Hotter Than It Looks: A Retrospective Review of Patients With Cholecystitis and With Negative Imaging.

INTRODUCTION: Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis. MATERIALS AND METHODS: Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology. RESULTS: Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d). CONCLUSIONS: This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.

Are motorcycles really "donorcycles"? Examining organ donation rates between unhelmeted and helmeted motorcyclists.

INTRODUCTION: Motorcycles are colloquially referred to as "donorcycles" among medical staff. However, the actual impact of helmet laws and helmet use on organ donation is unknown. Michigan's 35-year-old universal helmet law (UHL) was repealed in April 2012 and replaced by a partial-helmet law. We hypothesized that there would be an increase in organ donation rates from unhelmeted motorcyclist fatalities. METHODS: Michigan's Gift of Life Michigan organ donation database was queried from April 2008 through May 2015 in conjunction with the Michigan Trauma Quality Improvement Program database from the same time period. All in-hospital motorcycle crash fatalities were examined. RESULTS: A three-fold increase was found in the rate of organ donation for unhelmeted motorcyclists compared to helmeted motorcyclists (p = 0.006). Motorcycle crash fatalities tended to be younger in age after the UHL repeal with an average age of 32.8 years versus 40.8, however, this finding was not statistically significant (p = 0.071). Additionally, there was no significant difference in organ donation rates pre-UHL repeal (2008-2012) versus post-repeal (2012-2015). CONCLUSIONS: This is the first study to demonstrate an increased rate of organ donation among unhelmeted motorcyclist fatalities compared to helmeted rider fatalities. There was no significant increase in the rate of organ donation following the Michigan UHL repeal. However, we identified that some motorcycle crash fatalities were from illegally unhelmeted riders in the past, prior to the repeal. Practical Application: Unhelmeted motorcyclists are three times more likely than helmeted riders to become organ donors, possibly due to the well documented increase in severe traumatic brain injuries in this population. From a public health perspective, helmets should be required for all motorcyclists and efforts to advocate in favor of helmet legislation should be supported by trauma systems and health professionals.

The danger zone: Injuries and conditions associated with immediately fatal motorcycle crashes in the state of Michigan.

BACKGROUND: Immediately fatal motorcycle crashes have not been well characterized. This study catalogues injuries sustained in fatal motorcycle crashes and assesses the impact of crash conditions on injury patterns. METHODS: Autopsy records from the office of the medical examiner of Kent County, MI and publicly available traffic reports were queried for information pertaining to motorcyclists declared dead on-scene between January 1, 2007, and December 31, 2016. RESULTS: A total of 71 autopsies of on-scene motorcycle crash fatalities were identified. The two most prevalent injuries were traumatic brain injury (TBI) (85%) and rib fractures (79%). The majority of fatalities occurred in daylight hours (54.3%) and in a 55 mph speed limit zone (63.8%). CONCLUSIONS: This study provides a catalogue of the injuries sustained in immediately fatal motorcycle crashes and the associated conditions. Advocacy efforts that highlight the risks associated with motorcycle riding and that promote safe riding practices are warranted.

Variability in management of blunt liver trauma and contribution of level of American College of Surgeons Committee on Trauma verification status on mortality.

