Cerebrospinal fluid and plasma oxytocin concentrations are positively correlated and negatively predict anxiety in children.

The neuropeptide oxytocin (OXT) exerts anxiolytic and prosocial effects in the central nervous system of rodents. A number of recent studies have attempted to translate these findings by investigating the relationships between peripheral (e.g., blood, urinary and salivary) OXT concentrations and behavioral functioning in humans. Although peripheral samples are easy to obtain in humans, whether peripheral OXT measures are functionally related to central OXT activity remains unclear. To investigate a possible relationship, we quantified OXT concentrations in concomitantly collected cerebrospinal fluid (CSF) and blood samples from child and adult patients undergoing clinically indicated lumbar punctures or other CSF-related procedures. Anxiety scores were obtained in a subset of child participants whose parents completed psychometric assessments. Findings from this study indicate that plasma OXT concentrations significantly and positively predict CSF OXT concentrations (r=0.56, P=0.0064, N=27). Moreover, both plasma (r=-0.92, P=0.0262, N=10) and CSF (r=-0.91, P=0.0335, N=10) OXT concentrations significantly and negatively predicted trait anxiety scores, consistent with the preclinical literature. Importantly, plasma OXT concentrations significantly and positively (r=0.96, P=0.0115, N=10) predicted CSF OXT concentrations in the subset of child participants who provided behavioral data. This study provides the first empirical support for the use of blood measures of OXT as a surrogate for central OXT activity, validated in the context of behavioral functioning. These preliminary findings also suggest that impaired OXT signaling may be a biomarker of anxiety in humans, and a potential target for therapeutic development in individuals with anxiety disorders.

The effect of perch availability during pullet rearing and egg laying on the behavior of caged White Leghorn hens.

Enriched cages, compared with conventional cages, allow egg laying strains of chickens to meet some behavioral needs, including a high motivation to perch. The objective of this study was to determine if perch availability during rearing affected perch use as adults and if perch presence affected eating and drinking in caged White Leghorn hens. Chickens were assigned to 14 cages each with and without 2 round metal perches from hatch to 16.9 wk of age. At 17 wk of age, pullets were assigned to laying cages consisting of 1 of 4 treatments. Treatment 1 chickens never had access to perches (controls). Treatment 2 chickens only had access to 2 round metal perches during the laying phase (17 to 71 wk of age). Treatment 3 chickens only had access to 2 round perches during the pullet phase (0 to 16.9 wk of age). Treatment 4 chickens had access to the perches during both the pullet and laying phase. Each treatment during the adult phase consisted of 9 cages with 9 birds/cage for a total of 36 cages. Automatic infrared cameras were used to monitor behavior of hens in each cage for a 24-h period at 19, 24, 29, 34, 39, 44, 49, 54, 59, 64, and 69 wk of age. Behavior was also recorded twice weekly by an observer in the room where the hens were housed during photophase from 25 to 68 wk of age. Behavioral data were analyzed using ANOVA with repeated measures and the MIXED model procedure. A greater proportion of hens without perches as pullets used the rear perch more during both photophase and scotophase than hens with prior pullet perching experience. Eating and drinking activities of caged adult Leghorns were not impaired by their prior experience to perches as pullets or by the presence of perches in laying cages. It is concluded that providing perches in cages to White Leghorns during pullet rearing did not facilitate use of perches as adults.

Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence.

BACKGROUND: Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds. METHODS: A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed. RESULTS: Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n=6072) of patients were initially managed non-operatively and 15.5% (n=943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay. CONCLUSIONS: SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.

Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia.

A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.

Can seeds help mice with the daily grind?

