Motorcycle Helmets: The Economic Burden of an Incomplete Helmet Law to Medical Care in the State of Connecticut.

The lack of a mandatory motorcycle helmet law leads to increased injury severity and increased health care costs. This study presents a financial model to estimate how the lack of a mandatory helmet law impacts the cost of health care in the state of Connecticut. The average cost to treat a helmeted rider and a nonhelmeted rider was $3,112 and $5,746 respectively (cost adjusted for year 2014). The total hospital treatment cost in the state of Connecticut from 2003 through 2012 was $73,106,197, with $51,508,804 attributed to nonhelmeted riders and $21,597,393 attributed to helmeted riders. The total Medicaid cost to the state of Connecticut for treating nonhelmeted patients was $18,277,317. This model demonstrates that the lack of a mandatory helmet law increases overall health care costs to the state of Connecticut, and provides a framework by which hospital costs can be reduced to contribute to the economic stability of health care economics in the state.

Statin-induced Liver Injury Patterns: A Clinical Review.

Since their introduction in 1987, hydroxymethyl glutaryl coenzyme A reductase (HMG-CoA) inhibitors, more commonly known as statins, have become some of the most widely prescribed medications in the world. Though generally considered to be safe and well tolerated, statins have been associated with several side effects including mild liver dysfunction manifested by increases in aminotransferases. Rarely, statins have been noted to induce more serious hepatic injury, including liver injury with autoimmune features. Current literature supports statin induced liver injury presenting in either hepatocellular or cholestatic patterns, though with the former being the prevailing pattern of injury. Fortunately, severe liver injury is uncommon with statin use and is generally reversible without any intervention other than offending statin cessation. When evaluating cases of suspected statin-induced liver injury, a complete medical history, laboratory tests including a complete metabolic panel, autoimmune markers, and viral panel, as well as hepatic imaging, are crucial for a complete causality analysis with validated tools such as Roussel Uclaf Causality Assessment Method. The aim of this review is to review the current evidence for statin-induced liver injury and cholestasis.

The Value of Family History in Colorectal Screening Decisions for Oldest Old Geriatric Populations.

INTRODUCTION: Colorectal cancer (CRC) is the second most common form of cancer affecting both men and women. Extensive screening guidelines have been developed to help reduce the incidence of disease. Currently, United States Preventative Service Task Force guidelines recommend against routine screening in those 85 years and older. However, octogenarians and nonagenarians continue to be screened for CRC with no consensus on indications. The aim of this study is to examine family history of CRC as a risk factor and clinical indication for providing screening colonoscopies to the "oldest old" geriatric population, defined as aged 80 years and above. METHODS: We conducted a retrospective review of a Veterans' Health Administration database to identify male veterans aged 80 years and older who underwent screening colonoscopy. Subsequently, we examined those who tested positive for CRC with a family history of CRC. RESULTS: Of the 458,224 patients who are 80 years and older in the Veterans Affairs (VA) database, 17.8% underwent a screening colonoscopy; 11.42% of these individuals were further diagnosed with CRC; and 8.89% of those with diagnosed CRC had a documented family history of CRC. CONCLUSION: Family history should not be used as an inclusionary criterion for CRC screening in the 80 years and above age group as the rate of CRC in these patients with a family history of CRC is significantly lower than that in the younger age groups with a family history of CRC.

High-risk motor vehicle drivers engage in more risk behaviors than motorcyclists.

