Measurement of the major ignored burden of multiple myeloma, pernicious anaemia and of other haematological conditions on partners and family members: A cross-sectional study.

BACKGROUND: Having a haematological condition can adversely affect the quality of life (QoL) of family members/partners of patients. It is important to measure this often ignored burden in order to implement appropriate supportive interventions. OBJECTIVE: To measure current impact of haematological conditions on the QoL of family members/partners of patients, using the Family Reported Outcome Measure-16 (FROM-16). METHODS: A cross-sectional study, recruited online through patient support groups, involved UK family members/partners of people with haematological conditions completing the FROM-16. RESULTS: 183 family members/partners (mean age = 60.5 years, SD = 13.2; females = 62.8%) of patients (mean age = 64.1, SD = 12.8; females = 46.4%) with 12 haematological conditions completed the FROM-16. The FROM-16 mean total score was 14.0 (SD = 7.2), meaning 'a moderate effect on QoL'. The mean FROM-16 scores of family members of people with multiple myeloma (mean = 15.8, SD = 6.3, n = 99) and other haematological malignancies (mean = 13.9, SD = 7.8, n = 29) were higher than of people with pernicious anaemia (mean = 10.7, SD = 7.5, n = 47) and other non-malignant conditions (mean = 11, SD = 7.4, n = 56, p < .01). Over one third (36.1%, n = 183) of family members experienced a 'very large effect' (FROM-16 score>16) on their quality of life. CONCLUSIONS: Haematological conditions, in particular those of malignant type, impact the QoL of family members/partners of patients. Healthcare professionals can now, using FROM-16, identify those most affected and should consider how to provide appropriate holistic support within routine practice.

Responsiveness and minimal important change of the Family Reported Outcome Measure (FROM-16).

BACKGROUND: The FROM-16 is a generic family quality of life (QoL) instrument that measures the QoL impact of patients' disease on their family members/partners. The study aimed to assess the responsiveness of FROM-16 to change and determine Minimal Important Change (MIC). METHODS: Responsiveness and MIC for FROM-16 were assessed prospectively with patients and their family members recruited from outpatient departments of the University Hospital Wales and University Hospital Llandough, Cardiff, United Kingdom. Patients completed the EQ-5D-3L and a global severity question (GSQ) online at baseline and at 3-month follow-up. Family members completed FROM-16 at baseline and a Global Rating of Change (GRC) in addition to FROM-16 at follow-up. Responsiveness was assessed using the distribution-based (effect size-ES, standardized response mean -SRM) and anchor-based (area under the receiver operating characteristics curve ROC-AUC) approaches and by testing hypotheses on expected correlation strength between FROM-16 change score and patient assessment tools (GSQ and EQ-5D). Cohen's criteria were used for assessing ES. The AUC ≥ 0.7 was considered a good measure of responsiveness. MIC was calculated using anchor-based (ROC analysis and adjusted predictive modelling) and distribution methods based on standard deviation (SD) and standard error of the measurement (SEM). RESULTS: Eighty-three patients with 15 different health conditions and their relatives completed baseline and follow-up questionnaires and were included in the responsiveness analysis. The mean FROM-16 change over 3 months = 1.43 (SD = 4.98). The mean patient EQ-5D change over 3 months = -0.059 (SD = 0.14). The responsiveness analysis showed that the FROM-16 was responsive to change (ES = 0.2, SRM = 0.3; p < 0.01). The ES and SRM of FROM-16 change score ranged from small (ES = 0.2; SRM = 0.3) for the distribution-based method to large (ES = 0.8, SRM = 0.85) for anchor-based methods. The AUC value was above 0.7, indicating good responsiveness. There was a significant positive correlation between the FROM-16 change scores and the patient's disease severity change scores (p < 0.001). The MIC analysis was based on data from 100 family members of 100 patients. The MIC value of 4 was suggested for FROM-16. CONCLUSIONS: The results of this study confirm the longitudinal validity of FROM-16 which refers to the degree to which an instrument is able to measure change in the construct to be measured. The results yield a MIC value of 4 for FROM-16. These psychometric attributes of the FROM-16 instrument are useful in both clinical research as well as clinical practice.

