Seasonal temperature patterns and durations of acceptable temperature range in houses in Brisbane, Australia.

A paradigm shift to the use of indoor rather than outdoor temperature to estimate the exposure risk of low and high temperatures is vital for better prediction of temperature health effects and timely health warnings, and will also assist in understanding the influence of temperature on energy consumption and comfort. This study aimed to quantify the percentage of hours during the year that indoor temperature (living room) was in the extended comfort band (18-28 °C) of a subtropical climate, and identify the diurnal pattern of indoor temperatures in different seasons. Data used was collected in a previous study on the association between indoor and outdoor temperature. A k-shape cluster analysis resulted in two clusters of indoor temperature patterns for both weekdays and weekends. A bimodal pattern was identified during the cool season and a flat top pattern for the warm season, with many variations at weekends. These patterns can be attributed to the influence of cooling and heating processes depending on the season as well as occupancy, occupants' interference, and building materials. During the intermediate season, a sinusoidal pattern was observed for both weekdays and weekends because occupants likely relied on outdoor temperature conditions which were similar to those expected indoors without heating or cooling devices. The percentage of hours in which the indoor temperature of the houses ranged within the extended comfort band was 72-97% throughout the year, but for the coldest and hottest months it was 50-75%. These findings show that Brisbane residents are at possible risk of exposure to cold and hot temperatures due to the poor thermal performance of houses, and confirm that there is no standard indoor temperature pattern for all houses.

Effect of fluid irrigation on core body temperature during laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration uses large volumes of intraperitoneal irrigation fluid. Much of this fluid crosses the peritoneal cavity. This study was performed to examine its effect on core body temperature. MATERIALS AND METHODS: Ten patients undergoing laparoscopic bile duct exploration were studied. Core temperature was measured intraoperatively. Patients were covered with a warming blanket. The volume of fluid irrigated, carbon dioxide used, and intravenous fluid infused were recorded. Ten patients having cholecystectomy alone were studied as a control group. RESULTS: There was a small but significant rise in core temperature in both the study (P = 0.010) and control (P = 0.002) groups. There was no significant difference in the change in core temperature between the groups (P = 0.706).The mean volume of irrigation fluid used was 2640 mL in the study group and 915 mL in the control group. Mean gas volume used was 162.9 L and 73.3 L and the volume of intravenous fluid infused was 1620 mL and 1190 mL in the study and control groups, respectively. CONCLUSION: The use of large volumes of irrigation fluid during laparoscopic bile duct exploration does not cause a fall in core temperature.

Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation.

BACKGROUND: Little is known about the spontaneous passage of bile duct stones. The aim of this study was to determine the rate of spontaneous stone passage and relate it to the clinical presentation of the bile duct stone. PATIENTS AND METHODS: Prospectively collected data were studied on a total of 1000 consecutive patients undergoing laparoscopic cholecystectomy with or without laparoscopic common duct exploration. Comparisons were made between 142 patients with common bile duct stones (CBDS), 468 patients who had no previous or current evidence of duct stones, and 390 patients who had good evidence of previous duct stones but none at the time of cholecystectomy. The evidence used for previous duct stones included a good history of jaundice or pancreatitis. In patients with biliary colic or cholecystitis, abnormal pre-operative liver function tests and/or a dilated common bile duct were taken as evidence of bile duct stones. RESULTS: Of the 1000 patients studied, 532 had evidence of stones in the common bile duct at some time prior to cholecystectomy. At the time of operation, only 142 patients had bile duct stones. By implication, 80%, 84%, 93% and 55% of patients presenting with pancreatitis, colic, cholecystitis and jaundice (73% overall) had passed their bile duct stones spontaneously. All 4 patients with cholangitis had duct stones at the time of operation. CONCLUSIONS: It is likely that most bile duct stones (3 in 4) pass spontaneously, especially after pancreatitis, biliary colic and cholecystitis but less commonly after jaundice. Cholangitis appears to be always associated with the presence of duct stones at the time of operation.

A prospective single-blinded controlled study comparing laparoscopic ultrasound of the common bile duct with operative cholangiography.