OBJECTIVE: The purpose of this study was to characterize and compare risk behaviors between motorcyclists and motor vehicle drivers who were involved in accidents and required hospitalization. The study focused on patients who were recently involved in motorcycle collisions (MCCs) and motor vehicle collisions (MVCs). METHODS: We identified 63 patients involved in MCCs and 39 patients involved in MVCs who were admitted to our level-1 trauma center from April 2014 to September 2015. These 102 patients completed a questionnaire designed to evaluate risky driving behaviors. Pearson's chi-squared tests and unpaired two-tailed t-tests were used to evaluate categorical and normally distributed continuous variables, respectively. Multivariable linear regression was used to analyze predictors of risk behavior. Significance was set at p < 0.05. RESULTS: When compared to patients involved in an MCC, patients involved in MVCs were more likely to be female (p = 0.007), drive more frequently (p < 0.001), and never perceive the risk of an accident (p = 0.036). MVC patients were more likely to have admitted to substance use on the day of the accident (p = 0.030), historically drive under the influence of drugs (p = 0.031), drive while tired (p < 0.001), drive while text messaging (p < 0.001), and speed while overtaking vehicles (p = 0.011). Overall, MVC patients engaged in more risk behaviors (3.3 ± 1.3 vs. 2.0 ± 1.5; p < 0.001) and were more likely to engage in multiple risk behaviors (p < 0.001). MVCs were associated with increased risk behavior, even after controlling for protective behaviors, driving history, and demographics (p = 0.045). CONCLUSIONS: Within our cohort of trauma patients at our institution, motor vehicle drivers were more likely than motorcyclists to engage in any one risk behavior and engage in a higher number of risk behaviors. In addition, motor vehicle drivers perceived their risk of a potential accident as lower than riding a motorcycle. Education initiatives should focus on motor vehicle driver safety interventions that reduce risk behaviors.

The Role of Automatically Generated Chicago Classification in Delayed Achalasia Diagnosis.

Achalasia is an esophageal motility disorder characterized by a lack of peristalsis and an increased lower esophageal sphincter pressure that does not relax with swallowing. High-resolution manometry (HRM), a valuable diagnostic tool for esophageal disorders, often comes with software for automated study interpretation. Although helpful, there are certain caveats in the diagnostic criteria for achalasia which the software may miss. We highlight 2 patients in whom software analysis of HRM studies resulted in misdiagnosis of achalasia as manometrically detected nonachalasia esophagogastric junction outflow obstruction and emphasize the importance of manual interpretation of HRM data by clinicians.

Hepatic Artery Thrombosis: A Rare Complication of Microwave Ablation in Hepatocelluar Carcinoma.

Microwave ablation (MWA) has become a popular therapeutic technique in hepatocellular carcinoma (HCC) alongside cryoablation, radiofrequency ablation, and liver resection/transplantation in patients with limited tumor burden. Generally well tolerated, and not as invasive as surgery, the technique results in low mortality and complication rates. We report the exceedingly rare complication of hepatic artery thrombosis with subsequent fatal ischemia of the left hepatic lobe in a 64-year-old female with cirrhosis and HCC who underwent MWA.

SPINK-1 Polymorphism as a Pancreatitis Risk Factor.

Pancreatitis in both acute and chronic variants is a common health concern in the US as well as globally. While the most common etiologies for disease remain gallstone impaction in the common bile duct and alcohol abuse, recent studies have shown that genetics may play a significant role as well. Unfortunately, this correlation is not clearly defined and at present, we lack the ability to identify which patients with known pancreatic genetic polymorphisms will develop pancreatitis. We describe the case of a middle-aged male who presented with recurrent pancreatitis in the setting of the serine peptidase inhibitor, Kazal type 1 (SPINK-1) genetic polymorphism. Additionally, we discuss the mechanism behind SPINK-1 polymorphisms in the development of pancreatitis as well as the role of genetic screening for the polymorphism in the general population.

Highlights for Dental Care as a Hepatitis C Risk Factor: A Review of Literature.

Hepatitis C (HCV) is a viral infection that affects an estimated 71 million people worldwide, with over 1 million new infections yearly. While medical treatments exist, HCV continues to be a significant public health concern. Primary prevention and transmission risk factor identification remain key in helping decrease disease prevalence. While intravenous drug use, healthcare exposure (i.e. blood transfusions and surgical care), and body modification (i.e. tattooing and piercings) are well accepted risk factors for HCV transmission, others remain controversial. Because dental practice is often associated with procedures and bleeding, the possibility of HCV transmission seemed reasonable to investigate. Here, we review the evidence for dental care as a potential risk factor for HCV transmission. We identified a total of 1,180 manuscripts related to HCV and dental care, of which 26 manuscripts were included in the study after exclusionary criteria were applied. As per our review of the available literature, in the developing world, the improper use of sterile technique and lack of provider education likely increases the risk of HCV transmission during dental care. In developed nations, on the other hand, general dental care does not appear to be a significant risk factor for HCV transmission in non-intravenous drug user patients; although, the improper use and reuse of anesthetics during procedures poses a rare potential risk for viral transmission.