Mapping of Family Reported Outcome Measure (FROM-16) scores to EQ-5D: algorithm to calculate utility values.

OBJECTIVE: Although decision scientists and health economists encourage inclusion of family member/informal carer utility in health economic evaluation, there is a lack of suitable utility measures comparable to patient utility measures such those based on the EQ-5D. This study aims to predict EQ-5D-3L utility values from Family Reported Outcome Measure (FROM-16) scores, to allow the use of FROM-16 data in health economic evaluation when EQ-5D data is not available. METHODS: Data from 4228 family members/partners of patients recruited to an online cross-sectional study through 58 UK-based patient support groups, three research support platforms and Welsh social services departments were randomly divided five times into two groups, to derive and test a mapping model. Split-half cross-validation was employed, resulting in a total of ten multinomial logistic regression models. The Monte Carlo simulation procedure was used to generate predicted EQ-5D-3L responses, and utility scores were calculated and compared against observed values. Mean error and mean absolute error were calculated for all ten validation models. The final model algorithm was derived using the entire sample. RESULTS: The model was highly predictive, and its repeated fitting using multinomial logistic regression demonstrated a stable model. The mean differences between predicted and observed health utility estimates ranged from 0.005 to 0.029 across the ten modelling exercises, with an average overall difference of 0.015 (a 2.2% overestimate, not of clinical importance). CONCLUSIONS: The algorithm developed will enable researchers and decision scientists to calculate EQ-5D health utility estimates from FROM-16 scores, thus allowing the inclusion of the family impact of disease in health economic evaluation of medical interventions when EQ-5D data is not available.

Efficacy and tolerance of oral versus parenteral cyanocobalamin supplement in hypocobalaminaemic dogs with chronic enteropathy: a controlled randomised open-label trial.

OBJECTIVES: Determine comparative tolerance of daily oral and weekly parenteral cobalamin supplementation, in hypocobalaminaemic dogs with chronic enteropathy. Determine whether oral is as effective as parenteral supplementation at achieving eucobalaminaemia, in hypocobalaminaemic dogs with protein-losing enteropathy, severe hypocobalaminaemia or high canine inflammatory bowel disease activity index at inclusion. MATERIALS AND METHODS: Thirty-seven client-owned dogs with hypocobalaminaemia and clinical signs of chronic enteropathy were prospectively enrolled in three UK referral centres. Dogs were randomly allocated to daily oral for 12 weeks or weekly parenteral cobalamin supplementation for 6 weeks and one additional dose 4 weeks later. Serum cobalamin, body condition score, canine inflammatory bowel disease activity index and bodyweight were assessed at inclusion, weeks 7 and 13. Serum methylmalonic acid concentration was evaluated at inclusion and at week 13. Owners completed treatment adherence, palatability, tolerance and satisfaction questionnaires at week 13. RESULTS: Nineteen dogs completed the study. All dogs orally supplemented achieved normal or increased cobalaminaemia at weeks 7 and 13. There was no statistical difference in cobalamin concentration at week 13 in dogs treated with oral or parenteral supplementation, regardless of presence of protein-losing enteropathy, severity of hypocobalaminaemia or canine inflammatory bowel disease activity index at inclusion. Serum methylmalonic acid concentration was not significantly different between oral and parenteral groups, neither were treatment adherence, satisfaction, and tolerance scores at week 13. CLINICAL SIGNIFICANCE: Oral is as effective and as well-tolerated as parenteral cobalamin supplementation in hypocobalaminaemic dogs with chronic enteropathy and severe clinical or biochemical phenotypes, and should be considered as a suitable treatment option regardless of disease severity.

Switching via wave interaction in topological photonic lattices.

A honeycomb Floquet lattice with helically rotating waveguides and an interface separating two counter-propagating subdomains is analyzed. Two topologically protected localized waves propagate unidirectionally along the interface. Switching can occur when these interface modes reach the edge of the lattice and the light splits into waves traveling in two opposite directions. The incoming mode, traveling along the interface, can be adjusted and routed entirely or partially along either lattice edge with the switching direction based on a suitable mixing of the interface modes.