BACKGROUND: Ultrasound examination of the bile duct during cholecystectomy compares well with operative cholangiography. Studies so for have not been blinded, nor has the stone content been validated immediately. We have, therefore, carried out a blinded comparison of laparoscopic ultrasound with fluoroscopic operative cholangiography. METHODS: This study included 135 patients (average age, 53 years) undergoing laparoscopic cholecystectomy with or without bile duct exploration. Laparoscopic ultrasound examination was performed by an experienced surgeon blinded to the patient's clinical condition. This was followed by an operative cholangiogram. Bile ducts were explored if stones were seen, and the patients were followed up. RESULTS: Laparoscopic ultrasound identified the bile ducts satisfactorily in 131 cases and operative cholangiography in 121 cases. Duct stones were present in 49 cases. They were correctly identified by ultrasound in 47 cases and by cholangiography in 42 cases. There was one false positive cholangiographic examination. The sensitivity was 96% for ultrasound and 86% for cholangiography. The specificities were 100% and 99%, respectively. CONCLUSION: Laparoscopic ultrasound examination of the bile duct is superior to operative cholangiography and could replace it.

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct.

BACKGROUND: Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence. METHODS: A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used. RESULTS: Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients. CONCLUSION: Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :

All-comers policy for laparoscopic exploration of the common bile duct.

BACKGROUND: Laparoscopic exploration of the common bile duct is associated with substantial variation in results suggesting that different patient populations are being reported. This report observes the results in a defined population and on an intention-to-treat basis. METHODS: All patients with suspected bile duct stones who were fit for surgery from April 1994 were offered laparoscopic bile duct exploration. There were 224 patients of mean age 56 years, of whom 174 were women. Endoscopic sphincterotomy was used in 149 patients deemed unfit for surgery. All data were recorded prospectively and checked at the time of discharge. Patients were followed up after 6 months and beyond after the operation. RESULTS: Stones were removed transcystically in 56 patients, transductally in 158 and by flushing in nine. The duct clearance rate was 96 per cent overall, 98 per cent for transcystic and 94 per cent for transductal exploration. Intracorporeal lithotripsy safely reduced the failure rate of exploration from seven of the first 28 to four of the subsequent 196 procedures. Biliary complications occurred in 16 per cent of procedures in which a T tube was used but only 4 per cent if the duct was closed by suturing. Conversion to open operation for severe gallbladder inflammation was necessary in 6 per cent of patients. There were no deaths, bile duct injuries or pancreatitis but complications occurred in 19 per cent, associated with use of T tubes and advancing age. Laparoscopic duct exploration succeeded in seven patients after previous cholecystectomy. CONCLUSION: Laparoscopic bile duct exploration is effective and safe when used for all patients. For young and fit patients it should replace endoscopic sphincterotomy.

Eosinophilic gastroenteritis mimicking pancreatic cancer.

Eosinophilic gastroenteritis is a condition characterised by eosinophilic infiltration of the gastrointestinal tract. Biliary obstruction is an unusual presentation. A case where the initial investigations were consistent with carcinoma of the head of pancreas but the resection specimen showed no malignancy is presented. The diagnosis was suspected from a review of the patient's past history and confirmed by re-examination of the histology.

Potential of laparoscopic ultrasonography as an alternative to operative cholangiography in the detection of bile duct stones.

BACKGROUND: Intraoperative cholangiography (IOC) is time consuming, requires radiation and sometimes fails. In contrast, laparoscopic ultrasonography (LUS) is a comparatively quick, safe and non-invasive technique. The aim of this study was to assess the potential of LUS as an alternative to IOC. METHODS: LUS was performed on 367 patients undergoing laparoscopic cholecystectomy. Laparoscopic duct exploration was performed in the presence of duct stones. Data were collected prospectively. The presence or absence and number of duct stones detected by LUS were recorded. The maximum bile duct diameter determined by LUS was compared with a preoperative ultrasonographic measurement according to age and the presence of duct stones. The final arbiter was the demonstration of stones removed at laparoscopic duct exploration (59 patients) or subsequently by endoscopic retrograde cholangiopancreatography (two patients). RESULTS: LUS visualized the CBD in 99 per cent of patients and the common hepatic duct in 92 per cent. It identified stones in 56 of the 61 patients with duct stones. No stones were demonstrated in the remaining 306 patients (sensitivity 92 per cent, specificity 100 per cent, positive predictive value 100 per cent, negative predictive value 98 per cent). LUS underestimated the total number of stones in 18 per cent of patients with common duct stones. The mean common bile duct diameter was 5.0 mm before operation and 5. 9 mm during the procedure in patients without duct stones, rising significantly to a mean of 9.2 mm before operation and 11.2 mm at LUS in those with duct stones (P < 0.0001). CONCLUSION: The combination of the demonstration of duct stones and bile duct diameter measurement makes LUS a potential replacement for IOC. Improved demonstration of the common hepatic duct would be advantageous.

