a whole, the sample felt partially ready to transition; analysis by domain revealed agencies were most ready to interface with managed care providers, and least ready to collect and evaluate outcome data. Significant differences in readiness were found depending by organizational characteristics (number of programs, licensure, and region). In anticipation of large-scale reforms, states would benefit from an initial needs assessment to identify gaps in knowledge and skills, which in turn, can then guide preparatory efforts and provide needed supports to facilitate major changes in service delivery and billing.

Improved Alpha Testing Using Hashed Sampling.

We further describe and analyze the idea of hashed alpha testing from Wyman and McGuire [1] , which builds on stochastic alpha testing and simplifies stochastic transparency. Typically, alpha testing provides a simple mechanism to mask out complex silhouettes using simple proxy geometry with applied alpha textures. While widely used, alpha testing has a long-standing problem: geometry can disappear entirely as alpha mapped polygons recede with distance. As foveated rendering for virtual reality spreads, this problem worsens as peripheral minification and prefiltering introduce this problem on nearby objects. We first introduce the notion of stochastic alpha testing, which replaces a fixed alpha threshold of ατ = 0.5 with a randomly chosen ατ ∈ [0..1). This entirely avoids the problem of disappearing alpha-tested geometry, but introduces temporal noise. Hashed alpha testing uses a hash function to choose ατ procedurally. With a good hash function and inputs, hashed alpha testing maintains distant geometry without introducing more temporal flicker than traditional alpha testing. We also describe how hashed alpha interacts with temporal antialiasing and applies to alpha-to-coverage and screen-door transparency. Because hashed alpha testing addresses alpha test aliasing by introducing stable sampling, it has implications in other domains where increased sample stability is desirable. We show how our hashed sampling might apply to other stochastic effects.

Phenomenological Transparency.

Translucent objects such as fog, clouds, smoke, glass, ice, and liquids are pervasive in cinematic environments because they frame scenes in depth and create visually-compelling shots. Unfortunately, they are hard to render in real-time and have thus previously been rendered poorly compared to opaque surfaces. This paper introduces the first model for a real-time rasterization algorithm that can simultaneously approximate the following transparency phenomena: wavelength-varying ("colored") transmission, translucent colored shadows, caustics, volumetric light and shadowing, partial coverage, diffusion, and refraction. All render efficiently with order-independent draw calls and low bandwidth. We include source code.

Aggregate G-Buffer Anti-Aliasing -Extended Version.

We present Aggregate G-Buffer Anti-Aliasing (AGAA), a new technique for efficient anti-aliased deferred rendering of complex geometry using modern graphics hardware. In geometrically complex situations where many surfaces intersect a pixel, current rendering systems shade each contributing surface at least once per pixel. As the sample density and geometric complexity increase, the shading cost becomes prohibitive for real-time rendering. Under deferred shading, so does the required framebuffer memory. Our goal is to make high per-pixel sampling rates practical for real-time applications by substantially reducing shading costs and per-pixel storage compared to traditional deferred shading. AGAA uses the rasterization pipeline to generate a compact, pre-filtered geometric representation inside each pixel. We shade this representation at a fixed rate, independent of geometric complexity. By decoupling shading rate from geometric sampling rate, the algorithm reduces the storage and bandwidth costs of a geometry buffer, and allows scaling to high visibility sampling rates for anti-aliasing. AGAA with two aggregates per-pixel generates results comparable to 32 × MSAA, but requires 54 percent less memory and is up to 2.6 × faster ( -30 percent memory and 1.7 × faster for 8 × MSAA).

Optical splitting trees for high-precision monocular imaging.

The authors present a design framework and optimizer for computational systems containing many sensors on a common optical axis.