Adolescent neurocognitive development and impacts of substance use: Overview of the adolescent brain cognitive development (ABCD) baseline neurocognition battery.

Adolescence is characterized by numerous social, hormonal and physical changes, as well as a marked increase in risk-taking behaviors. Dual systems models attribute adolescent risk-taking to tensions between developing capacities for cognitive control and motivational strivings, which may peak at this time. A comprehensive understanding of neurocognitive development during the adolescent period is necessary to permit the distinction between premorbid vulnerabilities and consequences of behaviors such as substance use. Thus, the prospective assessment of cognitive development is fundamental to the aims of the newly launched Adolescent Brain and Cognitive Development (ABCD) Consortium. This paper details the rationale for ABC'lected measures of neurocognition, presents preliminary descriptive data on an initial sample of 2299 participants, and provides a context for how this large-scale project can inform our understanding of adolescent neurodevelopment.

Noise pollution and detaining captured persons at sea.

During the course of military operations, the UK Armed Forces may have to capture and detain individuals. International law sets down a framework for the minimum basic standards that are applicable in these circumstances, and it is the responsibility of the UK Armed Forces to understand and implement these. This case review looks at a specific example of this issue related to noise pollution and appropriate detention facilities during anti-piracy operations, and how a flexible approach combined with good understanding of the regulations ensured compliance with these basic standards.

"It's a hidden issue": exploring the experiences of women with HIV-associated neurocognitive challenges using a disability framework.

PURPOSE: To use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to explore the experiences of women living with self-identified HIV-associated neurocognitive challenges. METHOD: This interpretive, qualitative study involved key informant interviews with 16 women with self-identified HIV-associated neurocognitive challenges. Data were collected through 60-90 min, in-depth, semi-structured interviews. Thematic analysis was performed using an inductive approach. Theoretical analysis then used the ICF to reconceptualize the data using a disability lens. RESULTS: Participants perceived impairments (e.g. memory loss, difficulty multi-tasking) and participation restrictions (e.g. parenting, work roles) resulting from their neurocognitive challenges as having a larger impact on their daily lives than activity limitations (e.g. difficulty with chores). Participants held contrasting views about parenting: women with children drew strength from parenting whereas women without children worried that parenting could compromise their health. Participation in work and volunteering roles was viewed as integral to managing neurocognitive challenges and health overall. CONCLUSIONS: Conceptualizing neurocognitive challenges through a disability lens focuses attention on how impairments interact with other realities in these women's lives. This exploratory study reveals the need for future research exploring perceptions among people living with HIV-associated neurocognitive challenges with attention to aging and among other vulnerable groups.

Solubilisation capacity of Brij surfactants.

The aim of this study was to investigate the potential of selected Brij non-ionic surfactants for enhancing the solubility of poorly water-soluble drugs. Griseofulvin was selected as a model drug candidate enabling comparisons to be made with the solubilisation capacities of other poly(ethylene oxide)-based copolymers. UV/Vis and (1)H NMR spectroscopies were used to quantify the enhancement of solubility of griseofulvin in 1 wt% aqueous micellar solutions of Brij 78 (C(18)H(37)E(20)), Brij 98 (C(18)H(35)E(20)) and Brij 700 (C(18)H(37)E(100)) (where E represents the OCH(2)CH(2) unit of the poly(ethylene oxide) chain) at 25, 37 and 40 °C. Solubilisation capacities (S(cp) expressed as mg griseofulvin per g Brij) were similar for Brij 78 and 98 (range 6-11 mg g(-1)) but lower for Brij 700 (3-4 mg g(-1)) as would be expected for the surfactant with the higher ethylene oxide content. The drug loading capacity of micelles of Brij 78 was higher than many di- and triblock copolymers with hydrophilic E-blocks specifically designed for enhancement of drug solubility.