Some laboratory mice gnaw food pellets without ingesting much of the gnawed material, resulting in the production of waste material called 'orts'. The fact that this food grinding behavior is not seen in all individuals of a particular strain suggests that it might be abnormal, and thus indicate a welfare concern. Furthermore, the increased rate of feed consumption and cage soiling is undesirable from a husbandry perspective. To try to determine possible motivations for the behavior, and identify potential treatments, outbred Crl:CD1(Icr) mice exhibiting food grinding were selected for one of three treatments placed in the feeder: no enrichment, a chewing device, or sunflower seeds. Both enrichment groups showed a significant decrease (P < 0.05) in ort production when compared with baseline measurements, but only mice provided with sunflower seeds maintained the decreased rate of food wastage after the treatment was withdrawn. A relationship between body weight and ort production was also found, in that cages with greater average body weights had lower levels of ort production. This suggests that a simple need to gnaw cannot alone explain food grinding, and that a nutritional motivation may also be involved.

Anorectal injury in pelvic blast.

The signature injury of the Afghanistan campaign has, amongst other things, included an increased incidence of destructive anorectal injury. There is no significant body of evidence about this type of injury on which to base management strategies. This review examines the historical military data, later civilian reports, many of which have challenged the military dogmas of Vietnam, and the spartan contemporaneous military data which does not particularly address pelviperineal blast injury. There is no evidence to support a move away from the doctrine of the four D's (diversion, distal washout, drainage and direct repair), but sound surgical judgement remains the mainstay of managing these challenging and highly morbid injuries.

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan.

INTRODUCTION: Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries. METHODS: The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included. RESULTS: During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality. CONCLUSIONS: Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.

Non-operative management of liver trauma.

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.

The effect of cage and house design on egg production and egg weight of White Leghorn hens: an epidemiological study.

Hen performance can be affected by many interacting variables related to cage design, such as floor area, height, tier arrangement, and feeder and drinker type and placement within the cage. Likewise, features of house design such as waste management and lighting can also affect hen productivity. The influence of these design aspects on hen performance has not been fully assessed. Determining the effects of numerous, interacting variables is impractical in a traditional experiment; therefore, an epidemiological approach, using variability in cage and house design among and within commercial producers, was employed to identify features that affect egg production and egg weight. A universal cage measurement system was created to calculate cage design variables. A database for recording information on cage design, resource location, waste management, environmental conditions, and hen productivity was developed. Production outcomes were assessed from placement to 60 wk of age in White Leghorns (n = 165-168 houses). Using GLM, a statistical model was identified that best described the variance in egg traits. Eggs/hen-housed increased with greater feeder space allocation (P = 0.031); taller cages (P = 0.029); rear (vs. front) drinker location in vertical cages (P = 0.026); and regular removal of manure from the house (P = 0.005). Case weight of eggs was greater in A-frame houses where manure was removed regularly instead of being left in the house (P < 0.001); with increasing cage floor slope (P = 0.001); in cages where drinkers were placed more toward the front or back of the cage as compared with the middle of the cage (P < 0.001); with more space/hen (P = 0.024); and with higher caloric intake (P < 0.001). Perhaps because of its negative correlation with egg production, case weight of eggs increased with less feeder space allocation (P = 0.004) and shorter cage heights (P < 0.001). These results reveal important effects of feeder space, floor space, cage height, drinker position, and waste management on hen productivity.

Surgical management of primary appendiceal malignancy.

AIM: Primary appendiceal neoplasms are rare, with carcinoid being more common than carcinoma. Preoperative diagnosis is infrequent. We report a series of 24 primary appendiceal neoplasms treated over a 5-year period. METHOD: All primary appendiceal neoplasms diagnosed in a university teaching hospital between April 2003 and June 2008 were identified from the prospective histopathology database. Patient records were reviewed for clinical, operative and pathological data. RESULTS: Fourteen carcinomas and 10 carcinoids were identified in the 5-year period. The former presented at median age 55.8 years with median symptom duration of 35 days, compared with 48 years and 3 days, respectively, for carcinoids. An abdominal mass was commoner in carcinomas (8/14 vs 1/10). Six patients with carcinoma underwent appendicectomy followed by completion right-hemicolectomy, two of whom had residual disease; seven underwent primary right-hemicolectomy and one had abscess drainage. Five patients with appendiceal carcinoma died of the disease during a median follow-up of 633 (256-1158) days. Six patients underwent appendicectomy for acute appendicitis, one had a primary right-hemicolectomy for a caecal mass. Three had a subsequent right-hemicolectomy for a high-risk carcinoid. An appendiceal carcinoid was an incidental finding in three right-hemicolectomy specimens removed for other indications. No metastases or deaths were recorded at median follow-up 451 (51-975) days. CONCLUSION: Appendiceal carcinomas follow a more protracted clinical course than carcinoids, which usually present as acute appendicitis. Caution is needed when diagnosing simple appendicitis in older patients with longer symptom duration, particularly if a mass is present. Patients with appendiceal carcinoma should be offered completion right-hemicolectomy. Carcinoma has a poor prognosis.

