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Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure. After IRB approval, a word search was used to identify “sludge” in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology. 2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other. Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.

BACKGROUND Helicopter emergency medical services (HEMSs) are used with increasing frequency for the transportation of injured patients from the scene and from treatment facilities to higher levels of care. Improved outcomes have been difficult to establish, and reports of overutilization and financial harm have been published. Our study was performed to evaluate statewide utilization for interfacility transfers (IFTs). METHODS Data from the North Carolina state trauma registry from 2013 to 2017 were evaluated and ground, and helicopter IFTs were compared. RESULTS Overall interfacility use of HEMSs peaked at 7,861 patient transports in 2016, and the percent of all IFTs fell from 17% to 13.3% over the study period. Helicopter emergency medical services patients were more likely to be male (69.8%) and younger (48.0 vs. 56.2 years), and have higher Injury Severity Scores (14.6 vs. 9.0) and higher mortality (10.5% vs. 2.8%) than ground emergency medical services (GEMSs) patients. When adjusted for age, sex, Injury Severity Score, and transport distance, HEMSs survival was significantly higher (odds ratio, 0.353; 95% CI, 0.308-0.404; p < 0.0001). Normal prehospital vital signs (VSs) and Glasgow Coma Scale score motor component (GCS-M) were associated with low mortality rates in both groups. Abnormal prehospital VSs and GCS-M were associated with an 11.8% mortality rate in HEMSs patients and 3.1% in GEMSs patients. Normal referring facility VSs and GCS-M did not confer similar protection with a mortality rate of 10.0% in HEMSs patients and 2.8% in GEMSs. Changes in prehospital to referring facility VSs did not demonstrate a low mortality group. Abbreviated Injury Scale and changes in VSs did not identify HEMSs transport benefit groups. CONCLUSION The proportion of HEMSs transfers fell over the study period and, while associated with a 10.5% mortality rate, had an outcome benefit compared with GEMSs. These patients could not be sorted into risk categories for transportation choice based on VSs or GCS-M derangement or by changes thereof, and opportunities for system improvement were not identified. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III; Care Management, level IV.

Obese patients with operative orthopedic trauma have increased risk of adverse outcomes, although the mechanisms accounting for the relationship remain unknown. This study examines the effect of body mass index (BMI) on outcomes after femur fracture fixation, and explores the mediating effects of pathophysiologic factors and clinical management.A retrospective chart review was performed of adult patients with femur fractures undergoing surgical fixation at a Level 1 trauma center from 2010 to 2016. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and mechanism of injury (MOI) were collected along with operative data and complications. Primary outcomes were hospital length of stay (HLOS), ICU length of stay (ICU-LOS), mortality, complications, and time to mobility (time first out of bed, TFOB). Bivariate correlations and multiple regression models were used to examine the relationship between BMI and outcomes. Path analysis tested whether the relationship between BMI and clinical outcomes was mediated by differences in 1) clinical management, or 2) physiologic variables.Of 333 patients included, the majority were male (57.4%) with a mean age of 43.4 (22.7) years and ISS of 12.5 (6.8). Predominant MOIs were motor vehicle crashes (42.8%) and falls (34.5%). There was no association between BMI category and age, ISS, or GCS. In univariate analysis, higher BMI was linked to longer HLOS (r = .12), longer ICU-LOS (r = .15), longer TFOB, (r = .18), and higher number of complications (r = .12), p 0.05. Controlling for age and ISS, obese patients had 6.66 times the odds of respiratory failure (p = 0.021, 95% CI 1.3,33.3) and a 3.88 odds of any complication (p = 0.020, 95% CI 1.24,12.1) compared to their normal weight counterparts. For every one point increase in BMI, time first out of bed was delayed 2.3 h (p 0.001; 95% CI 1.08, 3.62). The effect BMI on poor outcomes was accounted for by delayed mobility (longer TFOB) in a mediation model.Higher BMI increases the risk of longer hospital stays and systemic complications. Mediation models indicate that the adverse clinical outcomes associated with obesity are explained by delays in mobility, an intervenable factor. Clinical strategies should be directed at early mobilization to minimize morbidity.

Favorable neurologic outcomes have been reported in near-hanging (NH) victims treated with therapeutic hypothermia (TH), but variable methods and small samples sizes limit interpretability. This study examines the relationship between clinical predictors, TH, and outcomes in NH patients. A risk profile was created by examining relationships between variables. Categorical predictors were assessed with chi-square tests and continuous variables were assessed with

Trauma in pregnancy is a leading cause of poor fetal and obstetric outcomes. Trauma team activation (TTA) criteria include injury with ≥ 20 weeks gestational age (GA). A retrospective analysis was performed on pregnant patients evaluated at a Level 1 trauma center. Patients were characterized by TTA: full, partial, or non-TTA, and TTA criteria independent of pregnancy. Index trauma and delayed delivery hospitalization outcomes were examined. Bivariate analysis, t test, and logistic regression were used when appropriate. From 2010 to 2015, 216 full, 50 partial, and 50 non-TTAs presented. Independent of pregnancy, 79 per cent of patients did not meet the TTA criteria. Fourteen (4%) had a pregnancy-related complication during index hospitalization (eight fetal and two maternal deaths). Nine of ten deaths occurred in patients meeting TTA independent of pregnancy. Delivery complications were greater in the index (52%, 13/25) versus subsequent (5%, 17/155) hospitalizations and were predicted by the respiratory rate ( P = 0.016) and injury severity score ( P < 0.001). Poor delayed delivery outcomes were associated with earlier GA ( P < 0.002) and longer index hospitalization ( P < 0.024). Odds of complication are higher in patients meeting the physiologic and anatomic criteria criteria for TTA versus GA criteria alone, signifying overtriage. Trauma activation protocols should be adapted based on the physiologic and anatomic criteria criteria in pregnant patients.