Effect of water-soluble polymers, polyethylene glycol and poly(vinylpyrrolidone), on the gelation of aqueous micellar solutions of Pluronic copolymer F127.

The micellization of F127 (E(98)P(67)E(98)) in dilute aqueous solutions of polyethylene glycol (PEG6000 and PEG35000) and poly(vinylpyrrolidone) (PVP K30 and PVP K90) is studied. The average hydrodynamic radius (r(h,app)) obtained from the dynamic light scattering technique increased with increase in PEG concentration but decreased on addition of PVP, results which are consistent with interaction of the micelles with PEG and the formation of micelles clusters, but no such interaction occurs with PVP. Tube inversion was used to determine the onset of gelation. The critical concentration of F127 for gelation increased on addition of PEG and of PVP K30 but decreased on addition of PVP K90. Small-angle X-ray scattering (SAXS) was used to show that the 30 wt% F127 gel structure (fcc) was independent of polymer type and concentration, as was the d-spacing and so the micelle hard-sphere radius. The maximum elastic modulus (G(max)(')) of 30 wt% F127 decreased from its value for water alone as PEG was added, but was little changed by adding PVP. These results are consistent with the packed-micelles in the 30 wt% F127 gel being effectively isolated from the polymer solution on the microscale while, especially for the PEG, being mixed on the macroscale.

Surgical management of chronic suppurative otitis media with intracranial complications

@#Intracranial abscess is a serious, life-threatening condition with a dire prognosis. Although the advent of the antibiotic era has drastically reduced the incidence of the disease, predisposing factors such as untreated ear infections, poor personal hygiene, significant trauma with violation of the sterile cranial environment as well as existing co-morbidities such as an immunocompromised state make intracranial abscess a horrifying reality. Ear infections, in particular, are notorious for being the origin of roughly 50% of cerebellar abscesses.1 Chronic suppurative otitis media (CSOM) is one of the leading causes of brain abscess. Shaw and Russell2 reviewed 47 cases of cerebellar abscess and showed that 93% were caused by CSOM; the most common mechanism of entry into the brain parenchyma being direct extension. Chronic infection in the middle ear space could erode through the tegmen tympani and into the temporal lobe or through the tegmen mastoidei into the cerebellum. Neurological symptoms may be delayed as the abscess ‘grows’ in areas around the cerebellum that are regarded as ‘silent’, until vital areas such as those responsible for coordination and balance are violated. We describe a case of cerebellar abscess secondary to CSOM and discuss the possibility of performing ear surgery with simultaneous drainage of a contiguous abscess through a transmastoid approach in cases of chronic suppurative otitis media with intracranial complications.

Patient-derived outcome measures for HIV services in the developed world: a systematic review.

This review sought to establish the themes and approaches used in the measurement of patient satisfaction regarded by HIV service users as crucial to improving service quality. It also investigated how feedback has been measured previously and whether a gold standard instrument exists that is generalizable across HIV inpatient and clinic settings. Twelve databases and other sources yielded 1474 titles. Using a clinically-focused question and pre-defined inclusion and exclusion criteria, 32 articles were retrieved and reviewed for quality using a quality appraisal checklist. Two reviewers used a data extraction form to identify and verify key patient experiences. Thematic analysis revealed that clinic staffs' current knowledge of HIV was an essential factor in positive feedback. Treating patients with dignity and respecting their autonomy and confidentiality were also important. Developments in treatment, extended life expectancy and quality of life have altered patients' experience and level of satisfaction. Three instruments developed to assess patient satisfaction with HIV care were identified but there was no gold standard method of measuring it. There is a need to develop a specific, valid instrument that is easy to complete and analyse, and the data should be used to inform the redesign of services to promote a dynamic model of care.

Opposite effects of acute ethanol exposure on GAP-43 and BDNF expression in the hippocampus versus the cerebellum of juvenile rats.