Abdominal trauma in primary blast injury.

BACKGROUND: Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure. METHODS: MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations. RESULTS: Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes. CONCLUSION: Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.

Traumatic diaphragmatic injury.

Traumatic diaphragmatic injury is a not uncommon accompaniment to blunt or penetrating trauma to the abdomen or thorax; it may present acutely with haemodynamic and respiratory compromise and be associated with significant injury to other organs or may not be diagnosed at the initial trauma at all and present later as a diaphragmatic hernia. This overview examines the incidence, pathophysiology and management of this condition.

Excellent outcomes after emergency groin hernia repair.

PURPOSE: Emergency repair of incarcerated inguinal and femoral hernias has traditionally been regarded as carrying an increased risk of morbidity and mortality in a patient population that tends to be elderly with significant co-morbidities. Excessive waiting times for elective repair and delays in diagnosis and treatment increase the risk of strangulation, bowel resection and overall mortality. This study examined the management of emergency surgery for groin hernias for a 3 year period in a large teaching hospital. METHOD: The notes of all patients undergoing emergency groin hernia repair in our hospital between 1 January 2005 and 31 December 2007 were examined. Patient demographics and details of perioperative course and outcome were analysed. RESULTS: Seventy-nine (50 males) patients had emergency groin hernia repair in the 3 year study period. Inguinal hernias predominated (61 vs 18); 12/79 (15%) had previously been assessed as outpatients prior to emergency presentation-all had inguinal hernias and nine (11.4 %) were on the waiting list for elective repair at the time of emergency surgery (mean wait 59 days). Complications were observed in 24% of patients. Two patients (2.5%) required small bowel resection, both performed without recourse to formal laparotomy, and two patients died within 30 days of surgery (2.5%). CONCLUSIONS: It is possible to achieve excellent complication, bowel resection and 30-day mortality rates in emergency groin hernia repair even in patients who have previously declined surgery due to perceived anaesthetic risks. As NHS waiting times for surgery decrease, the number of hernias repaired emergently whilst awaiting elective surgery will also fall.

Aggressiveness and brain amine concentration in dominant and subordinate finishing pigs fed the beta-adrenoreceptor agonist ractopamine.

