Background Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. Methods An International Prospective Register of Systematic Reviews–registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy “intraoperative AND cholangiogra* AND cholecystectomy.” Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. Results Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%–96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80–3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65–1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78–1.06, P value = .23). Conclusion The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.

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Introduction: Hyperfibrinolysis (HF), an integral component of trauma-induced coagulopathy, is associated with increased mortality and need for massive blood transfusion (MT). Clot lysis 30 minutes after maximum clot strength (LY30) is the standard measure of fibrinolysis by thrombelastography (TEG). The critical level to define HF and initiate anti-fibrinolytic therapy has ranged from 3-7.5%, and this variability might be due to diversity in injury type and severity. For example, less severely injured patients could tolerate higher levels of HF than more injured counterparts. We hypothesize that LY30 cutoffs that define HF are dependent on levels of injury severity and shock. Methods: Adults requiring trauma activations from 2010-2017 in two urban trauma centers were included. Cutoffs defined using the Youden Index and ROC curve analysis using MT ([ 10RBC) or death/ 24hrs as the outcome. Relative risks of MT for each cutoff were derived using Poisson regression with robust standard errors to account for intra-facility clustering. Severe traumatic brain injury (sTBI) was defined as AIS Head [ 3 and Glasgow Coma Scale (GCS) \ 9. Results: 904 patients, median age 33.5 (25-48), 81% male, ISS 10 (2-26), and 51% blunt injuries, were included. Mortality was 12%, and 11% required MT. The cutoff for HF (level with optimal prediction of MT) decreased with higher ISS and hypotension. Presence of sTBI further decreased the LY30 threshold level by 1-4%. LY30 (%) Cutoff for MT MT Total MT % + Predictive value (%) Relative Risk (95% CI) All patients 7 98 904 11 52 2.9(2-4.3) Injury Severity Score (ISS) \26 35.4 6 609 1 83 41.9(21.0-83.4) 26-50 7.0 34 196 17 50 5.3(3.2-8.7) [50 3.0 8 14 57 100 2.2(0.8-6.0) Arrival SBP (mmHg)

The statistics which show an infant mortality of from 20 to 25 per cent. before the end of the first year of life are a woeful and terrible comment on the ignorance or carelessness of some one, be it parent, family physician, modern circumstances or environment. Wherever the blame belongs it must soon be known, and a remedy applied which will stop such a sacrifice of human life. Such a record does not comport with modern achievement and advancement, and can not long be tolerated as one of the failures of medicine. In this percentage there is a large, too large, ratio of ear conditions presented as a causal or complicating element in the cause of death. The ear conditions which are most frequently met with in infancy and childhood are acute middle-ear suppuration with or without its more or less severe and serious complications, impacted cerumen, foreign bodies, furunculosis, granulations, eczema. necrosis, polypi, meningitis, extradural abscess, cerebral abscess and traumatisms. Of these, it is well known, acute and chronic middleear suppuration are by far the most frequent and most important. It occurs much more frequently than all