Diagnostic and Therapeutic Strategies for Peritoneal Tuberculosis: A Review.

Peritoneal tuberculosis (PTB), although rarer than its pulmonary counterpart, is a serious health concern in regions of the world with high tuberculosis prevalence. Individuals with baseline immunocompromise condition, whether acquired or medically induced, are at greatest risk for experiencing PTB. While medical treatment of the condition is similar to that of the pulmonary disease, the generally immunocompromised state of those infected with PTB, along with a lack of highly sensitive and specific testing methods make early diagnosis difficult. This review discusses the risks factors, clinical features, diagnostic methods, and treatment options for PTB.

Secondary Gastrointestinal Melanoma of Unknown Origin: A Case Report of a Rare Entity.

Metastatic oculocutaneous melanoma is a malignant process most commonly identified in the lungs, bone, gastrointestinal tract (most frequently the liver), and brain. In most cases, the primary oculocutaneous lesion responsible for the metastases is identified. However, in very rare cases, patients present with metastatic lesions with an occult primary site, termed melanoma of unknown primary (MUP), secondary to the partial or complete regression of the primary lesion. We describe the case of an 89-year-old male whose initial diagnosis of achalasia was later identified to be MUP in the cardia of the stomach with protrusion into the esophagus.

A Rare Case of Clostridium difficile Enteritis: A Common Bug in an Uncommon Place.

Clostridium difficile (CD), a bacterium responsible for causing 15%-25% of all cases of infectious diarrhea, is most commonly associated with infection of the colon. Rarely, though with increasing frequency, it has been noted to infect the small intestine in what is referred to as CD enteritis. We present the case of a patient who was diagnosed and treated for CD enteritis, review the pathophysiology behind the infection, and discuss the diagnostic and treatment options available to healthcare professionals.

An Unexpected Passage: A Complex Enterovesicular Fistula.

Enterovesicular fistulas (EVFs) are abnormal connections between the colon and the urinary bladder. They are estimated to account for one in every 3,000 surgical hospital admissions and are rarely associated with long-standing Crohn's colitis. We present an interesting case of a 93-year-old man with a long-standing history of Crohn's colitis on mesalamine, whose mechanical fall at home lead to the discovery of a colovesicular fistula with invading urothelium concerning for squamous cell carcinoma.

Biliary Mucinous Cystadenoma: A Review of the Literature.

Biliary mucinous cystadenomas are cystic neoplasms commonly mistaken for simple cysts. They are rare and generally benign tumors, often incidentally found on imaging and during unrelated surgical interventions. They tend to be slow growing though may reach symptomatic dimensions. Misdiagnosis of biliary mucinous cystadenomas may have serious consequences secondary to their potential for malignant transformation into biliary mucinous cystadenocarcinomas. Here, we review the epidemiology, etiology, pathology, diagnostic modalities, histology, and available treatment methods for mucinous cystadenomas reported in current literature.

Role of Biologics in the Development of Autoimmune Hepatitis: A Review.

Autoimmune hepatitis (AIH) is a cause of chronic, immune-mediated liver injury which without treatment may progress to end-stage liver disease. The disease state, characterized by elevations in liver enzymes, autoantibodies, and interface hepatitis on histology, has been noted to be induced by a wide range of insults. Medications, most commonly minocycline and nitrofurantoin, have long been established as potential inducers of AIH. Recently, biologics, powerful immune-modulators, have also been reported to induce AIH. We conclude that there is an association between administration of biologics in the development of AIH, and whether the relationship is causal will require appropriate studies in the future.

Evidence for Viral Induction of Biliary Atresia: A Review.

Biliary atresia (BA) is a childhood disease which manifests with abnormal narrowing, blockage or complete absence of bile ducts within the liver. Many possible etiologies have been reported for the development of BA, including congenital, perinatal and acquired conditions. Since the 1970's, there has been increasing evidence linking BA development to viral perinatal infections. The viral vectors most commonly implicated include members of the herpesviridae family (cytomegalovirus and Epstein-Barr virus) as well as those of the reoviridae family (reovirus and rotavirus). While extensive work has been done on a murine model of disease, the current review focuses primarily on evidence from human studies of viral vectors in children afflicted with BA.