Under farm conditions, aggression related to the formation of social hierarchy and competition for resources can be a major problem because of associated injuries, social stress, and carcass losses. Any factor that may affect the regulation and amount of aggression within a farmed system, for instance, feeding the beta-adrenoreceptor agonist ractopamine (RAC), is therefore worthy of investigation. The objectives of this study were to assess the effects of the widely used swine feed additive RAC, considering also the effects of sex and social rank on aggressiveness and concentrations of brain amines, neurotransmitters essential for controlling aggression, in finishing pigs. Thirty-two barrows and 32 gilts (4 pigs/pen by sex) were fed either a control diet or a diet with RAC (Paylean, Elanco Animal Health, Greenfield, IN) added (5 mg/kg for 2 wk, followed by 10 mg/kg for 2 wk). The top dominant and bottom subordinate pigs (16 pigs/sex) in each pen were determined after mixing by a 36-h period of continuous behavioral observation. These pigs were then subjected to resident-intruder tests (maximum 300 s) during the feeding trial to measure aggressiveness. At the end of wk 4, the amygdala, frontal cortex, hypothalamus, and raphe nuclei were dissected and analyzed for concentrations of dopamine (DA); serotonin (5-HT); their metabolites 3,4-dihydroxyphenyl acetic acid (DOPAC) and homovanillic acid, and 5-hydroxyindoleacetic acid (5-HIAA), respectively; norepinephrine; and epinephrine using HPLC. Ractopamine-fed gilts performed more attacks during the first 30 s of testing than pigs in all other subgroups (P < 0.05). By the end of the resident-intruder test (300 s), the dominant control gilts and barrows, and both dominant and subordinate RAC-fed gilts performed the greatest percentage of attacks (P < 0.05). Gilts had decreased norepinephrine and DOPAC concentrations in the amygdala and frontal cortex, and when fed RAC, gilts also had the least 5-HIAA concentration and greatest DA turnover rate in the amygdala (P < 0.05). The 5-HT concentration was less in the frontal cortex of gilts compared with barrows and in the raphe nuclei (single site for brain 5-HT synthesis) of dominant gilts (P < 0.05). Ractopamine may be affecting aggressive behavior through indirect action on central regulatory mechanisms such as the DA system. The aggressive pattern observed in the tested pigs, especially in gilts, is likely linked to brain monoamine profiling of a deficient serotonergic system in the raphe nuclei, amygdala, and frontal cortex, and enhanced DA metabolism in the amygdala, brain areas vital for aggression regulation.

The effect of feeder space allocation on productivity and physiology of Hy-Line W-36 hens housed in conventional cages.

Insufficient feeder space for laying hens could increase competition at the feed trough, leading to disrupted feeding, inadequate nutrient intake, stress, and reduced productivity. The effects of feeder space allocation (FSA) on physiology and productivity were evaluated in beak-trimmed Hy-Line W-36 hens (n=480). They were obtained at 16.5 wk of age and housed on 4 tiers of shallow conventional cages. Five pullets/cage were housed at a stocking density of 434 cm2/hen and a feeder space of 12.2 cm/hen. After 1.5 wk of acclimation, baseline measurements were taken for feed utilization, bone mineralization, and heterophil:lymphocyte ratios. At 20 wk of age, pullets were given 5.8, 7.1, 8.4, 9.7, 10.9, or 12.2 cm of feeder space/bird (16 cages/treatment). Physiological and production measures were calculated monthly or twice a month for 12 mo. The heart, spleen, and right adrenal gland were collected from each hen at the end of the study. Data were analyzed using a repeated measures GLM incorporating cage, tier, FSA, and hen age. There were no effects of FSA on total egg production, bone mineral density, bone mineral content, heterophil:lymphocyte ratios, or organ weights. Hens with reduced FSA utilized more feed (P<0.001), had poorer feed conversion (P<0.001), and laid eggs with slightly thicker and heavier shells (P<0.001). There were effects of FSA on total egg weight (P<0.001) and hen-day egg production (P<0.001), but they were of low magnitude and not linear (P>0.05). Because BW was similar among FSA treatments, the results suggest that reduced feeder space did not limit feed intake. In addition, reduced FSA did not lower bone mineralization or cause physiological stress in W-36 hens housed in shallow cages, suggesting that it did not impair hen welfare. However, it did result in poorer feed efficiency, possibly related to greater feed wastage, predictive of an adverse economic effect from reducing feeder space.

Development of a large animal model for investigating resuscitation after blast and hemorrhage.