A prospective, randomised trial of prophylactic antibiotics versus bag extraction in the prophylaxis of wound infection in laparoscopic cholecystectomy.

Septic complications are rare following laparoscopic cholecystectomy if prophylactic antibiotics are given, as demonstrated in previous studies. Antibiotic treatment may be unnecessary and, therefore, undesirable, so we compared two forms of prophylaxis: a cephalosporin antibiotic and bag extraction of the dissected gallbladder. A total of 76 patients undergoing laparoscopic cholecystectomy were randomised to either receive an antibiotic or to have their gallbladder removed from the abdomen in a plastic bag. Complicated cases were excluded. There was a total of 6 wound infections (7.9%), 3 in each of the study groups. All these were associated with skin commensals. There were no other septic complications. Bacteriological studies grouped the organisms isolated from the bile and the wound as potential pathogens and likely commensals. A total of 10 potential pathogens were isolated, 9 of which were found in the group receiving antibiotics. We conclude that septic sequelae of uncomplicated laparoscopic cholecystectomy are uncommon, but clearly not entirely prevented by antibiotic or mechanical prophylaxis. Prophylactic antibiotics may not be required in uncomplicated laparoscopic cholecystectomy. Further study is warranted.

A prospective study of faecal bile acids and colorectal cancer.

A prospective study of 7079 people aged 45-74 recruited through general practices in South Wales, Herefordshire and Edinburgh, Scotland was undertaken to test the hypothesis that faecal bile acids are implicated in the causation of large bowel cancer. The population was recruited between 1974 and 1980 and the response rate for stool collection was 67%. Bile acid analyses were performed on those cases that presented by 1990. It was decided in advance to examine the hypothesis separately for left- and right-sided bowel cancer because of known epidemiological differences between the two sites and to exclude the cases presenting within 2 years of the stool sample from the analyses because the cancer could have been present at recruitment and might have possibly affected faecal bile acid concentrations. Each case (n = 51 left-sided and 8 right-sided) was matched with three controls by age (within 5 years), sex, place of residence and time of providing the stool sample (within 3 months). Statistical analyses using conditional logistic regression showed no significant differences between the left-sided cases and controls for any of the concentrations of individual bile acids, total bile acid concentrations, faecal neutral steroids, percentage bacterial conversion and the ratio of lithocholic acid to deoxycholic acid concentrations. There was a statistically significant (P = 0.021) association of the presence of chenodeoxycholic acid (5/8 samples) in the right-sided cases compared with the controls (3/23), odds ratio 6.26 (95% confidence interval 1.19, 32.84). A high proportion of primary bile acids has also been found in other studies of patients with a genetic predisposition to proximal bowel cancer, however this pattern may also occur in low risk groups, such as Indian vegetarians, suggesting that they may predispose to right-sided bowel cancer only in the presence of other, as yet unknown factors. If bile acids are involved in the causation of large bowel cancer, they may be part of a complex set of interacting factors.

Cholecystectomy, conversion and complications.

BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate. METHODS: A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken. RESULTS: Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant. CONCLUSION: When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.

Neonatal group B streptococcal infection in South Bedfordshire, 1993-1998.

BACKGROUND: Group B streptococcus (GBS) is now the leading cause of neonatal bacterial sepsis in the western world. The incidence of GBS infection in the United States has been determined, and guidelines produced and implemented for the prevention of neonatal infection. Neither incidence nor guidelines are currently established in the United Kingdom. AIM: To define the pattern of neonatal infection within one hospital (Luton and Dunstable Hospital). METHOD: A six year retrospective analysis was performed. RESULT: An incidence of early onset GBS of 1.15 per 1000 deliveries, comparable with that documented in the United States, was found.