Acute Esophageal Necrosis: A Case Series.

Acute esophageal necrosis (AEN) is a particularly rare syndrome with an incidence of only 0.1-0.28%, whose appearance is notable for proximal extensions of black, necrotic appearing mucosa extending proximally in the esophagus and abruptly interrupted at the gastroesophageal junction. In this case series, we explore the cases of two males: one middle-aged and one elderly, who after presenting with emesis, were found to have acute esophageal necrosis on esophagogastroduodenoscopy.

Hepatic Angiosarcoma: A Challenging Diagnosis.

Hepatic angiosarcoma (HA) accounts for 2% of primary liver tumors. Though rare, it is exceptionally deadly. The initial presentation of HA is nonspecific and no tumor markers have been associated with it. In general, liver function is maintained until later stages of the disease, often leading to diagnosis once the disease is already advanced or metastatic. In this report, we present the case of a 54-year-old male whose vague symptoms and non-diagnostic liver biopsy delayed the diagnosis of a rapidly progressing HA.

PROMIS Computer Adaptive Tests Compared With Time to Brake in Patients With Complex Lower Extremity Trauma.

OBJECTIVES: To compare the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (PROMIS PF CAT and PROMIS PI CAT) with time to brake (TTB) in patients with complex lower extremity traumas for evaluating whether patients can safely return to driving. DESIGN: Prospective. SETTING: Level-1 trauma center. PATIENTS: Sixty-three patients with lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia/fibula, ankle, and foot within 15 weeks of treatment. INTERVENTION: The TTB of patients with complex lower extremity trauma were tested at various time points postoperatively on a computerized driving simulator. Patients concurrently completed PROMIS PF CAT and PROMIS PI CAT. MAIN OUTCOME MEASURE: Correlations between TTB, PROMIS PF CAT, and PROMIS PI CAT. RESULTS: The mean TTB for the healthy control group was 0.61 seconds. There was a statistically significant correlation between time since treatment and TTB (B = -0.008 s/d; P = 0.041) for right-sided lower extremity injuries below the knee (tibia/fibula, ankle, foot). TTB for right-sided injuries below the knee also significantly correlated with PROMIS PI CAT (B = 0.022; P = 0.029). The PROMIS PI CAT value was 43 when the healthy control group TTB was equal to 0.61 seconds. CONCLUSIONS: This study suggests that the PROMIS PI CAT can be used as an adjunct to the TTB in assessing whether a patient can safely return to driving.

The Economic Impact of Helmet Use on Motorcycle Accidents: A Systematic Review and Meta-analysis of the Literature from the Past 20 Years.

OBJECTIVE: The incidence and cost of motorcycle accidents are projected to increase. Motorcycle helmets are accepted as an effective strategy for reducing the morbidity and therefore the cost of motorcycle accidents. Despite this, states have continued to repeal helmet laws in the past 20 years. In addition, variations in the methodologies and outcomes of published reports have contributed to uncertainty regarding the health care dollars saved due to motorcycle helmet use. The purpose of this systematic review and meta-analysis is to clarify the economic impact of motorcycle helmet use. METHODS: Our primary source was Medline. Search terms included "motorcycle," "motorbike," "motorcycle helmet," "head protective devices," and "cost and cost analysis." The review only included articles that were primary studies, written in English, evaluations of periods after 1994, and published in a peer-reviewed journal. Two independent authors extracted data using predefined data fields. Meta-analysis was done using the R-metafor package. RESULTS: Twelve papers met the criteria for inclusion. Meta-analysis demonstrated that nonhelmeted patients required $12,239 more in hospital costs per patient. Nonhelmeted patients also required more postdischarge care and were more likely to use publicly funded insurance. Studies also found lower injury severity and better hospital course in the helmeted population. Study limitations included selection bias, unclear statistical assumptions, lack of precision measures, confounding variables, and lack of standardization to a common year. Meta-analysis demonstrated an I2 of 67%, attributing a significant proportion of outcome variation to study differences. CONCLUSIONS: Motorcycle helmet use reduces morbidity and contributes to significant health care cost savings. Continuing antihelmet legislation will impose a substantial economic burden to the health care system, the government, and the public.