BACKGROUND: Blast injuries are an increasing problem owing to the widespread terrorist threat, but hemorrhage remains the second leading cause of civilian trauma death. Against this background, increasing numbers of prehospital and military trauma organizations are advocating a hypotensive approach to resuscitation of the hypovolemic casualty, deliberately aiming not to achieve a normal blood pressure so as not to disturb any newly formed blood clots at the site of a vascular injury. METHODS: There are no data available to guide clinicians as to how best to resuscitate the blast-injured casualty who has also suffered a hemorrhagic injury. A large-scale program was initiated to examine this question and to offer clinical guidance on the optimal resuscitation strategy in such circumstances in terms of volume, type of fluid, speed of resuscitation, and appropriate endpoints. Before such experiments could be undertaken, a novel large animal model of blast and hemorrhage had to be devised and validated. This study outlines the derivation of such a large animal model utilizing terminally anesthetized Large White pigs exposed to a standardized primary blast wave followed by a controlled hemorrhage of 30% of the total blood volume. RESULTS AND CONCLUSION: The preliminary results confirm the reliability and reproducibility of this model.

Successful pregnancy and delivery following a Malone antegrade continence enema procedure.

Malone antegrade continence enema (MACE) procedures are an effective treatment for both intractable faecal incontinence and constipation of neurogenic aetiology and have traditionally been used in a paediatric setting. MACE procedures are now being performed more commonly in adults suffering idiopathic chronic constipation where they are also effective. Increasing use in otherwise healthy adult females raises concerns about the durability of the appendiceal conduit should the patient become pregnant. We report the first case of successful pregnancy after a MACE procedure with an umbilical stoma and discuss the impact of the pregnancy on MACE function.

The effect of feeder space allocation on behavior of Hy-Line W-36 hens housed in conventional cages.

Insufficient feeder space for laying hens could increase competition at the feed trough, resulting in exclusion of low-ranking hens from the feeder. To test this hypothesis, the effects of feeder space allocation (FSA) on feeding behavior, aggression, feather scores, BW, and mortality were evaluated in a common commercial strain of egg-laying chickens. Beak-trimmed Hy-Line W-36 hens (n = 480) were obtained as pullets at 16.5 wk of age and housed in conventional cages on 4 tiers. Five pullets/cage were housed at a stocking density of 434 cm(2)/pullet and an FSA of 12.2 cm/pullet. After 1.5 wk of acclimation, baseline measurements were taken for 2 wk and then pullets were given either 5.8, 7.1, 8.4, 9.7, 10.9, or 12.2 cm of feeder space/hen (16 cages/treatment). Feeding behavior was evaluated in each cage over a 24-h period each month. For each hen, percentage of time spent feeding and synchrony (mean number of additional hens feeding at the same time) were determined and scores were averaged for each cage. For each cage, feeder switching (number of observations in which hens changed from feeding to not feeding) and feeder sharing (probability that feeder access was equally distributed among all hens) were calculated. At monthly intervals, individual hens were weighed and their feathers scored using a 5-point scale on 8 body regions. Data were analyzed using a repeated measures GLM incorporating cage, tier, FSA, and age of the hen. Hens with reduced feeder space spent less time feeding (P < 0.001), synchronized their feeding bouts to a lesser extent (P < 0.001), made fewer switches at the feeder (P < 0.001), and shared the feeder less (P < 0.001). However, feather scores, BW, and BW uniformity were not affected by FSA. There was almost no aggressive behavior and little mortality. These results demonstrate that Hy-Line W-36 hens did not respond to reduced feeder space by aggressively excluding cage-mates from the feeder but instead desynchronized their feeding behavior.

The cost of ignoring acute cholecystectomy.

INTRODUCTION: Biliary symptoms whilst awaiting elective cholecystectomy are common, resulting in hospital admission, further investigation and increased hospital costs. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications. PATIENTS AND METHODS: The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place. RESULTS: In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There were 112 patients who initially presented acutely and were managed conservatively. Twenty-four patients were re-admitted 37 times, which utilised 231 hospital bed-days and repeat investigations costing over 40,000 pounds. There would have been a marginal increase in tariff income if a policy of acute laparoscopic cholecystectomy had been in place. CONCLUSIONS: Adoption of a policy of acute laparoscopic cholecystectomy on the index admission would result in substantial cost savings to the trust, reduce elective cholecystectomy waiting times and increase tariff income.