The adolescent brain is particularly vulnerable to the effects of alcohol, with intoxications at this developmental age often producing long-lasting effects. The present study addresses the effects of a single acute ethanol exposure on growth-associated protein-43 (GAP-43) and brain-derived neurotrophic factor (BDNF) gene expression in neurons in the cerebellum and hippocampus of adolescent rats. Male postnatal day 23 (P23) Sprague-Dawley rats were exposed to ethanol vapors for 2h and after a recovery period of 2h, the cerebellum and hippocampus were harvested and samples were taken for blood alcohol concentration (BAC) determinations. We found that this exposure resulted in a mean BAC of 174 mg/dL, which resembles levels in human adolescents after binge drinking. Analyses of total RNA and protein by quantitative reverse transcription PCR and western blotting, respectively, revealed that this single ethanol exposure significantly decreased the levels of GAP-43 mRNA and protein in the cerebellum but increased the levels of mRNA and protein in the hippocampus. BDNF mRNA and protein levels were also increased in the hippocampus but not in the cerebellum of these animals. In situ hybridizations revealed that GAP-43 and BDNF mRNA levels were primarily increased by alcohol exposure in hippocampal dentate granule cells and CA3 neurons. Overall, the reported alterations in the expression of the plasticity-associated genes GAP-43 and BDNF in juvenile rats are consistent with the known deleterious effects of binge drinking on motor coordination and cognitive function.

NICE guidance and current practise of recurrent and bilateral groin hernia repair by Scottish surgeons.

BACKGROUND: NICE (National Institute of Health and Clinical Excellence) in England recommended laparoscopic repair for recurrent and bilateral groin hernias in 2004. The aims of this survey were to evaluate the current practise of bilateral and recurrent inguinal hernia surgery in Scotland and surgeons' views on the perceived need for training in laparoscopic inguinal hernia repair (LIHR). METHODS: A postal questionnaire was sent to Scottish consultant surgeons included in the Scottish Audit of Surgical Audit database 2007, asking about their current practice of primary, recurrent and bilateral inguinal hernia surgery. A response was considered valid if the surgeon performed groin hernia surgery; further analysis was based on this group. Those who did not offer LIHR were asked to comment on the possible reasons, and also the perceived need for training in laparoscopic hernia surgery. Only valid responses were stored on Microsoft Excel (Microsoft Corporation, USA) and analysed with SPSS software version 13.0 (SPSS, Chicago, Illinois). RESULTS: Postal questionnaires were sent to 301 surgeons and the overall all response rate was 174/301 (57.8%). A valid response was received from 124 of 174 (71.2%) surgeons and analysed further. Open Lichtenstein's repair seems to be the most common inguinal hernia repair. Laparoscopic surgery was not performed for 26.6 and 31.5% of recurrent and bilateral inguinal hernia, respectively. About 15% of surgeons replied that an LIHR service was not available in their base hospital. Lack of training, financial constraints, and insufficient evidence were thought to be the main reasons for low uptake of LIHR. About 80% of respondents wished to attend hands-on training in hernia surgery. CONCLUSIONS: Current practice by Scottish surgeons showed that one in three surgeons did not offer LIHR for bilateral and recurrent inguinal hernia as recommended by NICE. There is a clear need for training in LIHR.

The effect of n-, s- and t-butanol on the micellization and gelation of Pluronic P123 in aqueous solution.

In dilute aqueous solution unimers of copolymer P123 (E(21)P(67)E(21)) associate to form micelles, and in more concentrated solution micelles pack to form high-modulus gels. We are interested in the use of the system as a templating agent in the synthesis of mesoporous materials, and the possibility of determining gel structure, hence mesoporosity, by use of n-, s- or t-butanol. Dynamic light scattering from clear dilute solutions has been used to confirm micellization, visual observation of mobility (tube inversion) to detect gel formation in concentrated solutions, oscillatory rheometry to confirm gel formation and provide values of elastic moduli over a wide temperature range, and small-angle X-ray scattering to determine gel structure. As expected, clear cubic gels (fcc) formed at moderate concentrations and temperatures, e.g. 30 wt.% P123, 20°C, and clear hexagonal gels at higher concentrations and temperatures. The transition on heating from cubic to hexagonal gel involved an intermediate turbid phase in which cubic and hex structures coexisted. Considering cubic gels of 35 wt.% P123 in 5 wt.% butanol/water, those in n-butanol/water had the lowest critical temperatures for gel formation and the highest maximum values for the dynamic elastic modulus (G') of the gels, a result consistent with n-butanol/water being the poorest solvent for P123.