Despite all that is known and proven about the oppression of Palestinians, their position has become weaker and more inconsequential over time. Looking beyond the more obvious political explanations, this chapter examines another lesser understood but equally compelling reason for why the production of so much knowledge—evidence and data—has failed fundamentally to improve conditions for Palestinians in the West Bank and Gaza and the possibility of a meaningful resolution to the conflict.

Background Outcomes of complex pancreatic procedures have been used as an index for quality, and higher volume has been associated with improved outcomes, leading to advocacy for referral to those centers. The aim of the study was to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume referral center. Materials and Methods This retrospective study included patients who had a PD within a 7-year period. Operative performance parameters and outcomes were examined. Results Overall, there were 47 pancreatic resections, of which 38 met the inclusion criteria and were used for analyses. The overall median for blood loss, packed red blood cells units transfused, and postoperative days in hospital was as follows, respectively: 675 mL (interquartile range [IQR] = 500-900), 0 units (IQR = 0-2), 12 days (IQR = 9-18). Demographic characteristics, comorbidities, and complications align with the literature. The 30-day in-hospital mortality rate was 5%. Survival probability for those with pancreatic adenocarcinoma at 1 year was 52% and 7% for years 2 and 3. Discussion As cases increased, significant improvement was noted in process outcomes including blood loss, blood transfusion rates, and length of stay (LOS). Survival was comparable to that in the literature, with limitation of not being adjusted for adjuvant therapy. Outcomes of complex pancreatic procedures, like PD, at a low-volume center with commitment and adequate support systems, can match those at high-volume centers.

While I have only known of Professor Stoler's work indirectly, I am truly grateful for the chance to engage with it more closely. Duress is a compelling work, an intellectual provocation demanding ...

Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.

Objectives New genomic tests for Autism Spectrum Disorders (ASD) are being offered to children and families with ASD; however, these tests are underutilized by parents of children affected with ASD. Methods We designed, implemented and pilot-tested an educational intervention to enhance parental genetic knowledge and assist them to make informed decisions about genomic testing. We utilized a pre-/post-test design to evaluate genetic knowledge and test perceptions in a sample of parents of children with ASD. Results Fifty-three parents participated in our online training (5 modules) and completed pre- and post-assessments. Our surveys queried knowledge, attitudes, and intention to test. The knowledge section contained questions regarding autism, genes, and genetic testing for autism. The other 2 sections included attitudinal questions about testing as well as parents' behavioral intention to seek genetic testing for autism. Conclusions Our results indicate that knowledge significantly improved following the intervention (p < .001). Although attitude and intention scores changed from pre-to post-assessment, these changes were not statistically significant. Our results demonstrate that this first-of-its-kind educational program designed for parents of children with ASD was effective at increasing parents' knowledge related to genomic testing for autism.

The aim of this study was to evaluate the impact of prehospital antiplatelet and/or anticoagulant (APAC) use on treatment and outcomes in patients with severe blunt chest injury. Patients with three or more rib fractures and a hospital length of stay (LOS) > three days admitted from 2014 to 2015 were included. Demographics, mortality, complications, injuries, hospital and ICU LOS, use of blood products, and thoracostomy were studied. Of 383 patients, 27.4 per cent were on APAC medication. Patients on APAC were older ( P < 0.0001), had higher Glasgow Coma Score ( P < 0.0001), and had lower Injury Severity Score ( P < 0.0001) and total number of fractures ( P = 0.0013) than the non-APAC group. APAC was not a predictor of mortality with or without age adjustment. In multiple linear regressions, APAC did not predict an increased LOS. APAC patients did not demonstrate an increase in admission diagnosis or complication of hemothorax, blood transfusions, tube thoracostomy, tracheostomy, LOS, or mortality rates. Similar findings are present in the subgroup of patients studied with high kinetic energy mechanism of injury. Our study does not support the perceived morbidity of APAC therapy in patients with severe blunt chest injury.

Trauma in pregnancy is a leading cause of poor fetal and obstetric outcomes. Trauma team activation (TTA) criteria include injury with ≥ 20 weeks gestational age (GA). A retrospective analysis was performed on pregnant patients evaluated at a Level 1 trauma center. Patients were characterized by TTA: full, partial, or non-TTA, and TTA criteria independent of pregnancy. Index trauma and delayed delivery hospitalization outcomes were examined. Bivariate analysis

India and most of the developing countries have unplanned cities in which roads are narrow and unkempt. Due to increasing vehicular density, repair of roads and traffic rules violation, traffic congestion is increasing at an alarming rate. Delay in arrival of High Priority Vehicles (HPV) like ambulances and fire engines cause severe loss to life and property. Although most HPVs are equipped with sirens, it is not efficient to guarantee a clear road to HPVs due to its audibility range. Hence, we propose a system by which the vehicles near the traffic junction will be alerted about the oncoming of HPV much in advance of its arrival so that they can make way for the HPV. In this system, every HPV is provided with an active RFID tag. Few kilometers before the main signal, an active RFID reader would be placed which would detect the vehicle and send this information to the display screen placed near the traffic junction signal via LoRa wirelessly, starting to make way for the HPV. Therefore, this project proposes to streamline the traffic and allow HPV to pass easily.