BACKGROUND: Patients who sustain blunt liver trauma and are treated at an American College of Surgeons Committee on Trauma-verified Level I trauma center have an overall lower risk of mortality compared with patients admitted to a level II trauma center. However, elements contributing to these differences are unknown. We hypothesize that practice variation exists between trauma centers in management of blunt liver injury. Our objective is to identify practice variations and their effect on clinical outcomes. METHODS: Data from a statewide collaborative quality initiative for trauma were used. The data set contains information from 29 American College of Surgeons Committee on Trauma verified Levels I and II trauma centers from 2011 to 2016. Propensity score matching was used to create cohorts of patients treated at Levels I or II trauma centers. The 1:1 matched cohorts were used to compare in-hospital mortality, management strategy, complications, intensive care unit (ICU) and hospital length of stay, and failure to rescue. RESULTS: Four hundred fifty-four patients with grade 3 or higher blunt liver injury were included. Patients treated at level II trauma centers had higher in-hospital mortality than those treated at Level I trauma centers (15.4% vs 8.8%, p = 0.03). Level II trauma centers used angiography less compared with Level I centers (p = 0.007) and admitted significantly fewer patients to the ICU (p = 0.002). The ICU status was associated with reduced mortality (7.2% vs 23.9%, p < 0.001). Despite a lower rate of overall complications, Level II trauma centers were more likely to fail in rescuing their patients (p = 0.045). CONCLUSION: Admission with a high-grade liver injury to a Level II trauma center is associated with increased in-hospital mortality. Level II trauma centers were less likely to use angiography or admit high-grade liver injuries to the ICU. This variation in practice may lead to the inability to rescue critically ill patients. Future research should investigate contributors to underutilization of resources for patients with high-grade liver injuries. LEVEL OF EVIDENCE: Care management, level IV.

The impact of the repeal of Michigan's universal helmet law on traumatic brain injury: A statewide analysis.

BACKGROUND: In April of 2012, Michigan repealed its 35-year-old universal motorcycle helmet law in favor of a partial helmet law, which permits motorcyclists older than 21 years old with sufficient insurance and experience to drive un-helmeted. We evaluated the clinical impact of the repeal. METHODS: The Michigan Trauma Quality Improvement Program's trauma database was queried for motorcycle crash patients between 1/1/09-4/12/12 and between 4/13/12-12/31/14. RESULTS: There were 1970 patients in the pre-repeal analysis and 2673 patients in the post-repeal analysis. Following the repeal, patients were more likely to be un-helmeted (p < 0.001) and to have a traumatic brain injury (p < 0.001). Patients were also more likely to require neurosurgical interventions (relative risk 1.4, p = 0.011). CONCLUSION: Following the repeal of the universal helmet law, there has been a significant increase in traumatic brain injuries and neurosurgical interventions. This analysis highlights another detrimental impact of the repeal of the universal helmet law.

Incidence and propagation of infrageniculate deep venous thrombosis in trauma patients.

BACKGROUND: The incidence and propagation of thrombosis involving vessels distal to the popliteal vein has not been clearly defined in trauma patients. Our aim was to determine the incidence and rate of propagation of infrageniculate deep venous thrombosis (DVT) in a trauma population and identify potential risk factors specific to propagation. METHODS: Retrospective review of all trauma admissions between the years 2001 and 2003 was conducted. Only those 18 years or older with an isolated infrageniculate DVT who underwent a lower extremity venous duplex scan during admission were included in the study. Nature of injury, injury severity score (ISS), method of DVT prophylaxis, thrombus location, and risk factors for hypercoagulable states were recorded. RESULTS: During the study period, 698 trauma admissions were included, and 109 (15.7%) with infrageniculate DVT were identified. Thirty-nine (35.7%) had thrombus propagation (14 suprageniculate and 25 infrageniculate) with a mean ISS of 27.6. Seventy (64.3%) had infrageniculate DVT without propagation and a mean ISS of 19.6. Thirty-eight (97%) patients with propagating infrageniculate DVT had received mechanical prophylaxis, and 33 (84%) also received chemical prophylaxis. The 14 patients with suprageniculate thrombus propagation were the most severely injured (mean ISS = 35.1). Elevated ISS, operation, age < or =62 years, and intensive care unit admission were positively correlated with propagation of infrageniculate DVT. CONCLUSION: The incidence and propagation of infrageniculate DVT in an aggressively prophylaxed trauma population are greater than previously reported. The clinical significance of isolated infrageniculate DVT remains to be determined, but when associated with a multiple injury trauma, the patient may be at risk for future suprageniculate DVT formation and may benefit from therapeutic anticoagulation.