Variation of laparoscopic hernia repair in Scotland: a postcode lottery?

BACKGROUND AND PURPOSE: The laparoscopic approach is now recommended by NICE as the preferred technique for repair of bilateral and recurrent inguinal hernia and an accepted option for unilateral hernia. This study was set up to examine whether patients across Scotland had equal access to this method of treatment. METHODS: Information was collected on laparoscopic hernia repairs in adults at all acute general NHS hospitals in Scotland between the financial years 1997/8 and 2007/8. Private hospitals were excluded due to lack of data. The data were derived from SMR01 data of inpatient and daycase discharges from non-paediatric general acute NHS hospitals in Scotland as collected by the Information Services Division (ISD) of NHS National Services Scotland. FINDINGS: Of 6821 repairs in 2007/8, only 890 (13.0%) were performed laparoscopically, a small increase from 294 (4.5%) in 1997/8. The highest incidence of laparoscopic hernia repair in 2007/8 was in NHS Lothian, where 435 (41.1%) of all repairs were performed using the laparoscopic technique. Excluding NHS Lothian, the number of laparoscopic hernia repairs in the rest of Scotland showed a much smaller rise, from 184 (3.3%) to 455 (7.9%). NHS Lothian, (which has 20% of the Scottish population) performed 54.5% of laparoscopic repairs in Scotland between 1997/8 and 2007/8. In the most recent year available, 2007/8, 63.1% of bilateral primary, 53.7% of bilateral recurrent and 26.8% of unilateral recurrent hernia operations in Lothian were laparoscopic. This compares to only 9.9%, 7.0% and 7.1%, respectively, for other Scottish hospitals. CONCLUSIONS: Despite the fact that laparoscopic hernia repair has several proven advantages over open techniques, particularly in bilateral and recurrent hernias, activity remains at a low level in Scotland with the exception of NHS Lothian. In Scotland, laparoscopic techniques are not being used as recommended by NICE guidelines and there appears to be a "postcode lottery" in the provision of this method of treatment. Possible reasons are discussed and action plans are suggested.

Lightweight mesh improves functional outcome in laparoscopic totally extra-peritoneal inguinal hernia repair.

BACKGROUND: Prosthetic mesh reinforcement is standard practice for inguinal hernia repair but can cause considerable pain and stiffness around the groin and affect physical functioning. This has led to various types of mesh being engineered, with a growing interest in a lighter weight mesh. The aim of this prospective study was to compare the outcome after laparoscopic totally extra-peritoneal (TEP) inguinal repair using new lightweight or traditional heavyweight mesh performed in a single specialist centre. METHODS: Between November 2004 and July 2005, 250 patients underwent laparoscopic TEP inguinal repair using either lightweight (Ultrapro, 30 g/m(2)) or heavyweight (Prolene, 100 g/m(2)) mesh. Follow-up data was obtained using case note review and telephone-based questionnaire. Patients were followed up within the early and late post-operative periods to assess any changes in outcome. RESULTS: Follow-up information was obtained for 188 (75%) out of 250 patients. There was no difference between lightweight and heavyweight groups in the incidence or severity of pain/discomfort at mean 4 and 15 months follow-up. There was significantly less interference with physical activity at short and long term follow-up in the lightweight group, in particular lifting (9% vs 21% at mean 4 months, Mann-Whitney U, P = 0.024), walking (1% vs 11% at mean 15 months, Mann-Whitney U, P = 0.006) and vigorous activities (7% vs 19% at mean 15 months, Mann-Whitney-U, P = 0.012). There was no significant difference in awareness of mesh or stiffness in the groin. CONCLUSIONS: Laparoscopic TEP inguinal hernia repair with a lightweight mesh improves functional outcome in the short and long term. There was significantly less interference with all aspects of physical activity with the lightweight mesh. Pain in both groups was very mild, highlighting the benefits of laparoscopic surgery.