Association between Streptococcus milleri and abscess formation after appendicitis.

Abscesses after appendicitis occur in some patients despite timely surgery and antibiotics. The Streptococcus milleri group of bacteria are commonly associated with gastrointestinal abscesses. This study investigated the relationship between S. milleri and abscess formation after appendicectomy a total of 301 patients (172 males, 129 females, median age 22 years) with appendicitis were identified retrospectively from the hospital PAS computer system who had an appendicectomy and peritoneal bacteriology swabs taken. All but one patient had prophylactic antibiotics. Patients were divided into three groups according to peritoneal bacteriology: group 1 (S. milleri +/- mixed faecal organisms, n = 61); group 2 (mixed faecal organisms, n = 126); and group 3 (sterile, n = 114). The chi squared and Student t-tests were used for statistical analysis. Thirteen (21%) of group 1 patients developed an intra-abdominal abscess compared with 4 (3%) in group 2 and 2 (1.7%) in group 3 (P < 0.0001). There was no difference in the prevalence of gangrenous or perforated appendicitis between groups 1 and 2 (56% versus 52%) but these worse forms of appendicitis were less common in group 3 (22%). Group 1 patients had a mean total hospital stay of 10 days versus 6 days for group 2 and 4 days for group 3 (P < 0.001). S. milleri was associated with a 7-fold increase in abscess formation after appendicectomy and a longer hospital stay. Antibiotic prophylaxis did not prevent this complication.

Neonatal diabetes mellitus and cerebellar hypoplasia/agenesis: report of a new recessive syndrome.

Classical neonatal diabetes mellitus is defined as hyperglycaemia occurring within the first six weeks of life in term infants. Cerebellar agenesis is rare. We report three cases of neonatal diabetes mellitus, cerebellar hypoplasia/agenesis, and dysmorphism occurring within a highly consanguineous family. This constellation of abnormalities has not previously been described. Two of these cases are sisters and the third case is a female first cousin. The pattern of inheritance suggests this is a previously undescribed autosomal recessive disorder. Prenatal diagnosis of the condition in this family was possible by demonstration of the absence of the cerebellum and severe IUGR.

Laparoscopic splenectomy in pregnancy.

A laparoscopic splenectomy during pregnancy is described in this case report. The operation took place at 18 weeks' gestation for life-threatening thrombocytopaenia secondary to antiphospholipid syndrome that had failed to respond to medical therapy. The patient made a full and rapid recovery and was delivered of a healthy baby girl at term.

Faecal pH, bile acid and sterol concentrations in premenopausal Indian and white vegetarians compared with white omnivores.

Faecal bulk, pH, water content, the concentrations of neutral sterols and bile acids and dietary intakes were measured in twenty-two Indian vegetarian, twenty-two white omnivorous and eighteen white vegetarian premenopausal women. Faecal bulk and water content were greater and pH lower in the Indian vegetarians. Total faecal animal sterol and coprostanol concentrations expressed on a dry-weight basis were lower in the vegetarians compared with the omnivores. The faecal sterol concentrations were correlated with dietary cholesterol intake. Primary bile acids were detected in six Indian vegetarians, two white vegetarians and two white omnivores; secondary bile acids were detected in all the white omnivores and vegetarian subjects but not in two of the Indian vegetarians. Total faecal free bile acid and conjugated bile acid concentrations were lower in the white vegetarians compared with the omnivores. Faecal lithocholic acid concentrations were lower in both Indian and white vegetarians. The lithocholic: deoxycholic acid ratio and coprostanol: total animal sterols ratio were significantly lower in the Indian vegetarians compared with the omnivores. Both ratios were positively correlated with faecal pH. Stepwise multiple regression analyses were undertaken in order to identify which nutrients influenced faecal pH, lithocholic and deoxycholic acid concentrations. The intakes of starch and dietary fibre were negatively associated with faecal concentrations of lithocholic and deoxycholic acid. Starch intake alone was negatively associated with faecal pH. The results of this study confirm that diets high in dietary fibre decrease faecal bile acid concentrations and suggest that the complex carbohydrates present in Indian vegetarian diets influence faecal pH and inhibit the degradation of faecal steroids.