Recurrence after inguinal hernia repair at ten years by open darn, open mesh and TEP--no advantage with mesh.

BACKGROUND: Whilst mesh repair is now standard in inguinal hernia surgery, with the expectation of a reduction in recurrence rate, the incidence of recurrent hernias shows little evidence of decline. Long-term follow-up studies after hernia surgery are few. METHODS: 1361 patients underwent 1473 inguinal hernia repairs by open mesh, open sutured or total extraperitoneal (TEP) techniques with more than ten years' follow-up. FINDINGS: Recurrence rates after open mesh and open sutured repair were similar. There has been no benefit in terms of declining recurrence from the increasing use of mesh. There was a high rate of early recurrence after TEP due to learning curve effects. Late recurrence, occurring after two years was uncommon with all techniques, but was lowest after TEP, double the rate after open mesh and four times the rate after sutured repair. This may be due to mesh protecting the area of muscle weakness' with larger meshes conferring a greater long-term benefit. CONCLUSION: Our findings help to explain why there has been no significant fall in the incidence of recurrent inguinal hernias in national data sets and large scale audits, despite a widespread use of mesh.

Intraoperative cholangiography in modern surgical practice.

BACKGROUND/AIMS: The aim of this study was to assess the practice of performing intraoperative cholangiography (IOC) during laparoscopic cholecystectomy in a busy teaching hospital. METHODS: Data were obtained from a surgical database for patients who underwent laparoscopic cholecystectomy between January 2000 and December 2003. The findings of IOC and follow-up were analysed. RESULTS: 1,651 patients were included in the study. Of the 745 patients (45.1%) who underwent IOC, this was normal in 586 patients and abnormal in 68 patients. Of these 68 patients, 4 underwent immediate conversion to open common bile duct exploration. 33 patients underwent endoscopic retrograde cholangiopancreatography and 31 patients were observed. During a median follow-up period of 920 days (range 371-1,821), 5 of the 745 patients had retained stones. Two patients re-presented after a failed IOC while 5 of the 906 patients from the non-cholangiogram group returned with stones. Of the 1,651 patients, definite stones were identified in 1.5% patients. CONCLUSION: When the surgeon deemed that IOC was not required, very few subsequent problems were encountered. An observational policy with monitoring of the liver function tests may be appropriate to avoid unnecessary invasive interventions in patients with an abnormal IOC.

Improved management of acute gallstone disease after regional surgical subspecialization.

PURPOSE: Acute gallstone disease is a common indication for emergency hospital admission, and evidence now strongly supports early laparoscopic cholecystectomy as the treatment of choice. Recent data from the UK suggest that this is achieved in a minority of cases with a high proportion of patients managed by deferred elective surgery or emergency open cholecystectomy. We present results of a policy of definitive treatment during index admission after subspecialist reorganization of a regional emergency surgical service. METHODS: Data for all emergency gallstone admissions were retrieved from a prospectively collected regional surgical audit database and results were compared from 31 month periods before and after subspecialist service reorganization in August 2002. RESULTS: A total of 2442 patients were analyzed. Before subspecialization, 458 of 733 patients (62.4%) underwent cholecystectomy during index admission; after subspecialization, cholecystectomy during index admission for biliary colic/acute cholecystitis was achieved in 666 of 817 (81.5%) patients (90.2% laparoscopic, 6.5% conversion rate, and 3.3% primary open cholecystectomy) with a reduction in hospital stay from median 5 to 4 days. The rate of deferred surgery decreased from 37.5% to 18.4%. Early surgery reduced total hospital admission by more than 1 day per patient compared with deferred surgery. CONCLUSIONS: Early laparoscopic cholecystectomy during emergency admission is cost-effective and should be regarded as the standard of care. However, it requires appropriately trained surgeons and availability of a dedicated emergency room, which at present are not consistently provided in all regions of the UK.